Mediterranean Diet and Its Association with Cardiovascular Disease Risk Factors: A Scoping Review

Epigenetic regulation of cardiovascular diseases induced by behavioral and environmental risk factors: Mechanistic, diagnostic, and therapeutic insights

Behavioral and environmental risk factors are critical in the development and progression of cardiovascular disease (CVD). Understanding the molecular mechanisms underlying these risk factors will offer valuable insights for targeted preventive and therapeutic strategies. Epigenetic modifications, including DNA methylation, histone modifications, chromatin remodeling, noncoding RNA (ncRNA) expression, and epitranscriptomic modifications, have emerged as key mediators connecting behavioral and environmental risk factors to CVD risk and progression. These epigenetic alterations can profoundly impact on cardiovascular health and susceptibility to CVD by influencing cellular processes, development, and disease risk over an individual's lifetime and potentially across generations. This review examines how behavioral and environmental risk factors affect CVD risk and health outcomes through epigenetic regulation. We review the epigenetic effects of major behavioral risk factors (such as smoking, alcohol consumption, physical inactivity, unhealthy diet, and obesity) and environmental risk factors (including air and noise pollution) in the context of CVD pathogenesis. Additionally, we explore epigenetic biomarkers, considering their role as causal or surrogate indicators, and discuss epigenetic therapeutics targeting the mechanisms through which these risk factors contribute to CVD. We also address future research directions and challenges in leveraging epigenetic insights to reduce the burden of CVD related to behavioral and environmental factors and improve public health outcomes. This review aims to provide a comprehensive understanding of behavioral and environmental epigenetics in CVD and offer valuable strategies for therapeutic intervention.

Plaque enhancement of middle cerebral artery and pre-stroke diet are associated with prognosis of subacute ischemic stroke: A prospective high-resolution MR vessel wall imaging study

OBJECTIVES

To explore the value of middle cerebral artery (MCA) plaque characteristics in predicting the outcomes of subacute ischemic stroke and the incremental value of the previous diet on predictive performance.

METHODS

One hundred and thirty-seven subacute ischemic stroke patients attributed to MCA plaques were included and analyzed in this prospective study. The National Institute of Health Stroke Scale (NIHSS) score, Mediterranean Diet Adherence Screener (MEDAS) score, and other clinical data were assessed. The plaque area, degree of stenosis, plaque burden, enhancement ratio, remodeling type, and intraplaque hemorrhage were measured using high-resolution MR vessel wall imaging (HR-VWI). Multivariable logistic regression analysis and receiver operating characteristic curve analysis were performed to assess the predictive performance of clinical and plaque characteristics for subacute ischemic stroke outcomes at 3 months.

RESULTS

Patients with poor outcomes exhibited high NIHSS scores, and low MEDAS scores (P<0.001). Plaque burden, enhancement ratio, and degree of stenosis were significantly higher in patients with poor outcomes (P<0.001). Multivariate analyses further indicated that NIHSS score (P=0.001), MEDAS score (P=0.013), and enhancement ratio (P=0.011) were independent predictors of subacute ischemic stroke outcomes. The three models' area under the curve (AUC) values were 0.811, 0.844, and 0.794. Combining these three factors resulted in an AUC of 0.908 (P<0.001).

CONCLUSIONS

The combination of NIHSS score, MEDAS score, and enhancement ratio showed significant superiority in the prognostic evaluation of subacute ischemic stroke. Clinical data combined with plaque characteristics improves the accuracy of 3-month outcome prediction on subacute ischemic stroke.

Prospective Association of the Mediterranean Diet with the Onset of Cardiometabolic Multimorbidity in a UK-Based Cohort: The EPIC-Norfolk Study

BACKGROUND

Cardiometabolic multimorbidity (CMM), defined as the co-occurrence of 2 or more cardiometabolic diseases, including myocardial infarction (MI), stroke, and type 2 diabetes (T2D), is an increasing public health challenge. Although poor diet is a known risk factor for a first cardiometabolic disease (FCMD), the relationship with subsequent occurrence of CMM is less studied.

OBJECTIVES

This study aims to investigate the prospective association between baseline adherence to the Mediterranean diet and the onset of CMM across various follow-up durations.

METHODS

We used data from the European Prospective Investigation into Cancer-Norfolk cohort study of 21,900 adults, aged 40-79 free of prevalent MI, stroke, and T2D at baseline (1993-1997). A median-based Mediterranean diet score and a pyramid-based MDS (pyr-MDS) were used to measure baseline adherence to the Mediterranean diet. Multistate modeling was employed to investigate associations with the FCMD and the subsequent CMM event.

RESULTS

Over the entire follow-up period of 21.4 y (median), we observed 5028 FCMD and 734 CMM events. Multistate analysis indicated that the association between baseline Mediterranean diet and the risk of CMM may be stronger in shorter follow-up durations. Particularly, baseline pyr-MDS was significantly associated with the risk of subsequent CMM transitioning from FCMD when follow-up durations were limited to 10 and 15 y, with hazard ratio (95% confidence interval) being 0.67 (0.53, 0.84) and 0.80 (0.70, 0.92) per SD increase in pyr-MDS, respectively. Additionally, we observed that the risk of CMM transitioning from FCMD was modified by social class across shorter to longer follow-ups, where the impact of baseline Mediterranean diet was only significant in nonmanual workers.

CONCLUSIONS

Baseline adherence to the Mediterranean diet was potentially associated with a lower risk of CMM transitioning from FCMD, particularly during shorter follow-up periods.

Effect of the Mediterranean diet on incidence of heart failure in European countries: a systematic review and meta-analysis of cohort studies

INTRODUCTION

Heart failure (HF) is one of the most common cardiovascular disorders, and its prevalence is increased due to age, genetics, and lifestyle factors. Emerging evidence suggests that the Mediterranean Diet (Med Diet) is linked to lower all-cause mortality in patients with increased cardiovascular disease risk, such as those with HF.

OBJECTIVE

To conduct a systematic review and meta-analysis of observational studies into the relationship between the Med Diet on HF risk.

DESIGN

Several databases (PubMed, Scopus, Web of Science and Cochrane Library) until the 01st of May 2023 were searched. Our research was conducted based on the updated 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were reported as risk ratios (RRs) with their 95% confidence intervals (CIs) as results of multivariate or univariate analyses.

RESULTS

From the original 1206 studies collected, six observational prospective studies were included, with a total of 216,385 European participants without evidence of HF at baseline. Over a mean period of 11 years of follow-up, a 1-point increase in the Med Diet score was associated with a significantly lower risk of HF (RR = 0.940; 95% CI: 0.912-0.969, p < 0.0001; I2 = 42.9%). Categorised by sex, a higher adherence to Med Diet was associated with a significantly lower incidence of HF in women (RR = 0.942; 95% CI: 0.912-0.973, p = 0.001; I2 = 41.8%), but not in men. The overall quality of included studies was good.

CONCLUSIONS

Higher adherence to Med Diet across European countries is associated with lower risk of HF, particularly in women.

The Association of Dietary Micronutrient Intake and Systemic Inflammation among Patients with Type 2 Diabetes: A Cross-Sectional Study

Inflammation contributes to the pathogenesis of type 2 diabetes (T2DM). This study sought to document how the systemic biomarkers of inflammation varied based on food choices among patients with T2DM. This cross-sectional study enrolled ambulatory patients with T2DM. Demographic and clinical information was collected. Five drops of fingerstick blood were collected using an absorbent paper device (HemaSpot HFR). C-reactive protein (CRP), serum amyloid A protein (SAA), and fibrinogen were measured using a Luminex assay. Patient-generated 7-day food diaries were analyzed using a validated food processor software. Data were analyzed by Pearson's correlation tests, linear regression and logistic regression with the significance level set at 0.05. Among the 71 participants, 43 (60.6%) were females. The average age and duration of T2DM were 64.1 ± 10.3 and 15.8 ± 9.1 years, respectively. In a simple linear regression run with selected micronutrients, iron [F (1, 53) = 5.319, p < 0.05, adj. R2 = 0.074] significantly predicted plasma CRP. This significance was lost with multiple linear regressions including age, gender, BMI, T2DM duration, T2DM complications, glycohemoglobin A1c (HbA1c) and other micronutrients. The average intake of most micronutrients by the participants was below the recommended daily intake. A higher intake of iron-rich foods was associated with higher levels of systemic inflammation in a simple linear regression model, but the association was not present after adjusting for patient factors like age, gender, BMI and T2DM-related variables. This relationship needs to be explored further given the key role of inflammation in the pathogenesis of T2DM and its associated complications.

Association between cMIND diet and hypertension among older adults in China: a nationwide survey

BACKGROUND

Existing research indicates that the Mediterranean diet has a positive impact on preventing and treating hypertension. However, its specific effect on hypertension among elderly Chinese individuals is unclear.

AIMS

The objective of this research was to explore the association between the Chinese version of the Mediterranean-DASH Intervention for Neurodegenerative Delay (cMIND) diet and hypertension among elderly Chinese individuals, aiming to offer novel strategies for alleviating the burden of hypertension in this demographic.

METHODS

In this study, we used cross-sectional data published in 2018 by the China Longitudinal Health and Longevity Survey (CLHLS) to develop a binary logistic regression model to investigate the correlation between cMIND diet and hypertension in a Chinese elderly population. Restricted cubic spline was used to test for linear associations, and further subgroup analyses were performed to test for interactions.

RESULTS

In total, 7,103 older adults were included in the study, with a prevalence of hypertension of 39.0%. When the cMIND diet score was used as a continuous variable, a significant protective effect against hypertension was present (OR = 0.955, 95% CI:0.923-0.988, p = 0.008); when used as a categorical variable, this protective effect was still present at higher levels (compared to lower levels) of the cMIND diet (OR = 0.869, 95% CI: 0.760-0.995, p = 0.042).

DISCUSSION

Although the Mediterranean diet has great potential to reduce the chance of hypertension, it should also consider the effect on the Chinese population. The results of this study provide new ways to reduce the disease burden of hypertension in Chinese older adults and improve quality of life in later life.

CONCLUSION

The cMIND diet can considerably reduce the risk of hypertension among older adults in China.

Characteristics, Physiopathology and Management of Dyslipidemias in Pregnancy: A Narrative Review

Dyslipidemia is a significant risk factor for atherosclerotic cardiovascular disease (ASCVD). During pregnancy, physiological changes elevate cholesterol and triglyceride levels to support fetal development, which can exacerbate pre-existing conditions and lead to complications such as pre-eclampsia, gestational diabetes, and increased ASCVD risk for both mother and child. Effective management strategies are necessary, especially for pregnant women with inherited forms of dyslipidemia (i.e., familial hypertriglyceridemia, hyperchylomicronemia), where personalized dietary adjustments are crucial for successful pregnancy outcomes. Pharmacological interventions and lipoprotein apheresis may be necessary for severe cases, though their use is often limited by factors such as cost, availability, and potential fetal risks. Despite the promise of advanced therapies, their widespread application remains constrained by limited studies and high costs. Thus, a personalized, multidisciplinary approach is essential for optimizing outcomes. This review provides a comprehensive overview of current strategies and evidence-based practices for managing dyslipidemia during pregnancy, emphasizing the balance of maternal and fetal health. Additionally, it discusses the physiological changes in lipid metabolism during pregnancy and their implications, particularly for women with inherited forms of dyslipidemia.

Adherence to the Mediterranean Diet and Cardiovascular Risk Factors among the Lebanese Population: A Nationwide Cross-Sectional Post Hoc Study

OBJECTIVE

This study aims to identify the association between adherence to healthy eating, using the Lebanese Mediterranean Diet Scale (LMDS), and cardiovascular risk factors in the Lebanese population.

MATERIALS AND METHODS

A cross-sectional study using a multistage cluster sample was conducted in Lebanon. Sociodemographic characteristics were collected through structured interviews and self-administered questionnaires. The LMDS assessed dietary habits. The associations between diabetes, dyslipidemia, and cardiovascular disease were investigated using stratification analysis.

RESULTS

The study included 2048 people (mean age: 41.54 ± 17.09 years). Higher adherence to the Mediterranean diet was associated with older age (Beta = 0.175, p < 0.001), being female (Beta = 0.085, p = 0.001), being married (Beta = 0.054, p = 0.047), participating in regular physical activity (Beta = 0.142, p < 0.001), and having cardiovascular disease (Beta = 0.115, p < 0.001) and diabetes (Beta = 0.055, p = 0.043). Adherence was, however, negatively associated with being a smoker (Beta = -0.083, p = 0.002), a previous smoker (Beta = -0.059, p = 0.026), and having higher distress levels (Beta = -0.079, p = 0.002). Stratification analysis by diabetes, dyslipidemia, and cardiovascular disease (CVD) consistently demonstrated these associations.

CONCLUSIONS

These findings suggest that demographic and health factors influence the Lebanese population's adherence to the Mediterranean diet. Older age, female gender, married status, physical activity, CVD, and diabetes were all found to be associated with adherence to the Mediterranean diet in the Lebanese population. In contrast, smoking and distress were inversely associated with it.

Effect of the Mediterranean diet in cardiovascular prevention

The Mediterranean diet is the best evidence-based model for cardiovascular prevention. In addition to 2 major randomized secondary prevention trials (Lyon Heart and CORDIOPREV) and 1 primary prevention trial (PREDIMED) that have demonstrated these benefits, there is an unprecedented body of high-quality prospective epidemiological evidence supporting these beneficial effects. The key elements of this traditional pattern are the abundant use of extra-virgin olive oil and high consumption of foods of natural plant-based origin (fruits, vegetables, nuts, and legumes) and fish, along with a reduction in processed meats, red meats, and ultraprocessed products. Moderate consumption of wine, preferably red wine, with meals is an essential element of this traditional pattern. Although removing wine consumption from the Mediterranean diet has been associated with a reduction in its preventive efficacy, doubts have recently arisen about the possible adverse effect of even low or moderate intake of any alcoholic beverages. A new large Spanish trial, UNATI, which will begin in June 2024, will randomize 10 000 drinkers aged 50 to 75 years to abstention or moderate consumption. UNATI aims to answer these doubts with the best possible evidence.

Longitudinal associations of the alternative healthy eating index with coronary artery calcification and pericardial adiposity in US adults with and without type 1 diabetes

BACKGROUND AND AIM

Long-term associations between the alternative healthy eating index (AHEI) score and two predictive indicators for CVD, pericardial adipose tissue (PAT) and coronary artery calcification (CAC) volume, are lacking. Our study aims to investigate the longitudinal associations of the AHEI score with measures of CAC and PAT in adults with and without type 1 diabetes (T1D).

METHODS AND RESULTS

The prospective Coronary Artery Calcification in T1D (CACTI) study included 652 people with T1D and 764 people without diabetes (non-DM) (19-56 years old) and was conducted in 2000-2002, 2003-2004, and 2006-2007. At each visit, food frequency questionnaires were collected and PAT and CAC were measured using electron beam computed tomography. Two variables were used for CAC analyses: a continuous variable for the square-root tranformed volume (SRV) for each visit and a second variable identified CAC progression from baseline to visit 3. Mixed effect models and a logistic regression model were used to conduct statistical analyses. A one-point increase in the AHEI score was significantly associated with a -0.12 cm3 (95% CI: -0.17, -0.08; p-value<0.0001) decrease in PAT volume in combined analyses, a -0.16 cm3 (95% CI: -0.22, -0.09; p-value<0.0001) decrease in the non-DM group, a marginally significant -0.07 cm3 (95% CI: -0.14, 0.002; p-value = 0.0571) decrease in the T1D group, and was not associated with either CAC outcome.

CONCLUSION

The AHEI score is inversely associated with PAT; the association revealed greater magnitude of PAT reduction in the non-DM group. The AHEI score did not associate with CAC progression.

Comprehensive Strategies for Metabolic Syndrome: How Nutrition, Dietary Polyphenols, Physical Activity, and Lifestyle Modifications Address Diabesity, Cardiovascular Diseases, and Neurodegenerative Conditions

Several hallmarks of metabolic syndrome, such as dysregulation in the glucose and lipid metabolism, endothelial dysfunction, insulin resistance, low-to-medium systemic inflammation, and intestinal microbiota dysbiosis, represent a pathological bridge between metabolic syndrome and diabesity, cardiovascular, and neurodegenerative disorders. This review aims to highlight some therapeutic strategies against metabolic syndrome involving integrative approaches to improve lifestyle and daily diet. The beneficial effects of foods containing antioxidant polyphenols, intestinal microbiota control, and physical activity were also considered. We comprehensively examined a large body of published articles involving basic, animal, and human studie, as well as recent guidelines. As a result, dietary polyphenols from natural plant-based antioxidants and adherence to the Mediterranean diet, along with physical exercise, are promising complementary therapies to delay or prevent the onset of metabolic syndrome and counteract diabesity and cardiovascular diseases, as well as to protect against neurodegenerative disorders and cognitive decline. Modulation of the intestinal microbiota reduces the risks associated with MS, improves diabetes and cardiovascular diseases (CVD), and exerts neuroprotective action. Despite several studies, the estimation of dietary polyphenol intake is inconclusive and requires further evidence. Lifestyle interventions involving physical activity and reduced calorie intake can improve metabolic outcomes.

The dynamics in food selection stemming from price awareness and perceived income adequacy: a cross-sectional study using 1-year loyalty card data

BACKGROUND

Higher cost of healthy foods may explain unhealthy dietary patterns in lower-income households. Unfortunately, combining food selection and nutrient intake data to price and expenditure is challenging. Food retailer's customer loyalty card data, linked to nutrient composition database, is a novel method for simultaneous exploration of food purchases, price, and nutrition.

OBJECTIVES

We studied the associations between perceived income adequacy (PIA) as a grouping variable with price (per kilogram or megajoule) and the volume of purchases (percentage of expenditure or energy) simultaneously as outcome variables for 17 most purchased food groups.

METHODS

We used 1-year (2018) loyalty card data from the largest grocery chain in Finland. Participants were 28,783 loyalty cardholders who made ≥41% of food purchases from the retailer and answered an online questionnaire at the midpoint of data collection. The 5-level PIA described the perceived financial situation in the household. Energy and nutrient content of foods purchased were from the Finnish Food Composition Database Fineli. We calculated the Nutrient Rich Food Index per 100 g food using 11 nutrients. Trends in prices and expenditures between PIA levels were analyzed using 2-sided Jonckheere-Terpstra tests, with false discovery rate control (Benjamini-Hochberg method) and confounder adjustments (inverse probability weighting).

RESULTS

Lower PIA participants selected cheaper foods per kilogram and megajoule within most food groups. They also favored unhealthy food groups cheap in energy [<1 € (USD 1.18)/MJ]. Despite lower purchase price, the expenditure (%) among lower PIA was higher on alcohol, snacks, sugar-sweetened beverages, and sweets and chocolates.

CONCLUSIONS

Participants with lower PIA showed stronger price awareness. It is crucial to consider the pricing of competing alternative food groups, when steering toward environmentally sustainable and healthier food purchases. Package labeling might also direct the selection of healthier choices among the less expensive items within a food group.

The Mediterranean Diet, Its Microbiome Connections, and Cardiovascular Health: A Narrative Review

The Mediterranean diet (MD), rich in minimally processed plant foods and in monounsaturated fats but low in saturated fats, meat, and dairy products, represents one of the most studied diets for cardiovascular health. It has been shown, from both observational and randomized controlled trials, that MD reduces body weight, improves cardiovascular disease surrogates such as waist-to-hip ratios, lipids, and inflammation markers, and even prevents the development of fatal and nonfatal cardiovascular disease, diabetes, obesity, and other diseases. However, it is unclear whether it offers cardiovascular benefits from its individual components or as a whole. Furthermore, limitations in the methodology of studies and meta-analyses have raised some concerns over its potential cardiovascular benefits. MD is also associated with characteristic changes in the intestinal microbiota, mediated through its constituents. These include increased growth of species producing short-chain fatty acids, such as Clostridium leptum and Eubacterium rectale, increased growth of Bifidobacteria, Bacteroides, and Faecalibacterium prausnitzii species, and reduced growth of Firmicutes and Blautia species. Such changes are known to be favorably associated with inflammation, oxidative status, and overall metabolic health. This review will focus on the effects of MD on cardiovascular health through its action on gut microbiota.

Human gut microbiome, diet, and mental disorders

Diet is one of the most important external factor shaping the composition and metabolic activities of the gut microbiome. The gut microbiome plays a crucial role in host health, including immune system development, nutrients metabolism, and the synthesis of bioactive molecules. In addition, the gut microbiome has been described as critical for the development of several mental disorders. Nutritional psychiatry is an emerging field of research that may provide a link between diet, microbial function, and brain health. In this study, we have reviewed the influence of different diet types, such as Western, Mediterranean, vegetarian, and ketogenic, on the gut microbiota composition and function, and their implication in various neuropsychiatric and psychological disorders.

Dietary oily fish intake is inversely associated with moderate-to-severe intracranial artery stenosis in older adults of indigenous Ecuadorian ancestry

BACKGROUND AND AIMS

Information on the association between dietary oily fish intake and intracranial atherosclerosis is limited and contradictory. Inconsistencies might be in part related to heterogeneous designs and differences in race/ethnicity of study populations. We aim to assess whether oily fish intake is inversely associated with intracranial artery stenosis (ICAS) in frequent fish consumers of indigenous ancestry living in coastal Ecuador.

METHODS

The study included 384 participants aged ≥60 years enrolled in the Atahualpa Project Cohort. Dietary oily fish intake was quantified systematically via validated surveys and all participants received a time-of-flight MRA of intracranial vessels. Poisson regression models, adjusted for demographics, level of education, traditional risk factors and severe tooth loss, were fitted to assess the association between amounts of oily fish intake and the number of intracranial arteries with moderate-to-severe (≥50 %) stenosis.

RESULTS

Participants had a mean age of 67.7 ± 7 years, and 56 % were women. The mean oily fish intake was 8.9 ± 5.2 servings/week; 283 (74 %) participants consumed ≥5.2 servings/week (2nd to 4th quartiles of fish intake). Forty-three (11 %) participants had at least one major intracranial artery with moderate-to-severe stenosis. Both univariate and multivariate models showed a significant inverse association between consumption of oily fish in the 2nd to 4th quartiles and ≥50 % stenosis in at least one artery (β: 0.46; 95 % C.I.: 0.27-077, and β: 0.52; 95 % C.I.: 0.30-0.90, respectively).

CONCLUSIONS

Consumption of more than five oily fish servings/week is associated with lower prevalence of moderate-to-severe ICAS in indigenous Ecuadorians.

Cardiovascular Disease and the Mediterranean Diet: Insights into Sex-Specific Responses

Cardiovascular disease (CVD) is a leading cause of mortality and disease burden in women globally. A healthy diet is important for the prevention of CVD. Research has consistently favoured the Mediterranean diet as a cardio-protective diet. Several studies have evaluated associations between the Mediterranean diet and cardiovascular outcomes, including traditional risk factors like hypertension, type 2 diabetes mellitus, and obesity. In addition, consistent evidence suggests that the components of the Mediterranean diet have a synergistic effect on cardiovascular risk due to its anti-inflammatory profile and microbiome effects. While the benefits of the Mediterranean diet are well-established, health advice and dietary guidelines have been built on largely male-dominant studies. Few studies have investigated the beneficial associations of the Mediterranean diet in sex-specific populations, including those with non-traditional risk factors that are specific to women, for instance polycystic ovarian syndrome and high-risk pregnancies, or more prevalent in women, such as chronic inflammatory diseases. Therefore, this review aims to provide a comprehensive overview of the current evidence regarding the Mediterranean diet in women in relation to cardiovascular health outcomes.

Effect of diet on the gut mycobiome and potential implications in inflammatory bowel disease

The gut microbiome is a complex, unique entity implicated in the prevention, pathogenesis, and progression of common gastrointestinal diseases. While largely dominated by bacterial populations, advanced sequencing techniques have identified co-inhabiting fungal communities, collectively referred to as the mycobiome. Early studies identified that gut inflammation is associated with altered microbial composition, known as gut dysbiosis. Altered microbial profiles are implicated in various pathological diseases, such as inflammatory bowel disease (IBD), though their role as a cause or consequence of systemic inflammation remains the subject of ongoing research. Diet plays a crucial role in the prevention and management of various diseases and is considered to be an essential regulator of systemic inflammation. This review compiles current literature on the impact of dietary modulation on the mycobiome, showing that dietary changes can alter the fungal architecture of the gut. Further research is required to understand the impact of diet on gut fungi, including the metabolic pathways and enzymes involved in fungal fermentation. Additionally, investigating whether dietary modulation of the gut mycobiome could be utilized as a therapy in IBD is essential.

Prospective associations between diet quality, dietary components, and risk of cardiometabolic multimorbidity in older British men

PURPOSE

Cardiometabolic multimorbidity (CMM) is a major public health challenge. This study investigated the prospective relationships between diet quality, dietary components, and risk of CMM in older British men.

METHODS

We used data from the British Regional Heart Study of 2873 men aged 60-79 free of myocardial infarction (MI), stroke, and type 2 diabetes (T2D) at baseline. CMM was defined as the coexistence of two or more cardiometabolic diseases, including MI, stroke, and T2D. Sourcing baseline food frequency questionnaire, the Elderly Dietary Index (EDI), which was a diet quality score based on Mediterranean diet and MyPyramid for Older Adults, was generated. Cox proportional hazards regression and multi-state model were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

During a median follow-up of 19.3 years, 891 participants developed first cardiometabolic disease (FCMD), and 109 developed CMM. Cox regression analyses found no significant association between baseline EDI and risk of CMM. However, fish/seafood consumption, a dietary component of the EDI score, was inversely associated with risk of CMM, with HR 0.44 (95% CI 0.26, 0.73) for consuming fish/seafood 1-2 days/week compared to less than 1 day/week after adjustment. Further analyses with multi-state model showed that fish/seafood consumption played a protective role in the transition from FCMD to CMM.

CONCLUSIONS

Our study did not find a significant association of baseline EDI with CMM but showed that consuming more fish/seafood per week was associated with a lower risk of transition from FCMD to CMM in older British men.

DASH vs. Mediterranean diet on a salt restriction background in adults with high normal blood pressure or grade 1 hypertension: A randomized controlled trial

BACKGROUND & AIMS

Non-pharmacological measures are recommended as the first-line treatment for individuals with high-normal blood pressure (BP) or mild hypertension. Studies directly comparing the BP effects of the Dietary Approaches to Stop Hypertension (DASH) vs. the Mediterranean diet (MedDiet) on a salt restriction background are currently lacking. Thus, our purpose was to assess the BP effects of a 3-month intensive dietary intervention implementing salt restriction either alone or in the context of the DASH, and the MedDiet compared to no/minimal intervention in adults with high normal BP or grade 1 hypertension.

METHODS

We randomly assigned never drug-treated individuals to a control group (CG, n = 60), a salt restriction group (SRG, n = 60), a DASH diet with salt restriction group (DDG, n = 60), or a MedDiet with salt restriction group (MDG, n = 60). The primary outcome was the attained office systolic BP difference among the randomized arms during follow-up.

RESULTS

A total of 240 patients were enrolled, while 204 (85%) completed the study. According to the intention-to-treat analysis, compared to the CG, office and 24 h ambulatory systolic and diastolic BP were reduced in all intervention groups. A greater reduction in the mean office systolic BP was observed in the MDG compared to all other study groups (MDG vs. CG: mean difference = -15.1 mmHg; MDG vs. SRG: mean difference = -7.5 mmHg, and MDG vs. DDG: mean difference = -3.2 mmHg, all P-values <0.001). The DDG and the MDG did not differ concerning the office diastolic BP and the 24 h ambulatory systolic and diastolic BP; however, both diets were more efficient in BP-lowering compared to the SRG.

CONCLUSIONS

On a background of salt restriction, the MedDiet was superior in office systolic BP-lowering, but the DASH and MedDiet reduced BP to an extent higher than salt restriction alone.

Association between adherence to the Mediterranean diet with cardiometabolic risk factors: a cross-sectional study on PERSIAN cohort study in Fasa

The relationship between Mediterranean diet and obesity-related markers is a matter of debate. We investigated the association between adherence to the Mediterranean diet and anthropometric indices, body composition, and cardiometabolic risk factors in Iranian population. The cross-sectional study was performed on data of 3386 participants from Fasa PERSIAN cohort study. The Mediterranean diet score (MDS) was calculated based on consumption of 11 food groups (unrefined cereals, potatoes, fruits, vegetables, legumes, fish, red meat, poultry, dairy, olive oil, and alcoholic beverages). The association between MDS and cardiometabolic risk factors was examined by linear regression analysis. MDS was inversely associated with waist circumference (β =  - 1.11; P = 0.033), waist-to-hip ratio (β =  - 0.007; P = 0.011), waist-to-height ratio (β =  - 0.009; P = 0.015), fasting glucose (β =  - 3.59; P = 0.001), and HDL-cholesterol (β =  - 0.96; P = 0.031) in unadjusted model. After adjusting for energy intake, the associations of MDS with markers of abdominal obesity and HDL-cholesterol disappeared. In fully adjusted model, MDS showed inverse relationships with waist-to-hip ratio (β =  - 0.005; P = 0.037) and fasting glucose (β =  - 2.71; P = 0.013). In conclusion, MDS showed an inverse relationship with fasting glucose and waist-to-hip ratio. Since energy intake increased along with increasing MDS, adherence to the Mediterranean diet may associate with lower abdominal obesity and better glycemic control if an energy-controlled Mediterranean diet is used.

Postpartum Depression Is Associated with Maternal Sociodemographic and Anthropometric Characteristics, Perinatal Outcomes, Breastfeeding Practices, and Mediterranean Diet Adherence

Postpartum depression, with a prevalence ranging between 14% and 25% worldwide, has been considered an urgent health concern that negatively affects both mothers' and their infants' health. Postpartum depression may negatively affect maternal sociodemographic and anthropometric parameters and lifestyle factors. Nutrition has recently been identified as a crucial factor for the management and co-treatment of postpartum depression. This survey aims to determine the possible association of postpartum depression with mothers' socio-demographic and anthropometric characteristics, perinatal outcomes, breastfeeding practices, and Mediterranean diet (MD) adherence.

METHODS

This is a cross-sectional survey, which was performed on 3941 women during the postpartum period. Postpartum depression was assessed by the Edinburgh Postnatal Depression Scale (EPDS). Anthropometric parameters and perinatal outcomes were retrieved from mothers' medical records. Sociodemographic data and breastfeeding practices were recorded by face-to-face interviews between enrolled mothers and trained personnel. Mediterranean diet adherence was assessed by MedDietScore. Both univariate and multivariate binary logistic regression were applied for analyzing our data.

RESULTS

Postpartum depression was significantly associated with lower educational level, Greek nationality, higher prevalence of multiparity and overweight/obesity postpartum, higher incidence of caesarean section and not breastfeeding, and lower levels of MD adherence. In multivariate analysis, postpartum depression was independently associated with mothers' educational level, postpartum BMI status, type of delivery, breastfeeding practices, and MD adherence after adjusting for multiple confounding factors.

CONCLUSIONS

This study has provided evidence that elevated MD compliance was related to a decreased risk of postpartum depression. Additionally, postpartum depression was associated with multiple sociodemographic and anthropometric parameters, perinatal outcomes, and breastfeeding practices. Future well-designed, prospective studies with high-quality methodology should be performed to obtain conclusive results.

Limosilactobacillus reuteri consumption significantly reduces the total cholesterol concentration without affecting other cardiovascular disease risk factors in adults: A systematic review and meta-analysis

As one of the most significant probiotics, Limosilactobacillus reuteri (L. reuteri) has been exploited as a nutritional supplement. We hypothesized that L. reuteri consumption might improve the significant risk factors of cardiovascular disease, including blood pressure, blood lipid, and blood glucose. However, previous clinical studies have shown controversial results. This study aims to explore the effect of L. reuteri consumption on these risk factors. PubMed, Embase, Scopus, the Cochrane Library, and Web of Science were searched for eligible randomized controlled trials published before May 2022. A total of 6 studies with 4 different L. reuteri strains and including 512 participants were included. The results showed that L. reuteri consumption significantly reduced total cholesterol (TC) by -0.26 mmol/L compared with the control group. In contrast, it did not affect systolic blood pressure, diastolic blood pressure, fasting blood glucose, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDL-C), or triglycerides. Subgroup analysis showed a significant reduction in TC when participants were <55 years old, had a body mass index between 25 and 30, or had hypercholesterolemia. In addition, TC decreased significantly when L. reuteri supplementation was >5 × 109 colony-forming unit or the length of the intervention was <12 weeks. Strain subgroup analysis showed that L. reuteri NCIMB 30242 significantly reduced TC and LDL-C. In conclusion, L. reuteri consumption has a significant TC-lowering effect, which can effectively reduce the risks of cardiovascular disease associated with hypercholesterolemia. However, the results do not support the effectiveness of L. reuteri consumption on other metabolic outcomes. Further examination of larger sample sizes is needed to confirm these findings.

Adherence to the Mediterranean Diet during Pregnancy: Associations with Sociodemographic and Anthropometric Parameters, Perinatal Outcomes, and Breastfeeding Practices

Background and Objectives: The Mediterranean diet (MD) has been recognized as a beneficial nutritional pattern that promotes human health, decreasing the risks of a variety of human disorders and pathological states, including adverse pregnancy outcomes. In this aspect, the current survey aimed to assess the potential association of compliance with the MD during gestation with various sociodemographic and anthropometric parameters, perinatal outcomes, and breastfeeding practices. Materials and Methods: This was a cross-sectional study performed on 5688 pregnant women from 10 distinctive Greek areas. Face-to-face interviews with qualified questionnaires and thorough retrievals of medical records were performed to collect data concerning the participants' sociodemographic and anthropometric parameters, perinatal outcomes, and breastfeeding practices. Results: Elevated compliance with the MD during pregnancy was independently related with older age, higher educational status, and better economic status as well as decreased incidences of pre-pregnancy overweight/obesity and excess gestational weight gain and a lower likelihood of gestational diabetes. Moreover, greater adherence to the MD was independently associated with an increased prevalence of delivering vaginally and a greater prevalence of exclusive breastfeeding for at least 16 weeks postpartum. Conclusions: A higher level of compliance with the MD for the period of gestation was associated with several favorable lifestyle factors that may promote maternal health. Further studies with a prospective design as well as studies exploring the potential effects of maternal compliance with the MD for the period of pregnancy on the health of children should be performed. Future studies should also be extended beyond the MD by assessing the potential beneficial effects of adopting a Mediterranean lifestyle on maternal and child health.

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.

Brain Injury: How Dietary Patterns Impact Long-Term Outcomes

Purpose of Review

Individuals with a history of traumatic brain injury (TBI) are at a much greater risk for developing cardiovascular disease (CVD) compared to the general population. This review discusses dietary patterns as a means of addressing modifiable risk factors following TBI exposure. Evidence-based resources for practicing Physiatrists and Brain Injury Medicine specialists pertaining to nutrition education and counseling are also provided.

Recent Findings

We examined Mediterranean, Dietary Approaches to Stop Hypertension, plant-based, ketogenic, and intermittent fasting dietary patterns through publications of clinical trials and systematic reviews. While many reviews had significant positive findings, some were limited by generalizability.

Summary

While there is extensive literature on the immediate nutrition goals in the inpatient setting following an acute TBI exposure, there is limited literature discussing the nature of diet and nutrition in the post-acute setting. Fortunately, most individuals with TBI exposure survive their initial injury and continue into the recovery phase. The scientific literature supports increased morbidity and mortality with chronic TBI exposure compared to matched counterparts, most notably with CVD. A diet rich in fiber and nutrients but limited in added sugars, saturated fats, and excess calories would likely have the greatest cardiovascular and related neurologic protection. Future studies are needed to assess the specific impact of dietary interventions in the chronic phase of brain injury recovery.

Mediterranean diet lowers all-cause and cardiovascular mortality for patients with metabolic syndrome

A Mediterranean-style diet (MED) can promote people lengthen the span of life and avoid atherosclerotic cardiovascular disease (ASCVD) in primary prevention. Metabolic syndrome (MetS) can significantly reduce life expectancy and increase the risk of ASCVD. However, few studies have focused on the role of the Mediterranean diet in patients with MetS. Participants in the National Health and Nutrition Examination Survey (NHANES) with MetS (N = 8301) from 2007 to 2018 were examined. A 9-point evaluation scorewas used to measure the degree of adherence to the MED diet. In order to compare the various levels of adherence to the MED diet and the effects of the specific MED diet components on all-cause and cardiovascular mortality, Cox regression models were utilized. Among the 8301 participants with MetS, about 13.0% (1080 of 8301) died after a median follow-up of 6.3 years. In this study, participants with MetS with adherence to high-quality and moderate-quality Mediterranean diet were significantly associated with lower all-cause mortality as well as cardiovascular mortality during the follow-up period. Futhermore, in joint analysis of the Mediterranean diet and sedentary behavior or depression, we found that high-quality or moderate-quality Mediterranean diet could attenuate, even reverse the adverse effects of sedentary behavior and depression on all-cause and cardiovascular mortality in participants with MetS. Among the components of the MED diet, greater intakes of vegetables, legumes, nuts and high MUFA/SFA ratio were significantly associated with lower all-cause mortality and greater vegetables intake was significantly associated with lower cardiovascular mortality, while more red/processed meat intake was significantly associated with higher cardiovascular mortality in participants with MetS.

Mediterranean Diet and Sarcopenia Features in Apparently Healthy Adults over 65 Years: A Systematic Review

Low muscle mass combined with changes in physical function and muscle quality is defined as sarcopenia. In people > 60 years, sarcopenia reaches 10% and tends to increase with age. Individual nutrients, such as protein, may have a protective role against sarcopenia, but recent evidence suggests that protein alone has been ineffective in increasing muscle strength. Dietary patterns, instead, with a high "anti-inflammatory" potential, such as the Mediterranean dietary pattern, have been considered as an emerging dietary remedy against sarcopenia. The aim of this systematic review was to summarize the evidence of the role of Mediterranean diet in sarcopenia prevention and/or improvement, including recent data, in healthy elders. We searched published studies about sarcopenia and the Mediterranean diet until December 2022 in Pubmed, Cochrane, Scopus search engine and grey literature. In total, ten articles were identified as relevant: four cross-sectional studies and six prospective. No clinical trial was identified. Only three studies assessed sarcopenia presence and four measured muscle mass, which is an essential criterion in sarcopenia diagnosis. Mediterranean diet adherence had, in general, a positive role in muscle mass and muscle function, while the results were less clear with regard to muscle strength. Additionally, there was no evidence of a positive effect of the Mediterranean diet on sarcopenia. There is a need for conduction of clinical trials in order to reach cause-effects conclusions regarding the importance of the Mediterranean diet in sarcopenia prevention and management in Mediterranean and non-Mediterranean populations.

Dietary Antioxidants, Quality of Nutrition and Cardiovascular Characteristics among Omnivores, Flexitarians and Vegetarians in Poland-The Results of Multicenter National Representative Survey WOBASZ

Several reports have shown that more plant-based dietary patterns provide a higher intake of antioxidants compared to diets rich in meat and animal products. Data on the intake of key nutrients in cardiovascular disease (CVD) prevention in relation to particular diets in countries of Central and Eastern Europe are scarce. The aim of this study was to assess quality of nutrition and CVD characteristics in a representative sample of Polish adults following different dietary patterns. Special regard was paid to the intake of natural antioxidants. The study comprised 13,318 (7159 females) randomly selected adults aged ≥ 20 years participating in the National Multicentre Health Surveys WOBASZ and WOBASZ II. The subjects were categorized into groups of omnivores (92.4%), flexitarians (7.4%) and vegetarians (0.16%) according to type of diet using the Food Frequency Questionnaire and 24 h dietary recall. The obtained results showed that neither flexitarians nor vegetarians represented better dietary habits or lifestyle behaviors compared to omnivores. Flexitarians had significantly lower daily energy intake than omnivores, but their diet was rich in total fat (above 30% of daily energy consumption) and low in fiber. Omnivores declared a higher consumption of fresh vegetables (p < 0.001), fresh fruit (p < 0.01), coffee (p < 0.01) and tea (p < 0.05, in women only) than flexitarians. Omnivores had significantly higher intake of natural antioxidants (vitamin C, E, zinc in both genders and vitamin A in men) as compared with flexitarians. Among women, the highest adherence to the intake of recommended amounts of antioxidant nutrients was noted among omnivores. Among men, vegetarians had the highest proportion of meeting the guidelines for vitamin A (77.8%), E (66.7%) and C (66.7%), while the lowest proportions were found in flexitarians (69.9%, 39.5% and 32.4%, respectively). The groups did not differ in terms of smoking and physical activity level. There were no significant differences in the analyzed CVD characteristics between omnivores and flexitarians. In women, vegetarians had substantially lower BMI than omnivores (p < 0.05) and flexitarians (p < 0.05) and a lower mean serum glucose compared with omnivores (p < 0.01) and flexitarians (p < 0.05). Vegetarians had lower prevalence of hypertension and obesity than meat eaters. In conclusion, the results of the current research showed an inappropriate intake of several nutrients, including highly potent antioxidants, irrespective of the dietary regimen. Flexitarians did not have a more favorable CVD profile than omnivores. Taking into account the growing popularity of diets with reduced animal products, there is a need to elaborate strategies providing Polish adults with guidance regarding properly balanced nutrition.