The Mediterranean Diet And Cardioprotection: Historical Overview And Current Research

Development of the first Iranian clinical practice guidelines for the diagnosis, treatment, and secondary prevention of acute coronary syndrome

Background

This article introduces the first national guidelines for the management including diagnosis, treatment, and secondary prevention of acute coronary syndrome (ACS) in Iran.

Materials and Methods

The members of the guideline development group (GDG) were specialists and experts in fields related to ACS and were affiliated with universities of medical sciences or scientific associations in the country. They carefully examined the evidence and clinical concerns related to ACS management and formulated 13 clinical questions that were sent to systematic review group who developed related evidence using Grade method. Finally the GDG developed the recommendations and suggestions of the guideline.

Results

The first three questions in the guideline focus on providing recommendations for handling a patient who experience chest pain at home, in a health house or center, during ambulance transportation, and upon arrival at the emergency department (ED) as well as the initial diagnostic measures in the ED. Subsequently, the recommendations related to the criteria for categorizing patients into low, intermediate and high-risk groups are presented. The guideline addressed primary treatment measures for ACS patients in hospitals with and without code 247 or having primary percutaneous coronary intervention (PCI) facilities, and the appropriate timing for PCI based on the risk assessment. In addition, the most efficacious antiplatelet medications for ACS patients in the ED as well as its optimal duration of treatment are presented. The guideline details the recommendations for therapeutic interventions in patients with ACS and acute heart failure, cardiogenic shock, myocardial infarction with nonobstructive coronary arteries (MINOCA), multivessel occlusion, as well as the indication for prescribing a combined use of anticoagulants and antiplatelet during hospitalization and upon discharge. Regarding secondary prevention, while emphasizing the referral of these patients to rehabilitation centers, other interventions that include pharmaceutical and nonpharmacological ones are addressed, In addition, necessary recommendations for enhancing lifestyle and posthospital discharge pharmaceutical treatments, including their duration, are provided. There are specific recommendations and suggestions for subgroups, such as patients aged over 75 years and individuals with heart failure, diabetes, and chronic kidney disease.

Conclusion

Developing guidelines for ACS diagnosis, treatment and secondary prevention according to the local context in Iran can improve the adherence of our health care providers, patients health, and policy makers plans.

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.

Fostering wellbeing and healthy lifestyles through conviviality and commensality: Underappreciated benefits of the Mediterranean Diet

Among the often-neglected features of healthy diets, such as the Mediterranean diet, is the preparation and sharing of food, which is (or was) done in a social environment governed by social rules rather than by time constraints. The act of eating is a daily human practice that is not limited to meeting nutritional and energy needs but also involves a constructed social dimension of sharing meals that is part of the process of human civilization and food cultures around the world. In this narrative review, we outline the importance of conviviality in steering part of the health effects of healthful diets, with special reference to the Mediterranean diet. Based on the available evidence, we suggest that public health initiatives (such as nudging to promote conviviality) to improve people's eating and living styles, reduce loneliness, and promote the sharing of meals could improve health. Interventions aimed at directly increasing/improving people's social relationships, networking, and conviviality can-directly and indirectly-improve both psychological well-being and general health.

The potential of the Mediterranean diet to improve metabolic control and body composition in youths with Type 1 Diabetes Mellitus

BACKGROUND

A chronic autoimmune disease with an increasing incidence rate, type 1 diabetes mellitus (T1DM) is typified by the degeneration of the pancreatic beta cells. Diabetes management is significantly impacted by nutrition. Although it has been demonstrated that following the Mediterranean diet (MD) improves metabolic control with type 2 diabetes in children and adults, its effects on children with T1DM have not received much attention.

OBJECTIVE

Therefore, the purpose of this study was to assess whether adherence to Mediterranean diet is associated with better metabolic control and body composition in youths with Type 1 Diabetes Mellitus. The study recruited T1DM patients aged 6-18 years at İstanbul University Cerrahpaşa Medical Faculty Hospital's Pediatric Endocrinology and Diabetes Outpatient Clinic for follow-up.

METHODS

In addition to demographic variables, some anthropometric measurements, body composition and biochemical parameters such as: Trygliceride(TG), Total cholesterol (TC), High density lipoprotein cholesterol (HDL-C), Low density lipoprotein cholesterol (LDL-C), (Aspartate aminotransferase) AST, Alanine transaminase (ALT) and glycated hemoglobin (HbA1c) was analyzed. The time in range (TIR) is a value obtained from continuous glucose monitoring. KIDMED was used to assess the participants' adherence with the MD.

RESULTS

Good adherence to the MD resulted in much larger height SDS than poor adherence. Poor adherence to MD resulted in higher body fat than moderate and good adherence. There is positivite correlation between TIR and KIDMED score. Adherence to MD is negatively associated with HbA1c. The regression anaylsis showed that a one-point rise in the KIDMED score would result in a 0.314-unit reduction in the HbA1c value (p < 0.01).

CONCLUSIONS

In conclusion, this study found that adhering to MD led to improved anthropometric measurements, biochemistry, and diabetes outcomes. Awareness among children, adolescents with T1DM, and their parents about the benefits of MD compliance for glycemic and metabolic control should be raised.

Natural Sirtuin1 Activators and Atherosclerosis: an Overview

PURPOSE OF REVIEW

The purpose of this review is to summarize the most recent findings investigating the impact of several natural sirtuin (SIRT) activators, particularly SIRT1, on atherosclerosis.

RECENT FINDINGS

Sirtuins that belong to a family of class III histone deacetylases are believed to be novel therapeutic targets to treat age-related and chronic diseases. SIRT expression is regulated by small molecules called SIRT-activating compounds that can be found in natural food products. SIRT1 may exert protective effects in atherosclerosis, which is said to be a major cause of cardiovascular diseases. Most of the evidence supporting the beneficial effects of these natural compounds comes from in vitro or animal-based studies, while there have been particularly few or inconsistent human-based studies evaluating their long-term impact in recent years. SIRT1 activation has been demonstrated to mitigate or prevent atherosclerosis through various mechanisms. However, further research is required to determine the optimal SIRT activator dosage and to establish a stronger correlation between health effects and the administration of bioactive compounds. Additionally, conducting more human clinical trials is necessary to ensure the safety of these compounds for preventing atherosclerosis development.

Examining the Nutrition of Cardiological Patients in Hospitals: Evaluating the Discrepancy between Received Diets and Reference Diet Based on ESC 2021 Guidelines-Hospital Diet Medical Investigation) (HDMI) Study

Cardiovascular diseases (CVDs) are the leading causes of death worldwide. CVDs have become the dominant cause of death and have been a significant health challenge since the second half of the 20th century in the Polish population. The aim of our HDMI (hospital diet medical investigation) study was to examine the quality of the hospital diets given to cardiac patients and assess how much they adhere to the European Society of Cardiology (ESC) 2021 guidelines. By comparing the diets received by patients with the recommended dietary patterns outlined in the ESC 2021 guidelines, we sought to identify discrepancies. The study was conducted in two steps: creating a 7-day model menu and comparing it with the received diets and then making comparisons with ESC 2021 guidelines. Additionally, we designed a survey to obtain the characteristics of the hospitals. The results show that the nutrition in hospitals remains substandard. None of the diets had an appropriate salt supply or predominance of plant-based food patterns. Only 1/7 diets avoided sweetened beverages, and 2/7 diets had an appropriate amount of fiber. This underscores a gap in the healthcare system to improve patients' health by implementing dietary interventions that foster the development of healthy eating habits.

Opportunities and challenges for sweat-based monitoring of metabolic syndrome via wearable technologies

Metabolic syndrome is a prevalent condition in adults over the age of 65 and is a risk factor for developing cardiovascular disease and type II diabetes. Thus, methods to track the condition, prevent complications and assess symptoms and risk factors are needed. Here we discuss sweat-based wearable technologies as a potential monitoring tool for patients with metabolic syndrome. We describe several key symptoms that can be evaluated that could employ sweat patches to assess inflammatory markers, glucose, sodium, and cortisol. We then discuss the challenges with material property, sensor integration, and sensor placement and provide feasible solutions to optimize them. Together with a list of recommendations, we propose a pathway toward successfully developing and implementing reliable sweat-based technologies to monitor metabolic syndrome.

Metabolic syndrome is a risk factor for developing cardiovascular disease and type II diabetes. Lyzwinski, Elgendi and colleagues discuss the potential role of sweat-based wearable technologies for monitoring metabolic syndrome along with engineering challenges towards implementation and optimization

High Alternative Health Eating Index-Taiwan Scores Are Associated With Prevention of Graft Dysfunction in Taiwanese Renal Transplant Recipients

BACKGROUND

Various dietary quality indices demonstrate that a higher dietary quality score is associated with a reduced risk of several chronic diseases. However, creating an index tailored to the national population is crucial. The study investigated the association between the Alternative Healthy Eating Index-Taiwan (AHEI-Taiwan) and graft dysfunction in Taiwanese renal transplant recipients (RTRs).

METHODS

A prospective cohort study recruited 102 RTRs with a functioning allograft without acute rejection in the last 3 months from September 2016 to June 2018. Laboratory data were obtained from the medical records of patients. Graft dysfunction was indicated by an estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m² in accordance with the Kidney Disease Outcomes Quality Initiative guideline. The dietary quality index AHEI-Taiwan was adapted from the AHEI based on Taiwanese dietary recommendations.

RESULTS

Mean age, renal transplant time, and eGFR were 48.9 ± 12.8 years, 8.5 ± 5.8 years, and 54.9 ± 17.8 mL/min per 1.73 m², respectively, in 102 RTRs. The RTRs with the highest quartile of AHEI-Taiwan scores were older and had a higher eGFR. Logistic regression analysis adjusted for age, sex, calories, Charlson comorbidity index, transplant time, and dialysis time showed that the highest quartile of the AHEI-Taiwan was associated with an 88% (odds ratio, 0.12; 95% CI, 0.03-0.59, P < .01) lower risk of graft dysfunction.

CONCLUSION

A high AHEI-Taiwan score was associated with a reduced risk of graft dysfunction in Taiwanese RTRs.

Nutrition Disturbances and Metabolic Complications in Kidney Transplant Recipients: Etiology, Methods of Assessment and Prevention-A Review

Nutrition disturbances occur at all stages of chronic kidney disease and progress with the decrease of the kidney filtration rate. Kidney transplantation (KTx) as the best form of kidney replacement therapy poses various nutritional challenges. Prior to transplantation, recipients often present with mild to advanced nutrition disturbances. A functioning allograft not only relieves uremia, acidosis, and electrolyte disturbances, but also resumes other kidney functions such as erythropoietin production and vitamin D3 metabolism. KTx recipients represent a whole spectrum of undernutrition and obesity. Since following transplantation, patients are relieved of most dietary restrictions and appetite disturbances; they resume old nutrition habits that result in weight gain. The immunosuppressive regimen often predisposes them to dyslipidemia, glucose intolerance, and hypertension. Moreover, most recipients present with chronic kidney graft disease at long-term follow-ups, usually in stages G2-G3T. Therefore, the nutritional status of KTx patients requires careful monitoring. Appropriate dietary and lifestyle habits prevent nutrition disturbances and may improve kidney graft function. Despite many nutritional guidelines and recommendations targeted at chronic kidney disease, there are few targeted at KTx recipients. We aimed to provide a brief review of nutrition disturbances and known nutritional recommendations for kidney transplant recipients based on the current literature and dietary trends.

Dietary Patterns vs. Dietary Recommendations

Dietary Reference Values (DRVs) are important for developing labeling laws, identifying populations at risk of over- or under-consumption, and promoting public health interventions. However, the process of developing DRVs is quite complex, and they should not be viewed as recommendations ready to use or goals for individuals. Rather, they require interpretation by professionals and can form the basis of dietary advice. On the other hand, focusing on foods rather than macronutrients can assist individuals in understanding a healthy diet by taking into consideration many variables that may help compliance with a healthy dietary style. Evolution, tradition within specific geographical and historical contexts, taste, economic affordability, season-associated local dietary resources, and lifestyle may all explain the increasing popularity of dietary patterns that are highly successful today. Three models (the Mediterranean, New Nordic, and Japanese) have been recently characterized for geographical setting and food composition, as well as the associated lifestyle. Of note, all these three models rely on pyramids sharing a large basis made up of local vegetal resources and a top of red meats (allowed in many cases, but in limited amounts), thus allowing for the urgent demand of sustainability for the planet's health. This mini-review aimed to summarize the meaning of DRVs and to describe the dietary patterns that better contemplate health, diet diversity, and sustainability.

A Combination of Mediterranean and Low-FODMAP Diets for Managing IBS Symptoms? Ask Your Gut!

Among other factors, food intolerance is cardinal in triggering irritable bowel syndrome (IBS) symptoms in a significant percentage of patients. As a result, specific dietary patterns are the first-line therapeutic approach. The low-FODMAP diet (LFD) is gaining ground as the most well-documented diet intervention that significantly reduces IBS symptoms. Though the LFD improves symptoms, the diet’s impact on intestinal low-grade inflammation, one of the cardinal mechanisms contributing to symptom development, remains doubtful. On the other hand, the Mediterranean diet (MedDiet) is recommended for chronic low-grade inflammation-related diseases because of its anti-inflammatory properties, derived predominantly from olive oil and phenolic compounds. Thus far, the role of a modified LFD, enriched with the MedDiet’s anti-inflammatory components, has not been evaluated in IBS patients. This review aims to examine the hypothesis of a potential combination of the immunomodulatory effects of the MedDiet with the LFD to improve IBS symptoms.

Effectiveness of Workplace Mediterranean Diet Interventions on Cardiometabolic Risk Factors: A Systematic Review

BACKGROUND

There are numerous health benefits related to high adherence to the Mediterranean diet (MedDiet), providing a protective effect against cardiometabolic diseases, but there are very few MedDiet studies conducted in the workplace. Therefore, the purpose of this systematic review is to analyze the effectiveness of MedDiet workplace interventions on cardiovascular risk factors.

METHODS

Studies were identified in four databases: PubMed, Scopus, Web of Science, and CINAHL, published from the earliest time point until 15 May 2021. The inclusion criteria were (a) adults aged 18 to 70 years; (b) MedDiet intervention only; (c) intervention was conducted in a workplace; and (d) the outcomes included measurement of cardiometabolic biomarkers. Exclusion criteria were (a) abstract not in English; (b) full-text non-available; and (c) review articles. Ninety-five studies were retrieved and assessed for inclusion by two independent reviewers, who also used the Cochrane Collaboration Tool to assess study quality and risk of bias.

RESULTS

Five high-quality studies were included (n = 436, 89% male). MedDiet interventions carried out within the workplace were effective in improving cardiovascular risk factors such as lipid profile and insulin sensitivity compared with a low-fat diet, especially among obese participants. Blood pressure and inflammatory markers were not improved after the MedDiet interventions.

CONCLUSIONS

Worksite occupational health teams should consider promoting MedDiet by conducting regular nutritional sessions and providing tailored menus in workplace cafeterias. However, more high-quality studies are necessary to bring more evidence to this topic.

A Narrative Review of Dietary Approaches for Kidney Transplant Patients

A healthy eating pattern has proven to lower the risk of metabolic and cardiovascular diseases. However, there are sparse dietary recommendations for kidney transplant recipients, and the ones available focus only on single nutrients intake, such as sodium, potassium, and proteins, and not on the overall eating pattern. Considering that individuals do not typically consume nutrients in isolation, but as part of a complete dietary pattern, it is challenging for the average transplanted patient to understand and implement specific dietary recommendations. Also, single-nutrient interventions demonstrate largely inconclusive effects, and it seems improbable that they could have a strong enough impact on transplant outcomes. Dietary trends such as plant-based diets, intermittent fasting, low-carb diet/keto-diet, and juicing, have gained major attention from the media. Herein, we review the potential risks and benefits of these diets in kidney transplant recipients and provide an updated dietary recommendation for this population with consideration of current nutritional trends. Overall, the Mediterranean and DASH diets have demonstrated to be the most beneficial dietary patterns to the post kidney transplant population by focusing on less meat and processed foods, while increasing the intake of fresh foods and plant-based choices. We believe that to maintain a healthy lifestyle posttransplant, patients should be educated about the scientific evidence of different diets and choose a dietary pattern that is sustainable long-term.

Valle Agricola Chickpeas: Nutritional Profile and Metabolomics Traits of a Typical Landrace Legume from Southern Italy

Chickpea (Cicer arietinum L.) from Valle Agricola is a legume cultivated in Southern Italy whose intake is strictly linked to rural traditions. In order to get new biochemical insight on this landrace and to promote its consumption and marketing, nutritional values (moisture content, total proteins, lipids, total and free amino acids) and metabolic traits are deeply investigated. Valle Agricola chickpea is nutritionally rich in proteins (19.70 g/100 g) and essential amino acids (7.12 g/100 g; ~40% of total). Carbohydrates, whose identity was unraveled by means of UHPLC-HR MS/MS analysis, were almost 60% of chemicals. In particular, a di-galactosylglycerol, a pinitol digalactoside, and a galactosylciceritol were found as constitutive, together with different raffinose-series oligosaccharides. Although lipids were the less constitutive compounds, glycerophospholipids were identified, while among free fatty acids linoleic acid (C18:2) was the most abundant, followed by oleic (C18:1) and palmitic (C16:0) acids. Isoflavones and hydroxybenzoic acid derivatives were also detected. Valle Agricola chickpeas showed very good levels of several mineral nutrients, especially magnesium (164 mg/100 g), potassium (748 mg/100 g), calcium (200 mg/100 g), zinc (4.20 mg/100 g) and manganese (0.45 mg/100 g). The boiling process favorably decreases anti-trypsin and anti-chymotrypsin activities, depleting this precious seed of its intrinsic antinutritional factors.

How fragile are Mediterranean diet interventions? A research-on-research study of randomised controlled trials

INTRODUCTION

The Mediterranean diet (MD) is a traditional regional dietary pattern and a healthy diet recommended for the primary and secondary prevention of various diseases and health conditions. Results from the higher level of primary evidence, namely randomised controlled trials (RCTs), are often used to produce dietary recommendations; however, the robustness of RCTs with MD interventions is unknown.

METHODS

A systematic search was conducted and all MD RCTs with dichotomous primary outcomes were extracted from PubMed. The fragility (FI) and the reverse fragility index (RFI) were calculated for the trials with significant and non-significant comparisons, respectively.

RESULTS

Out of 27 RCTs of parallel design, the majority failed to present a significant primary outcome, exhibiting an FI equal to 0. The median FI of the significant comparisons was 5, ranging between 1 and 39. More than half of the comparisons had an FI <5, indicating that the addition of 1-4 events to the treatment arm eliminated the statistical significance. For the comparisons with an FI=0, the RFI ranged between 1 and 29 (Median RFI: 7). When the included RCTs were stratified according to masking, the use of a composite primary endpoint, sample size, outcome category, or dietary adherence assessment method, no differences were exhibited in the FI and RFI between groups, except for the RFI among different compliance assessment methods.

CONCLUSIONS

In essence, the present study shows that even in the top tiers of evidence hierarchy, research on the MD may lack robustness, setting concerns for the formulation of nutrition recommendations.

Nutritional Pearls: Diet and Rheumatoid Arthritis

Various studies have investigated the effect of diet on rheumatoid arthritis (RA) as a complimentary treatment along with standard drug therapy. Various types of diet have been investigated. Fasting, the Mediterranean diet, the Cretan Mediterranean diet, vegetarian diet, an anti-inflammatory diet and the use of various specific food substances have been in the focus of research interest. The relationship of obesity with disease activity in RA has also been investigated. A period of fasting followed by Mediterranean diet, the Cretan Mediterranean diet and an anti-inflammatory diet have been found to have a beneficial effect on disease activity in RA. Obesity has been found to be associated with increased disease activity in RA. However, weight loss appears to be related to increased mortality in RA. The use of flavonoids, resveratrol and curcumin may have a beneficial effect in RA. It appears that diet may aid in RA management as a complimentary factor to standard drug treatment.

Reflections on Atherosclerosis: Lesson from the Past and Future Research Directions

The clinical manifestations of atherosclerosis are nowadays the main cause of death in industrialized countries, but atherosclerotic disease was found in humans who lived thousands of years ago, before the spread of current risk factors. Atherosclerotic lesions were identified on a 5300-year-old mummy, as well as in Egyptian mummies and other ancient civilizations. For many decades of the twentieth century, atherosclerosis was considered a degenerative disease, mainly determined by a passive lipid storage, while the most recent theory of atherogenesis is based on endothelial dysfunction. The importance of inflammation and immunity in atherosclerosis’s pathophysiology was realized around the turn of the millennium, when in 1999 the famous pathologist Russell Ross published in the New England Journal of Medicine an article entitled “Atherosclerosis – an inflammatory disease”. In the following decades, inflammation has been a topic of intense basic research in atherosclerosis, albeit its importance has ancient scientific roots. In fact, in 1856 Rudolph Virchow was the first proponent of this hypothesis, but evidence of the key role of inflammation in atherogenesis occurred only in 2017. It seemed interesting to retrace the key steps of atherosclerosis in a historical context: from the teachings of the physicians of the Roman Empire to the response-to-injury hypothesis, up to the key role of inflammation and immunity at various stages of disease. Finally, we briefly discussed current knowledge and future trajectories of atherosclerosis research and its therapeutic implications.

The Mediterranean diet: A historical perspective on food for health

The Mediterranean diet (MedDiet) represents the crystallisation of the centuries-old cooking legacies of different civilisations. The association of the MedDiet with longevity and low cardiovascular risk prompted the Seven Countries Study, which provided epidemiological evidence on the health effects of diet. This led to further studies, both epidemiological and interventional. Scales to measure adherence as well as studies of food components have consolidated a body of knowledge that is of great interest to institutions and governmental agencies. The recognition of its benefits for health has made the widespread introduction of the MedDiet an urgent challenge. Parallel efforts are being made to extend research through experimental and clinical studies. The purpose of this review is to present the historical background of the MedDiet, the main steps leading to the recognition of its health benefits, and the current strategy to facilitate its global implementation.