Not all plant-based diets are associated with benefits on mortality: the Moli-sani Study

Background

Vegetarians diets are characterized by the absence of some animal foods (e.g. red and processed meats), and a high consumption of plant-based foods. However, plant-based foods can include foods with varying nutritional value and health effects. We examined the association of three different pro-vegetarian (PVG) food patterns defined as general (gPVG), healthful (hPVG) and unhealthful (uPVG), with the risk of all-cause and cardiovascular disease (CVD) mortality in Italians.

Methods

Longitudinal analysis on 22,912 men and women (mean age 55±12 y) from the Moli-sani Study (2005-2010) followed up for 11.2 y (median). Food intake was assessed by a 188-item FFQ. A provegetarian food pattern (FP) was constructed by assigning positive scores to plant foods and reverse scores to animal foods. A healthful and an unhealthful pro-vegetarian FP, which distinguished between healthy (e.g. fruits, vegetables, legumes) and less-healthy plant foods (e.g. fruit juices, potatoes, sugary beverages), were also built up.

Results

In multivariable-adjusted analyses controlled for known risk factors, higher adherence to a gPVG was associated with lower all-cause (HR = 0.83; 95%CI 0.73-0.94) but not CVD mortality (HR = 0.90; 0.72-1.12). Increasing adherence to a hPVG was associated with reduced all-cause mortality risk (HR = 0.82; 0.72-0.95) as well as lower risk of CVD mortality (HR = 0.75; 0.59-0.95). Finally, the uPVG was directly associated with both all-cause (HR = 1.17; 1.03-1.33) and CVD mortality risks (HR = 1.23; 0.99-1.53).

Conclusions

A general pro-vegetarian food pattern was associated with longer survival in Italians. Preferring healthful vegetarian foods provided protection against CVD mortality too. Consistently, a large dietary share of unhealthful vegetarian foods, mostly highly processed, was associated with increased risk mortality. Thus the quality of the plant food consumed is paramount to achieve diet-related benefits on mortality.

Key messages

• A pro-vegetarian food pattern was associated with longer survival but preferring healthful vegetarian foods provided protection against CVD mortality too.

• The quality of the plant food consumed is paramount to achieve diet-related benefits on mortality.

Gender and socioeconomic inequalities in changes in a Mediterranean lifestyle among elderly Italians

The COVID-19 pandemic and the adoption of restrictive measurements to control the SARS-CoV-2 spread disrupted general population lifestyles including dietary behaviours. However, there is poor knowledge on potential socioeconomic and gender disparities in dietary changes. We conducted a telephone-based survey during fall 2020 on a sample of 4,400 participants representative of the population aged 65-99 years living in Lombardy, Italy. Changes in a Mediterranean lifestyle were assessed retrospectively by asking participants to report modifications in the consumption of nine food groups and five diet-related behaviours (e.g., consumption of organic and local foods) compared to the previous year (2019). We then computed a Mediterranean COVID-19 Pandemic Score (MedCovid-19 Score), reflecting changes during pandemic, ranging from -14 to 14, with increasing values indicating improvements in line with a Mediterranean lifestyle. Overall, 18.3% of the study participants worsened their Mediterranean lifestyle (MedCovid-19 Score <0), 35.1% remained stable (MedCovid-19 Score = 0), while 46.6% reported improvements (MedCovid-19 Score ≥1). Predictors of favourable changes toward a Mediterranean lifestyle were educational level (OR = 1.52; 95% CI 1.19-1.95 for postgraduate vs lower education), wealth (OR = 1.52; 1.14-2.02 for high vs low wealth), and skilled manual occupations (OR = 1.57; 1.28-1.92 vs white collars). Women were more likely than men to move away from a Mediterranean lifestyle (OR = 1.86; 1.58-2.21). In conclusion, improvements in line with a Mediterranean lifestyle prevailed in almost half of a large sample of elderly Italians surveyed during the COVID-19 pandemic. However, changes towards a Mediterranean lifestyle were disproportionately distributed across gender and socioeconomic strata. These findings were similar to those from the general population of the Moli-sani study, where it was observed that healthful dietary changes were associated greater wealth.

Dietary factors and risk of SARS-CoV-2 infection in the Moli-sani Study Cohort

Background

A healthy diet plays a major role in supporting the immune system which is critical to protect the host from pathogenic organisms. To date, evidence on the relationship between dietary habits and the risk of SARS-CoV-2 infection is still scarce.

Methods

Analyses on 1,096 participants from the Moli-sani Study (2005-2010) who were re-examined in 2017-2020, and in January-September 2021. Food intake was assessed in 2017-2020 using a 188-item FFQ. Adherence to Mediterranean diet (MD) was evaluated using the Mediterranean Diet Score (MDS) ranging from 0 to 9. Multivariable logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (95%CI) for incident SARS-CoV-2 infection in association with dietary factors.

Results

Out of 1,096 participants, 90 either reported to have tested positive for COVID-19 or were positive for anti-SARS-CoV-2 antibodies before receiving any COVID-19 vaccine. In a multivariable-adjusted model controlled for known risk factors, a 1-point increase in MDS was associated, though not significantly, with lower risk of SARS-CoV-2 infection (OR = 0.90; 95%CI 0.78-1.04). Among individual dietary components, a high consumption of vegetables or fruits and nuts was associated with lower odds of SARS-CoV-2 infection (OR = 0.57; 0.34-0.96 and OR = 0.61; 0.37-1.00, respectively). High fish intake was otherwise linked to increased risk of infection (OR = 2.05; 1.25-3.36). Nutritional factors associated with reduced risk of infection were dietary fibre (OR = 0.50; 0.27-0.93 for 10 g/d increase), vegetable proteins (OR = 0.56; 0.33-0.94 for 10 g/d increase) and vitamin C (OR = 0.94; 0.89-0.99 for 10 g/d increase).

Conclusions

Adherence to MD was suggestive of a lower risk of SARS-CoV-2 infection. In particular, large amounts of fruit and vegetables were associated with reduced odds of being infected, as well as diets rich in fibre, vegetable proteins and Vitamin C.

Key messages

Nutritional and non-nutritional dietary factors affecting obesity and chronic related disorders

There is convincing evidence that diet quality represents one of the most important public health targets to prevent non-communicable diseases. Dietary risks alone have been estimated to be responsible for about 10 million deaths due to cardiovascular diseases, metabolic disorders, and certain cancers worldwide, with trends not expected to decrease. Results from meta-reviews and expert assessments are quite in line with robust key messages to deliver to the general public. From a nutritional point of view, lack of fibre, vitamins and antioxidants, and unsaturated fatty acids together with high content in free added sugars, sodium, and saturated/trans fats represent key features for unhealthy dietary patterns and are responsible for most diet-related non-communicable diseases. While the role of animal-derived foods is still controversial due to the registered excess consumption and the environmental impact, a general low intake of plant-derived foods remains a major detrimental factor for health. The concept of diet quality should thus overcome the over simplistic calorie-count when coming to prevent obesity and related non-communicable diseases, while an adequate communication on this matter to the public is highly warrant. Together with these general dietary recommendations relying on nutritional aspects affecting human health, emerging evidence is now also exploring the role of non-nutritional dietary factors. The level of processing, the alteration of the food matrix, the presence of additives (such as flavor enhancers, colorants, emulsifiers, artificial sweeteners, thickeners, foaming/anti-foaming agents, and preservatives) have been demonstrated to play a role in metabolic health and inflammatory-related disorders. These aspects are currently under investigation, but they might represent an underrated concern for public health due to the food market drive and a perfect fit into the obesogenic modern society.

Ultra-processed food consumption and survival in older Italians from the Moli-sani Study

Background

Ultra-processed food (UPF) is a major public health concern being reportedly associated with increased risk of non-communicable diseases and lower survival. However, most of the epidemiological evidence has been almost exclusively provided by research conducted in populations of youths or middle-aged adults. We tested the hypothesis that a large dietary share of UPF could be a risk factor also for vulnerable groups, as older adults (≥65 years).

Methods

Longitudinal analysis on 5,215 men and women (mean age 72±5 y) from the Moli-sani Study (2005-2010, Italy) followed up for 10.9 y (median). Food intake was assessed by a 188-item FFQ. UPF was defined using the NOVA classification according to degree of processing, and categorized as quartiles of the ratio (%) between UPF (g/d) and total food consumed (g/d; weight ratio). The overall nutritional quality of the diet was measured by the Food Standard Agency nutrient profiling system dietary index (FSAm-NPS DI).

Results

UPF contributed to 8% (min-max 0.0-58.4%) of the total food eaten daily and represented 14.4% (0.0-70.0%) of daily energy intake. In multivariable-adjusted analyses controlled for known risk factors, higher intake of UPF (Q4, ≥10.2% of total food), as opposed to the lowest (Q1, UPF&lt;4.3%), was associated with increased all-cause mortality (Hazard ratio [HR]=1.19; 95%CI 1.03-1.39); these results remained unchanged after adjustment for the FSAm-NPS DI (HR = 1.21; 95%CI, 1.04-1.41). A linear dose-response relationship of 1% increment in UPF intake with all-cause mortality was also observed (p = 0.017; p for non-linearity=0.85).

Conclusions

A large dietary share of UPF was associated with lower survival in older Italians consuming relatively low amounts of these foods. Expanding on previous studies on different age groups, these findings provide further justification to advise people to limit consumption of UPF even at older age.

Key messages

• A large dietary share of ultra-processed food was associated with lower survival in older Italians consuming relatively low amounts of these foods.

• These findings provide further justification to advise people to limit consumption of ultra-processed food even at older age.

Adherence to the Mediterranean Diet during COVID-19 national lockdowns: a systematic review

Background

The Mediterranean Diet (MD) is one of the healthy eating plans recommended to promote health and prevent chronic diseases. During the COVID-19 pandemic, many countries adopted restrictive measures to mitigate infection spread, which might have influenced people's lifestyle and dietary habits. We conducted a systematic review to evaluate the impact of stay-at home orders' implementation on adherence to MD.

Methods

Studies were identified searching Medline, Embase, and Web Of Science, the search strategy was developed using a combination of free text and mesh terms referring to COVID-19 pandemic, lockdown, and MD. Studies published until March 31st, 2021 were included. We only considered studies reporting original data from quantitative analysis and assessing modifications of adherence to the MD through validated dietary scores or any change in consumption of food categories that are typically ascribed to the MD. Data extraction, pooling and quality appraisal of the included studies, were conducted applying PRISMA guidelines.

Results

42 studies were retrieved. After duplicates removal, and in-blind two-step screening, 10 studies met our a priori defined inclusion criteria and were included in the review. 71.4% of the studies reporting a rate of change in adherence, measured through validated questionnaire both before and during lockdown, reported an increase, while 28.6% reported no significative changes. All included studies reporting the percentage of participants having a high adherence to the MD, based on their results on MEDAS questionnaire, before and during the lockdown, found an increase in this percentage.

Conclusions

Adherence to the MD could have raised in people undergoing lockdowns due to COVID-19.

Key messages

The impact of restrictive measures on determinants of health must be monitored.

Despite the literature suggests adherence to MD has declined in the last years, this trend may have reversed or, at least, slowed during the initial phases of the current pandemic.

Moderate partially skimmed milk consumption is associated with reduced mortality risk

Background

Data on milk and other dairy products intake with health outcomes are inconsistent. We investigated the association of milk and total dairy consumption with the risk of all-cause and cause-specific mortality in a Mediterranean population.

Methods

We performed a longitudinal analysis on 22,889 men and women (mean age 55.4±11.7 y; 52.3% women), from the Moli-sani Study cohort (enrollment 2005-2010) followed-up for a median of 11 years. Dietary data were collected through a 188-item food frequency questionnaire. Total dairy consumption (g/d) was calculated as the sum of milk (whole and partially-skimmed, g/d), yogurt (whole and partially skimmed, g/d) and cheese (fresh and hard, g/d). Hazard ratio (HRs) with 95% confidence interval (CI) were calculated by multivariable Cox regression, modelled by spline curves.

Results

In multivariable-adjusted analysis controlled for sociodemographic, clinical and dietary factors, cheese, yogurt or whole milk intake were not associated with either all-cause or cause-specific mortality (p for overall association &gt;0.38), as well as was total diary intake (p &gt; 0.18). On the contrary, non-linear J-shaped curves were observed for the association of partially skimmed milk intake with all-cause and cancer mortality (p value for total and non-linear association=0.0072 and 0.035, and 0.097 and 0.049, respectively; magnitude of the relative reduction =16% and 18% at nadir of 128 and 114 g/d, respectively). A linear association between partially skimmed milk intake and CVD mortality was observed (p for association =0.047; p for non-linearity= 0.41), with HR = 0.82 (95%CI: 0.68-0.98) at 125 g/d and a window of statistically significant protection ranging from 100 to 250 g/d.

Conclusions

In a large Mediterranean population of adults, consumption of 1 standard cup of partially skimmed milk was associated with lower all-cause, cancer and CVD mortality. Other dairy sources were not associated with mortality.

Key messages

In a large Mediterranean population, total dairy intake did not predict mortality. Daily consumption of 1 standard cup of partially skimmed milk lowers the risk of all-cause, cardiovascular and cancer mortality.

Psychological distress from the COVID-19 confinement is associated with unhealthy dietary changes

Background

The confinement due to COVID-19 pandemic had adverse effects on mental health, but the relation between psychological distress resulting from lockdown measures and dietary habits needs to be elucidated.

Methods

We analysed 2,741 subjects (mean age 58.1±15.3 y) pooled from 2 retrospective Italian cohorts recruited from May to September 2020: 1) The Moli-LOCK cohort consists of 1,401 adults, a portion of the larger Moli-sani Study (n = 24,325) who were administered a telephone-based questionnaire to assess lifestyles and psychological factors during confinement; 2) the ALT RISCOVID-19 is a web-based survey of 1,340 individuals distributed throughout Italy who self-responded to the same questionnaire by using Google® forms. Psychological distress was measured by assessments of depression (PHQ-9), anxiety (GAD-7), stress (PSS-4), and post-traumatic stress disorder (PTSD). Diet quality was assessed either as changes in consumption of ultra-processed foods (UPF) or adherence to Mediterranean diet (MD).

Results

In a multivariable regression analysis controlled for major sociodemographic factors, depression (β=-0.06, 95%CI -0.10, -0.01), anxiety (β=-0.05, -0.09, -0.004) and PTSD (β=-0.04, -0.08, -0.002) were inversely associated with MD and directly with UPF (β = 0.13, 0.09, 0.18; β = 0.12, 0.08, 0.16 and β = 0.10, 0.06, 0.13, respectively); stress was associated with UPF (β = 0.06, 0.02, 0.10) but not with MD (β=-0.03, -0.08, 0.01).

Conclusions

Psychological distress resulting from confinement due to the COVID-19 pandemic is directly associated with unhealthy dietary modifications in a sample of the Italian population. In view of possible future restrictive measures, particular attention should be paid to public health actions promoting psychological support to more vulnerable groups.

Key messages

Psychological distress resulting from confinement due to the COVID-19 pandemic is directly associated with unhealthy dietary modifications.

Particular attention should be paid to public health actions promoting psychological support to more vulnerable groups also in view of future restrictive measures to contain the pandemic spread.

Economic hardship from the great recession and long-term changes in depression and quality of life

Background

Economic downturns may have detrimental effects on mental health. We investigated whether economic hardship resulting from the late 2000s great recession is associated with long-term changes in mental health over 12.8 years of follow up.

Methods

We analysed data on 2,001 participants from the CASSIOPEA Study, a sub-cohort of the larger Moli-sani study (2005-2010, Italy), who were re-examined between 2017-2020 (mean age at baseline 53±9 y; 55% women). Economic hardship possibly experienced since participants' first visit was assessed retrospectively by a questionnaire scoring the following domains: 1) change in employment status; 2) financial hardship and 3) financial hardship for health expenditures. An Economic Hardship Score (EHS) was computed (range 0-14), with highest values indicating higher economic hardship. Mental health was reflected by measurements of depression (Patients' Health Questionnaire; PHQ-2; higher values indicating more depressive symptoms) and mental quality of life assessed by the 36-Item Short Form Health Survey (increased values indicating improved quality of life). In this analysis, the exposure was economic hardship and the outcomes were changes in depression and mental quality of life measured after a 12.8-y period. Multivariable linear regression analysis (95%CI) was used.

Results

Mean PHQ-2 and SF36 changes over 12.8 years were -0.08 (±1.28) and 0.47 (±9.90), respectively.

In a multivariable-adjusted analysis including duration of follow-up, relevant sociodemographic factors, lifestyles, clinical factors and related life course changes, 1-point increment in EHS was associated with increased depression (β = 0.041; 95%CI 0.022, 0.060) and lower mental quality of life (β=-0.037; 95%CI -0.052, -0.021).

Conclusions

Economic hardship resulting from the great recession in late 2000s was associated with a deterioration of mental health, as reflected by increased depression levels and reduced mental quality of life.

Key messages

Economic hardship resulting from the recession in late 2000s is associated with a deterioration of mental health. These findings support the notion that economic downturns may have detrimental effects on mental health and support the need for adequate strategies for more vulnerable groups.

Ultra-processed food consumption modifies the association of Nutri-Score with all-cause mortality

Background

The Nutri-Score front-of-pack label rates foods according to their nutritional quality while the NOVA classification is focused on degree of processing; both systems separately predicted mortality in epidemiological contexts. We evaluated whether ultra-processed food (UPF) modifies the association of the Nutri-Score with mortality.

Methods

Longitudinal analysis on 22,549 Italian men and women (mean age 54±12 y) from the Moli-sani Study (2005-2010) followed for 11.2 y. Food intake was assessed by a food frequency questionnaire. The Food Standards Agency nutrient profiling system (FSAm-NPS) score, used to derive the Nutri-Score, was calculated for each food based on its amount of energy, saturated fat, sugar, sodium, fibre, protein, fruits, vegetables, legumes and nuts per 100 g of product. The FSAm-NPS dietary index was calculated for each participant as an energy weighted mean of the FSAm-NPS score of all foods consumed, and increased values indicate lower nutritional quality. UPF intake was the proportion (%) of UPF in the total weight of food consumed (g/d) and categorized as low/high (below/above the population median, respectively).

Results

In a multivariable analysis, 1-SD increase in the FSAm-NPS index led to increased risk of all-cause (HR = 1.07; 95%CI 1.02-1.13) and CVD mortality (HR = 1.08; 1.00-1.18). UPF intake was an effect modifier since the association of FSAm-NPS index with mortality was confined to individuals with high UPF intake (HR = 1.14; 1.05-1.25) but not in those with low UPF (HR = 1.00; 0.93-1.07; p for interaction=0.034). Similar findings were reported for CVD mortality (HR = 1.14;0.99-1.31 and HR = 1.01;0.90-1.13 for high and low UPF consumers, respectively; p for interaction=0.18).

Conclusions

Higher mortality risk associated with a NutriScore revealing nutrient-poor food intake is limited to individuals also reporting high UPF intake. Food labelling systems should account for food processing in addition to nutritional content.

Key messages

Ultra-processed food modifies the association between the 5-color Nutri-Score front-of-pack label with all-cause mortality in an Italian general population. Food labelling systems, that are conceived to help consumers make healthier food choices, should also account for food processing in addition to nutritional content.

Consumption of ultra-processed foods and health status: a systematic review and meta-analysis

Increasing evidence suggests that high consumption of ultra-processed foods (UPF) is associated with an increase in non-communicable diseases, overweight and obesity. The present study systematically reviewed all observational studies that investigated the association between UPF consumption and health status. A comprehensive search of MEDLINE, Embase, Scopus, Web of Science and Google Scholar was conducted, and reference lists of included articles were checked. Only cross-sectional and prospective cohort studies were included. At the end of the selection process, twenty-three studies (ten cross-sectional and thirteen prospective cohort studies) were included in the systematic review. As regards the cross-sectional studies, the highest UPF consumption was associated with a significant increase in the risk of overweight/obesity (+39 %), high waist circumference (+39 %), low HDL-cholesterol levels (+102 %) and the metabolic syndrome (+79 %), while no significant associations with hypertension, hyperglycaemia or hypertriacylglycerolaemia were observed. For prospective cohort studies evaluating a total population of 183 491 participants followed for a period ranging from 3·5 to 19 years, highest UPF consumption was found to be associated with increased risk of all-cause mortality in five studies (risk ratio (RR) 1·25, 95 % CI 1·14, 1·37; P < 0·00001), increased risk of CVD in three studies (RR 1·29, 95 % CI 1·12, 1·48; P = 0·0003), cerebrovascular disease in two studies (RR 1·34, 95 % CI 1·07, 1·68; P = 0·01) and depression in two studies (RR 1·20, 95 % CI 1·03, 1·40; P = 0·02). In conclusion, increased UPF consumption was associated, although in a limited number of studies, with a worse cardiometabolic risk profile and a higher risk of CVD, cerebrovascular disease, depression and all-cause mortality.

Health benefits of Mediterranean and non-Mediterranean dietary pattern in different cultural contexts

Description of the problem

The increasing globalization of diet and dietary habits resulting from the large availability and diversity of food poses new questions for the actual health benefits of different dietary patterns in populations not traditionally exposed to a certain dietary model. Consuming a traditional Mediterranean diet (MD) has been found to be associated with lower mortality/disease risk also in non-Mediterranean populations but it is unclear whether healthful non-Mediterranean (non-MD) diets may reflect protective dietary patterns in Mediterranean populations.

Results

Data from the Moli-sani Study showed that participants reporting high adherence to the MD or the DASH diet experienced lower risk of both all-cause and CVD death risks. On the other side, risk reduction associated with the Palaeolithic diet was limited to total and other cause death, whereas the Nordic diet did not alter risk of mortality. Increasing adherence to MD was also associated with higher survival in each stratum of non-MD diets, suggesting that a closer high adherence to a traditional MD may counterbalance the weak effects on CVD mortality risk associated with non-MD diets. Similarly, data form the Swedish Mammography Cohort indicated an advantage to be adherent to the MD as compared to a healthy Nordic diet.

Conclusions

From a public health perspective, these data provide further incentive and support to the efforts aimed to preserving a traditional MD in order to prolong survival among Mediterranean populations, and to reduce CVD mortality risk. Evidence on the health effects deriving from classifying participants in joint exposure strata reflecting the combined adherence to different diets is scarce but more efforts should be made to see whether, at a time of food globalization, healthy dietary patterns are possibly interchangeable among populations.

Psychological resilience and cardiovascular disease? A systematic review of the literature

Background

Psychosocial resilience is the capacity of responding positively to stressful events in life. We performed a systematic review of the literature to find whether resilience has any protective effect on cardiovascular disease (CVD) or mortality.

Methods

We searched Pubmed and Prospero systematic Review Registry using terms resilience, psychological or resiliency or resilience or resilient or hardiness, cardiovascular or stroke or or myocardial infarction or CVD or mortality or hospitalization. The references of each included paper were also searched for relevant studies. Longitudinal studies conducted on all populations, in English, with no time restriction were searched. They were included in the review if they examined resilience as primary exposition, and mortality for all causes, mortality for CVD, CVD events and hospitalization as outcomes and if they were longitudinal.

Results

The search identified 1,471 studies, of which only 8 were retained and fully examined based on the study design reported in the abstract, and 3 met all the inclusion criteria. Two studies on 237,879 young Swedish men showed that lower resilience compared with the highest (scores from an interview) resulted associated with both coronary heart disease (HR = 2.61, 95%CI:2.52-2.70) and stroke risk (HR = 1.54, 1.40-1.70) in adulthood (follow up 23 yrs). A third study on 2,765 postmenopausal Afro-American women showed that a modified Brief Resilience Scale was not associated with CVDs (lowest vs highest quartile, HR = 0.95, 95%CI:0.63-1.42; follow up 12.5 yrs).

Conclusions

There is not sufficient evidence of a protective attitude of resilience towards CVD: only 3 studies were eligible, with heterogeneity in sample size, exposures to stressors and scales used to measure resilience, and with resilience data available only at baseline. Further studies are necessary, since resilience is a powerful concept, and, if proved protective, might be improved in populations to ameliorate CV health.

Key messages

No clear association between resilience and CVD risk has been shown in literature. This is the first systematic review on the topic and further research is needed to broaden our understanding of the relation between resilience and CVD.

Lifestyle and biological factors influence the relationship between mental health and low-grade inflammation

Mental health modulates the risk of common chronic conditions. Although inflammation is thought to partly explain this link, its relation with mental health is still unclear and largely unexplored. We investigated three scales assessing psychological resilience (CD-RISC), depression symptoms (PHQ9-6) and mental wellbeing (SF36-MCS) in an Italian adult population cohort (N_max = 16,952). This showed a slightly higher frequency of men, more educated and younger participants, compared to samples with incomplete questionnaires. We performed stepwise generalized linear models to test the association between each scale and INFLA-score, a composite blood-based inflammation index. At each step, a class of potential mediators was included in the model, namely health conditions, lifestyle factors, or both (full model). Full model analysis was also conducted on single blood markers involved in the inflammatory process. In the baseline model, we observed significant associations of PHQ9-6 (standardized β(SE) = 0.024(0.009), p = 8.9 × 10^-3) and SF36-MCS (β(SE) = -0.021(0.008), p = 7 × 10^-3) with INFLA-score. These associations survived adjustment for health conditions but not for lifestyle factors, which explained 81% and 17% of the association with PHQ9-6 and SF36-MCS. Significant associations (p < 4.2 × 10^-3) after mediator adjustment were observed for single low-grade inflammation markers, including platelet distribution width (with PHQ9-6 and CD-RISC), granulocyte- and neutrophil-to-lymphocyte ratios, monocyte and lymphocyte fractions (with SF36-MCS). After imputation of missing data, we observed substantially consistent associations. These findings suggest that the relationship between mental health and low-grade inflammation is largely influenced by lifestyle. However, the associations with specific biomarkers related to inflammation are partly independent and might be explained by biological factors.

Socioeconomic trajectories and risk of hospitalization in the Moli-sani Study cohort

Background

A life course approach was used to explore the impact of socioeconomic status (SES) on risk of hospitalizations for all-cause and for cardiovascular disease (CVD).

Methods

Longitudinal analyses on 19,999 subjects apparently free from CVD and cancer, recruited in the Moli-sani Study, Italy (2005-2010). Low and high SES in childhood, educational attainment (low/high) and SES during adulthood (measured by a score including material resources and dichotomized as low/high) defined the trajectories over life course. First hospital admissions were recorded by direct linkage with hospital discharge form registry. Hazard ratios (HR) with 95% confidence interval (95%CI) were calculated by multivariable Cox-regression.

Results

Over a median follow up of 7.3 y, we ascertained a total of 7,594 all-cause and 2,539 CVD hospitalizations. Poor childhood SES was associated with 11% and 17% increased risk of all-cause and CVD hospitalizations, respectively. Among subjects with poor childhood SES, an upward trajectory in education was associated with lower risk of hospital admission for all-cause (HR = 0.85; 95%CI 0.76-0.94) and CVD (HR = 0.78; 0.64-0.95), as opposed to subjects remained stably low (low education and adulthood SES). Individuals with high childhood SES, but not educational achievement, were at 26% increased risk of hospitalization for any cause, as compared to the stably high SES group, while failure to achieve both educational and material advancements was associated with 37% higher risk of CVD hospitalization.

Conclusions

In a large sample of healthy adults, social mobility (educational and/or material upward trajectories) was associated with lower incidence of hospital admissions for all-cause and CVD.

Key messages

Social mobility may counterbalance the negative health burden associated with low early-life SES. High SES in childhood poorly affects hospitalization risk if no additional achievements across life course occur.

Mediterranean diet and risk of first hospitalization for heart failure and atrial fibrillation

Background

We aimed to explore the association of a traditional Mediterranean diet (MD) with risk of first hospitalization for heart failure (HF) or atrial fibrillation (AF) in a population-based cohort from a southern Italian region.

Methods

Longitudinal analysis on 20,598 men and women (aged≥35 y) free from HF, AF and cardiovascular disease recruited in the Moli-sani Study (2005-2010). First hospital admissions for HF or AF were recorded by direct linkage with hospital discharge form registry. Dietary data were collected by the EPIC food frequency questionnaire, adherence to MD was appraised by the Greek Mediterranean diet score (MDS ranging 0-9). Hazard ratios (HR) with 95% confidence interval (95%CI) were calculated by multivariable Cox-regression.

Results

Over a median follow up of 8.2 y, we ascertained 661 HF events and 337 AF cases. A 2-point increase in the MDS was associated with a downward trend in the risk of developing HF (HR = 0.94;0.85-1.04) after adjustment for potential confounders, while no association was found with risk of AF (HR = 1.07;0.94-1.21). Analyses run separately by gender revealed that higher adherence to an MD was associated with lower risk of HF among women (HF = 0.83;0.72-0.95 for 2-point increase in the MDS) but not in men (HR = 1.07;0.93-1.22; p for interaction=0.011). No gender-related difference was observed for AF risk (p for interaction=0.62). Among women, higher intake of monounsaturated over saturated fats was associated with 38% (20% to 52%) lower risk of HF, while in men moderate alcohol intake was likely to reduce HF risk (HR = 0.87;0.70-1.08).

Conclusions

Closer adherence to a traditional MD is associated with lower risk of first hospitalization for HF among women but not in men. No association was found with risk of AF.

Key messages

A traditional MD reduces the risk of HF in women but not in men. Minor dietary changes inspired to a traditional MD could be valuable primary prevention measures for risk of HF.

Health-related quality of life and risk of hospitalization in a healthy general population

Background

The association of health-related quality of life (HRQL) with total and cardiovascular (CVD) hospitalization was assessed in a population-based cohort of apparently healthy subjects; several pathways possibly accounting for such associations were also tested.

Methods

Longitudinal analysis on 16,849 subjects free from CVD and cancer from the Moli-sani Study, Italy (2005-2010). HRQL was performed by the 36-Item Short Form Health Survey including both mental and physical domains. First hospital admissions were recorded by direct linkage with hospital discharge form registry. Hazard ratios (HR) with 95% confidence interval (95%CI) were calculated by multivariable Cox-regression.

Results

Over a median follow-up of 7.3 y, 6,061 all-cause, 1907 CVD, 431 IHD and 294 stroke hospital admissions were ascertained. The highest quintile of mental HRQL was associated with 23% (95%CI: 17% to 29%), 26% (15% to 36%) and 30% (5% to 48%) lower risk of total, CVD and IHD admissions to hospital, respectively, as compared to the lowest.

Risk estimates for physical health were 0.60 (0.56-0.65 for Q5 vs Q1), 0.57 (0.50-0.65) and 0.73 (0.55-0.97) for total, CVD and IHD hospital admissions, respectively. A downward trend with stroke hospitalizations was found for both mental and physical HRQL. Healthy behaviours explained up to 13% of the association between mental HRQL and IHD risk; inflammatory markers (i.e. C-reactive protein and white blood cell count)) accounted for a significant proportion (34%) of the association of physical HRQL with IHD hospitalizations.

Conclusions

In a large sample of disease-free subjects, not only physical, but also higher mental HRQL is associated with lower risk of total and CVD hospitalizations.

Key messages

HRQL adds meaningful information beyond traditional risk factors to the prediction of hospitalization. HRQL assessment may be useful in stratifying hospitalization risk among a general population of healthy adults.

Egg consumption and risk of total and cause-specific mortality in a Mediterranean population

Background

The relation between egg intake and health outcomes is controversial. We aimed to evaluate the association of egg consumption and risk of mortality in a large sample of an adult Mediterranean population.

Methods

We prospectively analyzed 22,849 men and women aged ≥35 y, recruited within the Moli-sani Study (2005-2010). Dietary data were collected by the EPIC food frequency questionnaire, egg intake was expressed as g/d and used as ordered quintiles. Hazard ratios (HR) with 95% confidence interval (95%CI) were calculated by multivariable Cox-regression and competing risk models.

Results

Over a median follow up of 8.2 y, a total of 1,237 deaths were ascertained. Mean weekly intake was 1.8 eggs (13 g/d) and regular consumers (27 g/d corresponding to more than 2 eggs per week) were more likely to report less risk factors (e.g. history of cardiovascular disease, diabetes, smoking habit). After adjustment for possible confounders, eating eggs &gt;2 times/week) was associated with increased risk of all-cause mortality (HR = 1.21; 95%CI 1.02-1.44 for Q4 vs Q1) and coronary heart disease/cerebrovascular mortality (HR = 1.51;1.04-2.18, for Q4 vs Q1) in a non-stepwise manner; eating more than three eggs per week increased risk of cardiovascular mortality by 33% (HR = 1.33;95%CI 1.00-1.76 for Q5 vs Q1), while no association was found with cancer death or mortality for other causes. Dietary cholesterol explained up to 37% of the excess of CVD mortality risk associated with the highest egg intake (&gt;3 eggs/week).

Conclusions

Regular egg intake (&gt;2 times/week) was associated with increased risk of CVD mortality in a general Mediterranean population, and part of this association was likely due to its cholesterol content.

Key messages

Eating egg regularly is not associated with health benefits, rather it appears to increase CVD mortality risk. High dietary cholesterol content is likely to be on the pathway between egg intake and increased CVD mortality.

Combined healthy lifestyle factors and risk of all-cause and cardiovascular first hospitalization

Background

We aimed to explore the association of combined healthy lifestyles with risk of first hospitalization for all-cause, cardiovascular disease (CVD), ischemic heart disease (IHD) and stroke in a southern Italian population-based cohort. We also investigated several biological mechanisms possibly on the pathway between lifestyles and health outcomes.

Methods

Longitudinal analysis on 23,161 men and women (aged≥35 y) recruited in the Moli-sani Study (2005-2010). We defined 4 healthy lifestyle factors as abstention from smoking; high adherence to Mediterranean diet; physical activity; absence of abdominal obesity. First hospital admissions for any and CVD-related causes were recorded by direct linkage with hospital discharge form registry. Hazard ratios (HR) with 95% confidence interval (95%CI) were calculated by multivariable Cox-regression.

Results

Over a median follow up of 7.2 y, we ascertained a total of 9,482 hospitalizations, 3,556 CVD, 939 IHD and 589 stroke-related hospital admissions.

Adherence to all four healthy lifestyles, compared with none or 1, was associated with lower risk of hospitalization for any cause (HR = 0.82; 0.74-0.90), CVD (HR = 0.81;0.69-0.95) and IHD (HR = 0.63; 0.44-0.90) and, to a less extent, with stroke hospitalizations. Inflammatory biomarkers (e.g. C-reactive protein) were likely to partly explain the association between lifestyles and all-cause (14%) or CVD (15%) hospitalizations, while inflammation played a leading role towards risk of IHD (30%) and stroke-related hospital admissions (21%).

Conclusions

The impact of combined 4 healthy lifestyles on first hospitalization risk was considerable. Inflammatory biomarkers explained a large proportion of this association.

Key messages

Improvements to lifestyle reduce the risk of hospitalizations in a general adult population. Achieving a greater number of healthy behaviours has the potential to reduce the burden of hospitalizations and the associated healthcare costs.

Impact of combined healthy lifestyle factors on survival in an adult general population and in high-risk groups: prospective results from the Moli-sani Study

BACKGROUND

There is poor knowledge on the association between combined lifestyles with mortality risk among individuals at high risk, and little is known on the biological mechanisms that could be on the pathway.

METHODS

Longitudinal analysis on 22 839 individuals from the Moli-sani Study (Italy, 2005-2010). Among them, we identified 5200 elderly individuals (≥65 year), 2127 subjects with diabetes and 1180 with cardiovascular disease (CVD) at baseline. A healthy lifestyle score (HLS) was calculated, allocating 1 point for each of the following: abstention from smoking; adherence to Mediterranean diet; physical activity; absence of abdominal obesity. Hazard ratios (HR) with 95% confidence intervals (95%CI) were calculated by multivariable Cox regression and competing risk models.

RESULTS

During 8.2 years of follow-up, 1237 deaths occurred. In the general population, adherence to all four healthy lifestyles, compared with none or 1, was associated with lower risk of all-cause (HR = 0.53; 95%CI:0.39-0.72), CVD (HR = 0.54; 0.32-0.91), cancer (HR = 0.62; 0.39-1.00) and mortality from other causes (HR = 0.39; 0.19-0.81). A 1-point increase in HLS was associated with 20%, 22% and 24% lower risk of total mortality among the elderly, in subjects with diabetes or CVD, respectively. Traditional (e.g. blood lipids), inflammatory (e.g. C-reactive protein) and novel biomarkers (e.g. markers of cardiac damage) accounted for up to 24% of the association of HLS with all-cause mortality risk in the general population.

CONCLUSIONS

The impact of combined four healthy lifestyles on survival was considerable, both in the general population and among high-risk subgroups. Inflammatory and novel biomarkers of CVD risk explained a substantial proportion of this association.

Consumption of whole grain food and its determinants in a general Italian population: Results from the INHES study

BACKGROUND AND AIMS

Whole grain (WG) food consumption is associated with lower risk of cardiovascular disease, cancer and neurological diseases. The aim of this study was to assess the consumption of WG food and its major demographic, socioeconomic, psychosocial and behavioral determinants in a general Italian population.

METHODS AND RESULTS

Data were from the Italian Nutrition & Health Survey (INHES), a telephone-based survey established in 2010-2013 including 9422 participants aged ≥5 years from all over Italy. WG food intake was assessed by the European Food Propensity Questionnaire and included bread, pasta, breakfast cereals, biscuits and WG soups. WG consumption was categorized as none, occasional (<1 time/week) and regular (≥1 time/week). Overall, 26.9% of the sample reported a regular consumption of WG food (27.2% of adults aged 20-97 y, and 21.9% of children/adolescents aged 5-19 y). In both age-groups, the major food source contributing to total WG intake was WG bread followed by WG pasta. Among adults, greater consumption of WG was associated with healthier lifestyle (e.g. sport activity), and higher educational level. Eating meals outside of the house in adults, and spending >2 h/day watching TV in children/adolescents were inversely associated with WG intake.

CONCLUSIONS

The percentage of WG consumers in Italy in 2010-2013 appears to be quite low and still below that recorded in other countries of Europe where consumption is frequently over 50 percent. WG consumption is likely to be influenced by socioeconomic status and is associated with a number of psychosocial factors, meal patterns and eating-related behaviors.

Learning by counting blood platelets in population studies: survey and perspective a long way after Bizzozero

Platelet count represents a useful tool in clinical practice to discriminate individuals at higher risk of bleeding. Less obvious is the role of platelet count variability within the normal range of distribution in shaping the individual's disease risk profile. Epidemiological studies have shown that platelet count in the adult general population is associated with a number of health outcomes related to hemostasis and thrombosis. However, recent studies are suggesting a possible role of this platelet index also as an independent risk factor. In this review of adult population studies, we will first focus on known genetic and non-genetic determinants of platelet number variability. Next, we will evaluate platelet count as a marker and/or a predictor of disease risk and its interaction with other risk factors. We will then discuss the role of platelet count variability within the normal distribution range as a contribution to disease and mortality risk. The possibility of considering platelet count as a simple, inexpensive indicator of increased risk of disease and death in general populations could open new opportunities to investigate novel platelet pathophysiological roles as well as therapeutic opportunities. Future studies should also consider platelet count, not only platelet function, as a modulator of disease and mortality risk.

Diet and primary prevention of stroke: Systematic review and dietary recommendations by the ad hoc Working Group of the Italian Society of Human Nutrition

BACKGROUND AND AIMS

To systematically review the latest evidence on established and emerging nutrition-related risk factors for incidence of and mortality from total, ischemic and haemorrhagic strokes. The present review was conducted in the framework of the work carried out through 2015 and 2016 for the preparation of the Italian Guidelines for the Prevention and Treatment of Stroke, 8th Edition, by ISO-SPREAD (Italian Stroke Organization and the Stroke Prevention and Educational Awareness Diffusion).

METHODS AND RESULTS

Systematic review of articles focused on primary prevention of stroke published between January 2013 to May 2016 through an extensive search of the literature using MEDLINE/PUBMED, EMBASE and the Cochrane Library. Articles were ranked according to the SIGN methodology while the GRADE system was used to establish the strength of recommendations. As a result of our literature search, we examined 87 meta-analyses overall (mainly of prospective studies), a few isolated more recent prospective studies not included in the meta-analyses, and a smaller number of available randomized controlled trials and case-control studies. Based on the analysis of the above articles, 36 Syntheses of the available evidence and 36 Recommendations were eventually prepared. The present document was developed by organizing the available evidence into three individual areas (nutrients, food groups and dietary patterns) to provide a systematic and user-friendly overview of the available evidence on the relationship between nutrition and primary prevention of stroke. Yet analysis of foods and food patterns allowed translating the information about nutrients in a tool more amenable to use in daily life also in the light of the argument that people eat foods rather than nutrients.

CONCLUSIONS

The present literature review and dietary recommendations provide healthcare professionals and all interested readers with a useful overview for the reduction of the risk of total, ischemic and haemorrhagic stroke through dietary modifications.

Serum vitamin D deficiency and risk of hospitalization for heart failure: Prospective results from the Moli-sani study

BACKGROUND AND AIMS

Evidence indicates that Vitamin D deficiency may be associated with increased risk of cardiovascular disease, although findings on risk of heart failure (HF) are controversial. We investigated the relationship between serum Vitamin D and the incidence of hospitalization for HF in a large prospective cohort of Italian adults.

METHODS AND RESULTS

19,092 (49% men, age range 35-99 years) HF-free individuals from the Moli-sani study, with complete data on serum Vitamin D (25-hydroxyvitamin) levels and incident hospitalized HF, were analysed. The cohort was followed up for a median of 6.2 years. Baseline serum Vitamin D levels were categorized in deficient (<10 ng/mL), insufficient (10-29 ng/mL), and normal (≥30 ng/mL) Incident cases of hospitalization for HF were identified by linkage with the regional hospital discharge registry. Hazard ratios (HRs) were calculated using Cox-proportional hazard models. The prevalence of normal, insufficient or deficient levels of Vitamin D was 12.2%, 79.6% and 8.2%, respectively. During follow-up, 562 admissions to hospital for HF were identified. The incidence of HF was 1.6%, 2.9% and 5.3%, respectively in subjects with normal, insufficient and deficient levels of Vitamin D. After multivariable analysis, individuals with deficiency of Vitamin D had a higher risk of hospitalization for HF (HR: 1.61, 95%CI: 1.06-2.43) than those with normal levels. Further adjustment for subclinical inflammation did not substantially change the association between Vitamin D deficiency and HF.

CONCLUSION

Deficiency of Vitamin D was associated, independently of known HF risk factors, with an increased risk of hospitalization for HF in an Italian adult population.

Fish intake is associated with lower cardiovascular risk in a Mediterranean population: Prospective results from the Moli-sani study

BACKGROUND AND AIMS

Fish consumption reportedly reduces the risk of heart disease, but the evidence of cardiovascular advantages associated with fish intake within Mediterranean cohorts is limited. The aim of this study was to test the association between fish intake and risk of composite coronary heart disease (CHD) and stroke in a large population-based cohort adhering to Mediterranean Diet.

METHODS AND RESULTS

Prospective analysis on 20,969 subjects free from cardiovascular disease at baseline, enrolled in the Moli-sani study (2005-2010). Food intake was recorded by the Italian version of the EPIC food frequency questionnaire. Hazard ratios were calculated by using multivariable Cox-proportional hazard models. During a median follow-up of 4.3 years, a total of 352 events occurred (n of CHD = 287 and n of stroke = 66). After adjustment for a large panel of covariates, fish intake ≥4 times per week was associated with 40% reduced risk of composite CHD and stroke (HR = 0.60; 95%CI 0.40-0.90), and with 40% lower risk of CHD (HR = 0.60; 95%CI 0.38-0.94) as compared with subjects in the lowest category of intake (<2 times/week). A similar trend of protection was found for stroke risk although results were not significant (HR = 0.62; 95%CI 0.26-1.51). When fish types were considered, protection against the composite outcome and CHD was confined to fatty fish intake.

CONCLUSIONS

Fish intake was associated with reduced risk of composite fatal and non-fatal CHD and stroke in a general Mediterranean population. The favourable association was likely to be driven by fatty fish.

Mediterranean-type diet is associated with higher psychological resilience in a general adult population: findings from the Moli-sani study

BACKGROUND/OBJECTIVE

Psychological resilience is a measure of stress coping ability and has been associated with favourable health outcomes. While evidence on the relationship of dietary habits with a number of psychosocial conditions is available, there is lack of studies on their association with psychological resilience in a general adult population.

SUBJECTS/METHODS

Cross-sectional analysis on 10 812 subjects recruited within the cohort of the Moli-sani study (2005-2010). Psychological resilience was measured by the 25-item Connor-Davidson Psychological Resilience Scale. Food intake was recorded by the EPIC food frequency questionnaire and adherence to Mediterranean diet was appraised by both a Greek Mediterranean diet score and an Italian Mediterranean Index. Empirically derived dietary patterns were obtained by principal factor analysis. Multivariable linear regression analysis (95%CI) was used to test the association between dietary scores and psychological resilience.

RESULTS

Higher adherence to Mediterranean-type diets or consumption of a vegetable-based dietary pattern (obtained from principal factor analysis) were positively associated with psychological resilience (β=0.43; 95%CI: 0.19-0.66, β=0.92; 0.69-1.16, and β=1.18; 0.93-1.44, for Greek Mediterranean diet score, Italian Mediterranean Index and the 'Olive oil and vegetables pattern', respectively). Dietary polyphenol or antioxidant intakes and greater variety in fruit and vegetable consumption were also positively associated with psychological resilience, while the associations with Western-like diets were weak.

CONCLUSIONS

In conclusion, Mediterranean diet, vegetable-based dietary patterns and better diet quality were all positively associated with higher psychological resilience, whereas Western-type diets were not.

Food group consumption in an Italian population using the updated food classification system FoodEx2: Results from the Italian Nutrition & HEalth Survey (INHES) study

BACKGROUND AND AIM

Dietary habits evolve over time, being influenced by many factors and complex interactions. This work aimed at evaluating the updated information on food group consumption in Italy.

METHODS AND RESULTS

A total of 8944 (4768 women and 4176 men) participants aged >18 years from all over Italy recruited in 2010-13 (Italian Nutrition & HEalth Survey, INHES) was analyzed. The recruitment was performed using computer-assisted-telephone-interviewing and one-day 24-h dietary recall retrieved from all participants. The updated, second version, of FoodEx2 food classification system was applied to extract data on food group consumption. The participation rate was 53%; 6.2% of the participants declared to follow a special diet, the most prevalent being hypo-caloric diets (55.7% of special diets). Men compared to women presented significantly higher intakes of "grains and grain-based products", "meat and meat products", "animal and vegetable fats and oils and primary derivatives" and "alcoholic beverages" (P for all<0.001); moreover, men had lower intakes of "milk and dairy products", "water and water-based beverages" and "products for non-standard diets, food imitates and food supplements" (P for all<0.001). Differences in food group intake among age groups, geographical regions and educational level groups were also identified (P for all<0.05).

CONCLUSIONS

Data on the consumption of more than 70 food groups and sub-groups were illustrated in different strata. The present analysis could be considered as an updated source of information for future nutrition research in Italy and in the EU.

Challenges to the Mediterranean diet at a time of economic crisis

AIMS

The traditional Mediterranean diet (MD) is reportedly associated with lower risk of major chronic diseases and long considered to contribute to the reduced rates of cardiovascular and cerebrovascular events and to the highest life expectancy in adults who lived near the Mediterranean Sea. But despite its widely documented health benefits, adherence to this dietary pattern has been rapidly declining over the last decades due to a clear socioeconomic influence. The present review provides an overview of the evidence on the current major determinants of adherence to the Mediterranean diet, with a particular emphasis on Mediterranean Countries at a time of economic crisis; second it explores emerging socioeconomic inequalities in other domains of healthy dietary behaviours such as dietary variety, access to organic foods and food purchasing behaviour.

DATA SYNTHESIS

According to ecological evidence, the Mediterranean Countries that used to have the highest adherence to the Mediterranean pattern in the Sixties, more recently experienced the greatest decrease, while Countries in Northern Europe and some other Countries around the world are currently embracing a Mediterranean-like dietary pattern. A potential cause of this downward trend could be the increasing prices of some food items of the Mediterranean diet pyramid. Recent evidence has shown a possible involvement of the economic crisis, material resources becoming strong determinants of the adherence to the MD just after the recession started in 2007-2008. Beyond intake, the MD also encourages increasing dietary diversity, while international dietary recommendations suggest replacing regular foods with healthier ones.

CONCLUSIONS

Socioeconomic factors appear to be major determinants of the adherence to MD and disparities also hold for other indices of diet quality closely related to this dietary pattern.

Association of pasta consumption with body mass index and waist-to-hip ratio: results from Moli-sani and INHES studies

Background/Objectives:

Pasta as a traditional component of Mediterranean diet (MeD) in Italy has not been studied in detail in the management of body weight. This study aimed at evaluating the association of pasta intake with body mass index (BMI) and waist-to-hip ratio, in two large epidemiological datasets.

Subjects/Methods:

A total of 14 402 participants aged ⩾35 years randomly recruited from the general population of the Molise region (Moli-sani cohort) and 8964 participants aged >18 years from all over Italy (Italian Nutrition & HEalth Survey, INHES) were separately analyzed. The European Prospective Investigation into Cancer and Nutrition (EPIC)-food frequency questionnaire and one 24-h dietary recall were used for dietary assessment. Weight, height, waist and hip circumference were measured in Moli-sani or self-reported in INHES. Residuals methodology corrected for either total energy intake or body weight was used for the analysis of pasta intake.

Results:

Higher pasta intake was associated with better adhesion to MeD in both genders (P for both<0.001). In the Moli-sani study, after multivariable analysis, pasta-energy residuals were negatively associated with BMI in women but not in men (β-coef=−0.007, P=0.003 for women and β-coef=−0.001, P=0.58 for men). When pasta intake-body weight residuals were used, pasta intake was significantly and negatively associated with BMI in crude and multi-adjusted models (including adhesion to MeD) in both genders and Moli-sani and INHES studies (for all β-coef<0, P<0.05). In the Moli-sani study, pasta-body weight residuals were significantly and negatively associated with waist and hip circumference and waist-to-hip ratio (for all β-coef<0, P<0.05).

Conclusions:

As a traditional component of MeD, pasta consumption was negatively associated with BMI, waist circumference and waist-to-hip ratio and with a lower prevalence of overweight and obesity.

Flavonoid and lignan intake in a Mediterranean population: proposal for a holistic approach in polyphenol dietary analysis, the Moli-sani Study

BACKGROUND/OBJECTIVES

The objective of this study is to extract and assess data on the dietary intake of flavonoids and lignans in a healthy free-living Mediterranean population, using newly updated harmonized European Union food composition data. This work also aimed at analyzing in a holistic way the total content of the diet in major classes of polyphenols.

SUBJECTS/METHODS

Six thousand nine hundred and eighty-one men and 7048 women (aged ⩾ 35 years) of the Moli-sani cohort, randomly recruited from the general population, were analyzed. The European Prospective Investigation into Cancer (EPIC) and Nutrition-Food Frequency Questionnaire was used for dietary assessment. The polyphenol content of each food group was evaluated using Eurofir BioActive Substances in Food Information System and the United States Department of Agriculture food composition tables (FCTs), when data were missing. Flavonol, flavone, flavanone, flavanol, anthocyanin, isoflavone and lignan intakes were calculated and polyphenol antioxidant content (PAC) score (-28, 28) constructed, to assess the total content of the diet in these nutrients.

RESULTS

Seasonal and citrus fruits, leafy, grain, pod and root vegetables, and onions and garlic accounted for different proportions (11-70%) of the total intake of different polyphenols. Within the Moli-sani population, men or older, or no/former smokers, or physically active or obese/overweight individuals presented higher consumption of flavonoids, lignans and PAC score (P for all <0.01). Multiple regression analysis showed that PAC score and its seven components were positively associated with Mediterranean diet (MeD) adherence in both genders (β-coefficient >0, P<0.001). In addition, 1 unit increase in PAC score was associated with 7.1-7.8% increase in the likelihood of high MeD adherence (P<0.001).

CONCLUSIONS

The intake of flavonoids and lignans in an European Union population was calculated using harmonized European Union FCT data. In addition, a holistic approach in dietary analysis of polyphenol intake was proposed.

Decline of the Mediterranean diet at a time of economic crisis. Results from the Moli-sani study

BACKGROUND AND AIMS

Adherence to Mediterranean diet (MD) is reportedly declining in the last decades. We aimed to investigate the adherence to MD over the period 2005-2010 and exploring the possible role of the global economic crisis in accounting for the changing in the dietary habits in Italy.

METHODS AND RESULTS

Cross-sectional analysis in a population-based cohort study which randomly recruited 21,001 southern Italian citizens enrolled within the Moli-sani study. Food intake was determined by the Italian EPIC food frequency questionnaire. Adherence to MD was appraised by the Italian Mediterranean Index (IMI). A wealth score was derived to evaluate the economic position and used together with other socioeconomic indicators. Highest prevalence of adherence to MD was observed during the years 2005-2006 (31.3%) while the prevalence dramatically fell down in the years 2007-2010 (18.3%; P<0.0001). The decrease was stronger in the elderly, less affluent groups, and among those living in urban areas. Accordingly, we observed that in 2007-2010 socioeconomic indicators were strongly associated with higher adherence to MD, whereas no association was detected in the years before the economic crisis began; both wealth score and education were major determinants of high adherence to MD with 31% (95%CI: 18-46%) higher adherence to this pattern within the wealthier group compared to the less affluent category.

CONCLUSION

Adherence to MD has considerably decreased over the last few years. In 2007-2010 socioeconomic indicators have become major determinants of adherence to MD, a fact likely linked to the economic downturn.

[Factitious disorder and self-mutilation in hand and plastic surgery]

Self-mutilation in the context of factitious disorder can lead to prolonged and complicated treatment in every medical field. Because of a prevalence of 1-5% in hospitalised patients, it is important to be aware of this disorder to protect patients from self- and foreign-induced harm. Often the patient history gives important hints. The different manifestations of this disorder, the specific doctor-patient relationship, several techniques of confrontation and current treatment are presented. Clinical cases from the fields of hand and plastic surgery are presented.

[Intramedullary Kirschner wire osteosynthesis in treatment of distal metacarpal fractures]

The intramedullary Kirschner wire fixation of distal metacarpal fractures reported by Foucher et al. combines the known advantages of intramedullary implants with a reduction of iatrogenic soft tissue trauma. We applied this minimal invasive internal fixation technique in 38 patients with fractures dislocated by more than 20 degrees and/or with rotatory deformity. After opening the intramedullary cavity from the base of the respective metacarpal bone and after fracture reduction, two pre-bent Kirschner wires were intramedullary inserted in an orthograde fashion. The pre-bent distal end of the wire in the form of a hockey club allows an additional closed reduction of the displaced distal fracture fragment. Intraoperative complications did not occur. A fixation in a plaster splint followed for one week only. The elastic fixation of the wires working as springs is stable enough to allow physiotherapeutic exercises. After the third postoperative week, the intensity of physical exercise was increased. 36 of the 38 patients were followed. With one exception, all fractures were healed in a proper position. The wires were removed under local anaesthesia on an outpatient basis after six to eight weeks and full mobility of the fingers was achieved in 34 patients at that time. Complications included one redislocation and one distal wire perforation.

Functional characterization of heme proteins encapsulated in wet nanoporous silica gels

Myoglobin and hemoglobin were encapsulated in wet, nanoporous silica gels. A rigorous evaluation of the effect of the encapsulation on protein dynamics and function was carried out by measuring the kinetics of carbon monoxide rebinding after nanosecond laser flash-photolysis with transient absorption detection, and the oxygen affinity with absorption microspectrophotometry. The time course of carbon monoxide binding to myoglobin evidenced a strongly enhanced geminate recombination and a faster bimolecular rebinding with respect to solution, whereas T and R quaternary states of hemoglobin exhibited a geminate phase and a bimolecular binding rate very similar to those observed in solution. Oxygen affinity of T-state hemoglobin was found to be close to that observed for the binding of the first oxygen to T-state hemoglobin in solution. Results indicate that some conformational transitions are kinetically restricted, allowing to isolate distinct tertiary and quaternary states. This opens the way to their detailed functional characterization and application to biodevices.

High and low oxygen affinity conformations of T state hemoglobin

To understand the interplay between tertiary and quaternary transitions associated with hemoglobin function and regulation, oxygen binding curves were obtained for hemoglobin A fixed in the T quaternary state by encapsulation in wet porous silica gels. At pH 7.0 and 15 degrees C, the oxygen pressure at half saturation (p50) was measured to be 12.4 +/- 0.2 and 139 +/- 4 torr for hemoglobin gels prepared in the absence and presence of the strong allosteric effectors inositol hexaphosphate and bezafibrate, respectively. Both values are in excellent agreement with those found for the binding of the first oxygen to hemoglobin in solution under similar experimental conditions. The corresponding Hill coefficients of hemoglobin gels were 0.94 +/- 0.02 and 0.93 +/- 0.03, indicating, in the frame of the Monod, Wyman, and Changeux model, that high and low oxygen-affinity tertiary T-state conformations have been isolated in a pure form. The values, slightly lower than unity, reflect the different oxygen affinity of alpha- and beta-hemes. Significantly, hemoglobin encapsulated in the presence of the weak effector phosphate led to gels that show intermediate oxygen affinity and Hill coefficients of 0.7 to 0.8. The heterogeneous oxygen binding results from the presence of a mixture of the high and low oxygen-affinity T states. The Bohr effect was measured for hemoglobin gels containing the pure conformations and found to be more pronounced for the high-affinity T state and almost absent for the low-affinity T state. These findings indicate that the functional properties of the T quaternary state result from the contribution of two distinct, interconverting conformations, characterized by a 10-fold difference in oxygen affinity and a different extent of tertiary Bohr effect. The very small degree of T-state cooperativity observed in solution and in the crystalline state might arise from a ligand-induced perturbation of the distribution between the high- and low-affinity T-state conformations.

Release of anti-inflammatory mediators after mechanical trauma correlates with severity of injury and clinical outcome

Excessive synthesis of proinflammatory cytokines [tumor necrosis factor (TNF)-alpha and interleukin (IL)-1 beta] after trauma has been correlated with poor outcome. Recently, naturally occurring inhibitors of TNF-alpha and IL-1 beta have been characterized such as soluble TNF receptors (sTNFRs) and IL-1 receptor antagonist (IL-1ra). The present study was undertaken to determine whether injury results in a rise of circulating sTNFRs and IL-1ra. If so, whether plasma levels of these anti-inflammatory mediators correlate with severity of injury and clinical outcome of these patients. Injured patients (n = 213) showed significantly increased sTNFR and IL-1ra plasma levels throughout the observation period of 14 days, compared with healthy volunteers (n = 127). Patients with severe injury (Injury Severity Score > 16 points) revealed higher levels (p < 0.05) of sTNFRs and IL-1ra than patients with minor trauma (Injury Severity Score < or = 16 points). Patients who died from injury demonstrated increased (p < 0.05) sTNFR p55 and IL-1ra plasma levels, compared with survivors. Thus, anti-inflammatory mechanisms are activated after trauma dependent on severity of injury. Because increased plasma levels of anti-inflammatory reacting proteins portended poorly for patient survival, these mediators may contribute to prediction of outcome after severe injury.

Increased release of soluble tumor necrosis factor receptors into blood during clinical sepsis

OBJECTIVES

To examine the kinetics of altered soluble tumor necrosis factor receptors (sTNFRs) released in patients with severe sepsis, their correlation with the morbidity and mortality of these patients, and the role of endotoxin to induce cleavage of sTNFRs.

DESIGN

Soluble TNFR levels in plasma obtained from 40 patients with severe sepsis (mean [+/- SD] Acute Physiology and Chronic Health Evaluation [APACHE] II score, 27.9 +/- 7.0 points) on days 0, 1, 3, 5, and 10 after sepsis diagnosis were measured using specific enzyme-linked immunological binding assays and compared with levels in 75 control patients without infection. In addition, an ex vivo model consisting of lipopolysaccharide stimulation of human whole blood as a relevant physiological milieu was used. Blood from patients with sepsis and control patients was incubated in the presence or absence of lipopolysaccharide (1 mg/L) for 0, 1, 2, 4, 8, and 24 hours. Plasma levels of sTNFRs from both groups were determined using the enzyme-linked immunological binding assays.

RESULTS

In patients with sepsis, plasma levels of both sTNFRs were markedly (P < .01) increased during the whole observation period, compared with those of control patients, and correlated (P < .001) with the simultaneously obtained APACHE II and multiple organ failure scores, as well as with mortality. Although incubation of whole blood with lipopolysaccharide increased the release of sTNFR p55 and p75 in both groups, sTNFR concentrations in blood from control patients remained low compared with those of patients with severe sepsis, despite stimulation of whole blood with a maximum lipopolysaccharide concentration.

CONCLUSIONS

These data indicate that an enhanced release of sTNFRs during severe sepsis is not solely induced by endotoxin. Since the degree of increased sTNFR levels portended poorly for patient survival, elevated sTNFR levels may represent a good marker for severity of sepsis, thus predicting outcome.

[The medical record at the center of medical informatics]

Several areas in medical institutions, particularly the technical and administrative ones have been governed by computers for a long time. The proper medical work field (diagnosis, treatment, follow-up, correspondence and billing) however has hitherto mostly been ignored by data processing. We describe an electronic medical record introduced 4 years ago. All aspects of medical practise and all the specialists involved in patient care are integrated in the electronic document. In the center is a medical base of knowledge adaptable to all specialties as well as an expert system for direct control of the data entered by all concerned persons.