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Background Research related to sustainable diets is is highly relevant to provide better understanding of the impact of dietary intake on the health and the environment. Aim To assess the association between the adherence to an energy-restricted Mediterranean diet and the amount of CO 2 emitted in an older adult population. Design and population Using a cross-sectional design, the association between the adherence to an energy-reduced Mediterranean Diet (erMedDiet) score and dietary CO 2 emissions in 6646 participants was assessed. Methods Food intake and adherence to the erMedDiet was assessed using validated food frequency questionnaire and 17-item Mediterranean questionnaire. Sociodemographic characteristics were documented. Environmental impact was calculated through greenhouse gas emissions estimations, specifically CO 2 emissions of each participant diet per day, using a European database. Participants were distributed in quartiles according to their estimated CO 2 emissions expressed in kg/day: Q1 (≤2.01 kg CO 2 ), Q2 (2.02-2.34 kg CO 2 ), Q3 (2.35-2.79 kg CO 2 ) and Q4 (≥2.80 kg CO 2 ). Results More men than women induced higher dietary levels of CO 2 emissions. Participants reporting higher consumption of vegetables, fruits, legumes, nuts, whole cereals, preferring white meat, and having less consumption of red meat were mostly emitting less kg of CO 2 through diet. Participants with higher adherence to the Mediterranean Diet showed lower odds for dietary CO 2 emissions: Q2 (OR 0.87; 95%CI: 0.76-1.00), Q3 (OR 0.69; 95%CI: 0.69-0.79) and Q4 (OR 0.48; 95%CI: 0.42-0.55) vs Q1 (reference). Conclusions The Mediterranean diet can be environmentally protective since the higher the adherence to the Mediterranean diet, the lower total dietary CO 2 emissions. Mediterranean Diet index may be used as a pollution level index.

Background Recent lifestyle changes include increased consumption of highly processed foods (HPF), which has been associated with an increased risk of non-communicable diseases (NCDs). However, nutritional information relies on the estimation of HPF consumption from food-frequency questionnaires (FFQ) that are not explicitly developed for this purpose. We aimed to develop a short screening questionnaire of HPF consumption (sQ-HPF) that integrates criteria from the existing food classification systems. Methods Data from 4400 participants (48.1% female and 51.9% male, 64.9 ± 4.9 years) of the Spanish PREDIMED-Plus (“PREvention with MEDiterranean DIet”) trial were used for this analysis. Items from the FFQ were classified according to four main food processing-based classification systems (NOVA, IARC, IFIC and UNC). Participants were classified into tertiles of HPF consumption according to each system. Using binomial logistic regression, food groups associated with agreement in the highest tertile for at least two classification systems were chosen as items for the questionnaire. ROC analysis was used to determine cut-off points for the frequency of consumption of each item, from which a score was calculated. Internal consistency of the questionnaire was assessed through exploratory factor analysis (EFA) and Cronbach’s analysis, and agreement with the four classifications was assessed with weighted kappa coefficients. Results Regression analysis identified 14 food groups (items) associated with high HPF consumption for at least two classification systems. EFA showed that items were representative contributors of a single underlying factor, the “HPF dietary pattern” (factor loadings around 0.2). We constructed a questionnaire asking about the frequency of consumption of those items. The threshold frequency of consumption was selected using ROC analysis. Comparison of the four classification systems and the sQ-HPF showed a fair to high agreement. Significant changes in lifestyle characteristics were detected across tertiles of the sQ-HPF score. Longitudinal changes in HPF consumption were also detected by the sQ-HPF, concordantly with existing classification systems. Conclusions We developed a practical tool to measure HPF consumption, the sQ-HPF. This may be a valuable instrument to study its relationship with NCDs. Trial registration Retrospectively registered at the International Standard Randomized Controlled Trial Registry ( ISRCTN89898870 ) on July 24, 2014.

It remains unclear whether caffeinated beverages could have deleterious renal effects in elderly population with underlying comorbid conditions. We investigated the associations between coffee, tea, or caffeine intake and 1-year changes in glomerular filtration rate (eGFR) in a large Spanish cohort of overweight/obese elderly with metabolic syndrome (MetS). This prospective analysis includes 5851 overweight/obese adults (55–75 years) with MetS from the PREDIMED-Plus study. We assessed coffee, tea, and caffeine consumption from a validated food-frequency questionnaire and creatinine-based eGFR using the Chronic Kidney Disease Epidemiology Collaboration equation. Multivariate-adjusted regression models were applied to test associations between baseline coffee, tea, or caffeine intake and 1-year eGFR changes. Caffeinated coffee (> 2 cups/day) and tea (at least 1 cup/day) drinkers had 0.88 and 0.93 mL/min/1.73 m 2 greater eGFR decrease respectively, compared to those with less than 1 cup/day of coffee consumption or non-tea drinkers. Furthermore, caffeinated coffee consumption of > 2 cups/day was associated with 1.19-fold increased risk of rapid eGFR decline > 3 mL/min/1.73 m 2 (95% CI 1.01–1.41). Similarly, individuals in the highest (median, 51.2 mg/day) tertile of caffeine intake had a 0.87 mL/min/1.73 m 2 greater eGFR decrease. Decaffeinated coffee was not associated with eGFR changes. In conclusion, higher consumption of caffeinated coffee, tea, and caffeine was associated with a greater 1-year eGFR decline in overweight/obese adults with MetS.

Background Metabolic syndrome (MetS) has become a growing risk factor of some non-communicable diseases. Increase of greenhouse gas emissions affects the planet. Aims To assess the association between MetS severity and amount of carbon dioxide (CO 2 ) emitted in an adult population. Design Cross-sectional study ( n  = 6646; 55-76-year-old-men; 60-75-year-old-women with MetS). Methods Dietary habits were assessed using a pre-validated semi quantitative 143-item food frequency questionnaire. The amount of CO 2 emitted due to the production of food consumed by person and day was calculated using a European database, and the severity of the MetS was calculated with the MetS Severity Score. Results Higher glycaemia levels were found in people with higher CO 2 emissions. The risk of having high severe MetS was related to high CO 2 emissions. Conclusions Low CO 2 emissions diet would help to reduce MetS severity. Advantages for both health and the environment were found following a more sustainable diet. Trial registration ISRCTN, ISRCTN89898870 . Registered 05 September 2013.

•High cumulative EVOO intake (>40 g/d) reduced major cardiovascular disease risk.•EVOO lowered the risk of stroke, peripheral artery disease, and atrial fibrillation.•Common olive oil showed weaker associations compared to EVOO.•Intake was evaluated with yearly repeated measures over 4.7 years of follow-up. Olive oil, increasingly consumed in the U.S., has been inversely associated with cardiovascular disease (CVD) risk. However, previous studies did not assess a broad spectrum of CVD outcomes, incorporated repeated annual dietary assessments, or distinguished between polyphenol-rich EVOO and common olive oil (COO), which lacks these compounds. We assessed 7102 high-risk participants from the PREDIMED trial (57.5% women; aged 55-80 years), all free of CVD at baseline. Olive oil consumption was assessed annually, and cumulative average intakes of EVOO and COO were calculated. The primary outcome was a composite of myocardial infarction, stroke, peripheral arterial disease, heart failure, atrial fibrillation, or cardiovascular death, whichever occurred first. Individual outcomes were also evaluated. Time-dependent Cox models were adjusted for major confounders, including trial intervention arm. Over a median follow-up of 4.7 years, 621 participants experienced at least one CVD event. Participants in the highest tertile of cumulative EVOO intake (mean: 49.2 g/d) had a 25% lower risk of the composite outcome (HR: 0.75; 95% CI: 0.60-0.94), with significant reductions in several individual CVD outcomes. In the decile analysis, the highest (mean: 60.9 g/d) versus lowest decile had a 48% lower risk (HR: 0.52; 95% CI: 0.35 to 0.79). COO consumption was not significantly associated with CVD risk when mutually adjusted for EVOO (HRper 10 g/d: 0.93; 95% CI: 0.87-1.00). High consumption of EVOO is associated with a substantial reduction in the risk of an outcome-wide composite of CVD events among high-risk individuals. In contrast, COO, which lacks polyphenols, showed weaker associations, highlighting the importance of differentiating olive oil types in CVD prevention strategies. This trial was registered in the ISRCTN registry (ISRCTN 35739639): https://www.isrctn.com/ISRCTN35739639. [Display omitted]

Clinical data on the direct health effects of energy deficit or surplus beyond its impact on body weight are scarce. We aimed to assess the association with all-cause, cardiovascular and cancer mortality of (1) sustained energy deficit or surplus, calculated according to each individual’s en-ergy intake (EI) and theoretical energy expenditure (TEE), and (2) mid-term change in total EI in a prospective study. In 7119 participants in the PREDIMED Study (PREvención con DIeta MEDi-terránea) with a mean age of 67 years, energy intake was derived from a 137-item food frequency questionnaire. TEE was calculated as a function of age, sex, height, body weight and physical ac-tivity. The main exposure was the proportion of energy requirement covered by energy intake, cumulative throughout the follow-up. The secondary exposure was the change in energy intake from baseline. Cox proportional hazard models were used to estimate hazard ratios and 95% con-fidence intervals for all-cause, cardiovascular and cancer mortality. Over a median follow-up of 4.8 years, there were 239 deaths (excluding the first 2 years). An energy intake exceeding energy needs was associated with an increase in mortality risk (continuous HR10% over energy needs = 1.10; 95% CI 1.02, 1.18), driven by cardiovascular death (HR = 1.26; 95% CI 1.11, 1.43). However, consum-ing energy below estimated needs was not associated with a lower risk. Increments over time in energy intake were associated with greater all-cause mortality (HR10% increase = 1.09; 95% CI 1.02, 1.17). However, there was no evidence that a substantial negative change in energy intake would reduce mortality risk. To conclude, in an older Mediterranean cohort, energy surplus or increase over a 5-year period was associated with greater risk of mortality, particularly cardiovascular mortality. Energy deficit, or reduction in energy intake over time were not associated with mortal-ity risk.

Atrial fibrillation has been associated with cognitive impairment. Whether subclinical abnormalities in atrial function and substrate predisposing to atrial fibrillation impact cognitive function has received limited attention. We tested associations of echocardiographic markers of atrial structure and function with cognitive function and decrease in 510 participants with obesity and metabolic syndrome (mean age SD of 64.4 [5.2] years in men and 66.5 [3.9] years in women). Left atrial (LA) markers (volume index, emptying fraction, strain, function index, and stiffness index) were estimated based on transthoracic echocardiography. General cognitive functioning (Mini-mental state examination), verbal ability (verbal fluency test), memory and attention (Digit Span Tests), and processing speed and executive function (Trail-Making Tests A and B) were assessed at baseline and at 2-year follow-up. Multiple linear regression was used to test associations of atrial markers (modeled in SD units) with baseline and 2-year changes in cognitive scores adjusted for demographic and health covariates. LA structure and function were not associated with cognitive function at baseline. Larger LA volume index (standardized β [95% confidence interval] −0.13 [−0.22 to −0.03]), lower peak longitudinal strain (−0.11 [−0.20 to −0.01]), and higher stiffness index (−0.18 [−0.28 to −0.08]) were associated with 2-year worsening in Trail-Making Test A. Strain measurements were also associated with a 2-year change in the Controlled Oral Word Association Test. In conclusion, overall, adverse markers of LA structure and function were associated with 2-year detrimental executive function-related cognitive changes in a sample of participants at high risk for cardiovascular disease, highlighting LA substrate as a potential risk factor for cognitive decrease and dementia.

We aimed to assess the effects of the antioxidant-rich Mediterranean diet (MedDiet) onwhite blood cell count. Our study population included participants in the PREvención con DIetaMEDiterránea study (average age 67 years old, 58% women, high cardiovascular risk). We assessedwhether a MedDiet intervention enriched in extra-virgin olive oil or nuts, versus a low-fat controldiet, modified the incidence of leukocytosis (>11×109leukocytes/L), mild leukopenia (<4.5×109leukocytes/L), or severe leukopenia (<3.5×109leukocytes/L) in individuals without the conditionat baseline (n= 3190,n= 2925, andn= 3190, respectively). We also examined whether MedDietmodified the association between leukocyte count alterations and all-cause mortality. Both MedDietinterventions were associated with a lower risk of developing leukopenia (incidence rates: 5.06%in control diet, 3.29% in MedDiet groups combined; hazard ratio [95% confidence interval]: 0.54[0.36-0.80]) and severe leukopenia (incidence rates: 1.26% in control diet, 0.46% in MedDiet groupscombined; hazard ratio: 0.25 [0.10-0.60]). High cumulative adherence to a MedDiet was linked tolower risk of leukocytosis (incidence rates: 2.08% in quartile 1, 0.65% in quartile 4; HRQ4-Q1: 0.29[0.085-0.99]) and attenuated the association between leukopenia and all-cause mortality (P-interaction= 0.032). In brief, MedDiet decreased the incidence of white blood cell count-related alterations inhigh cardiovascular risk individuals.

The association between ultra-processed food (UPF) and risk of cardiometabolic disorders is an ongoing concern. Different food processing-based classification systems have originated discrepancies in the conclusions among studies. To test whether the association between UPF consumption and cardiometabolic markers changes with the classification system, we used baseline data from 5636 participants (48.5% female and 51.5% male, mean age 65.1 ± 4.9) of the PREDIMED-Plus (“PREvention with MEDiterranean DIet”) trial. Subjects presented with overweight or obesity and met at least three metabolic syndrome (MetS) criteria. Food consumption was classified using a 143-item food frequency questionnaire according to four food processing-based classifications: NOVA, International Agency for Research on Cancer (IARC), International Food Information Council (IFIC) and University of North Carolina (UNC). Mean changes in nutritional and cardiometabolic markers were assessed according to quintiles of UPF consumption for each system. The association between UPF consumption and cardiometabolic markers was assessed using linear regression analysis. The concordance of the different classifications was assessed with intra-class correlation coefficients (ICC3, overall = 0.51). The highest UPF consumption was obtained with the IARC classification (45.9%) and the lowest with NOVA (7.9%). Subjects with high UPF consumption showed a poor dietary profile. We detected a direct association between UPF consumption and BMI (p = 0.001) when using the NOVA system, and with systolic (p = 0.018) and diastolic (p = 0.042) blood pressure when using the UNC system. Food classification methodologies markedly influenced the association between UPF consumption and cardiometabolic risk markers.

Background and Aims: Plant-forward dietary patterns have been associated with cardiometabolic health benefits, which, in turn, have been related to cognitive performance with inconsistent findings. The objective of this study was to examine the relationship between baseline adherence to three a priori dietary patterns (Mediterranean, DASH, and MIND diets) with 2-year changes in cognitive performance in older adults with overweight or obesity and high cardiovascular disease risk. Methods: A prospective cohort analysis was conducted within the PREDIMED-Plus trial, involving 6,647 men and women aged 55–75 years with overweight or obesity and metabolic syndrome. Using a validated, semiquantitative 143-item food frequency questionnaire completed at baseline, the dietary pattern adherence scores were calculated. An extensive neuropsychological test battery was administered at baseline and 2-year follow-up. Multivariable-adjusted linear regression models were used to assess associations between 2-year changes in cognitive function z -scores across tertiles of baseline adherence to the a priori dietary patterns. Results: Adherence to the Mediterranean diet at baseline was associated with 2-year changes in the general cognitive screening Mini-Mental State Examination (MMSE, β: 0.070; 95% CI: 0.014, 0.175, P-trend = 0.011), and two executive function-related assessments: the Trail Making Tests Part A (TMT-A, β: −0.054; 95% CI: −0.110, − 0.002, P-trend = 0.047) and Part B (TMT-B, β: −0.079; 95% CI: −0.134, −0.024, P-trend = 0.004). Adherence to the MIND diet was associated with the backward recall Digit Span Test assessment of working memory (DST-B, β: 0.058; 95% CI: 0.002, 0.114, P-trend = 0.045). However, higher adherence to the DASH dietary pattern was not associated with better cognitive function over a period of 2 years. Conclusion: In older Spanish individuals with overweight or obesity and at high cardiovascular disease risk, higher baseline adherence to the Mediterranean dietary pattern may be associated with better cognitive performance than lower adherence over a period of 2 years.