The Sapienza count-down for a healthy and sustainable diet.

Abstract: The prevalence of obesity and of other non-communicable diseases related to overnutrition is significantly increasing in the past few years. Policy makers are called to counteract this pandemic, orienting consumers towards a healthier and more sustainable diet. Most of the proposed initiatives are dedicated to the content of nutrients with "unfavourable" effects but, in fact, focusing the attention only or mainly on single foods or nutrients is not effective in decreasing the incidence/prevalence of non-communicable diseases. Whole dietary patterns play by far a more important role than specific dietary components in promoting health and modulating survival; and the adherence to eating patterns like the Mediterranean diet reduces the risk of non-communicable diseases. The challenge is therefore to be able to transmit information relating to a healthy eating pattern through positive messages in a few simple indications which in turn represent the nutritional, but also the socio-cultural, environmental and economic characteristics of a healthy and sustainable dietary model. The Mediterranean Diet is normally proposed through a graphic depiction that represents a pyramid which is a simple and effective representation but not of immediate impact. For this reason, we are proposing to adopt the "Sapienza Count-down for a Healthy and Sustainable Diet" that will integrate the pyramid with a more immediate approach.

Adherence to the Mediterranean diet was positively associated with micronutrient adequacy and negatively associated with dietary energy density among adolescents.

BACKGROUND: The possible associations between adherence to the Mediterranean diet and micronutrient and energy intakes are unknown among Israeli adolescents. METHODS: A cross-sectional, nationally representative, school-based study was conducted in Israeli adolescents. Schoolchildren (n = 5005), aged 11-18 years, who completed a food frequency questionnaire and had complete data to compose a 14-item modified KIDMED score were included. RESULTS: The nutrient intakes for all the micronutrients showed a significant monotonic increase in the poor, average and good KIDMED groups (all P < 0.001). The same monotonic increasing was also shown in nutrient densities for most micronutrients (for calcium, magnesium, potassium, copper, vitamin A, vitamin E, vitamin C, thiamin, riboflavin, vitamin B6 , folate in both genders, additionally for phosphorus in girls) (all P < 0.05). A positive association was shown between the percentages of students with adequate intakes (AIs) or recommended dietary allowances (RDAs) in micronutrients and modified KIDMED scores. The positive association also existed between the number of micronutrients with AIs or RDAs and modified KIDMED scores (r = 0.495 and 0.501, P < 0.001) for boys and girls, respectively. By contrast, dietary energy density (calibrated by 1000 kcal) was negatively linearly associated with modified KIDMED scores, and a significant monotonic decrease in energy density was shown among the poor, average and good KIDMED groups (all P < 0.001). CONCLUSIONS: The modified KIDMED score was positively associated with better micronutrient profile and negatively associated with dietary energy density in Israeli adolescents, indicating that the KIDMED index is a useful tool for combating the malnutrition of micronutrient deficiency and overweight/obesity.

Med Diet 4.0: the Mediterranean diet with four sustainable benefits.

OBJECTIVE: To characterize the multiple dimensions and benefits of the Mediterranean diet as a sustainable diet, in order to revitalize this intangible food heritage at the country level; and to develop a multidimensional framework - the Med Diet 4.0 - in which four sustainability benefits of the Mediterranean diet are presented in parallel: major health and nutrition benefits, low environmental impacts and richness in biodiversity, high sociocultural food values, and positive local economic returns. DESIGN: A narrative review was applied at the country level to highlight the multiple sustainable benefits of the Mediterranean diet into a single multidimensional framework: the Med Diet 4.0. Setting/subjects We included studies published in English in peer-reviewed journals that contained data on the characterization of sustainable diets and of the Mediterranean diet. The methodological framework approach was finalized through a series of meetings, workshops and conferences where the framework was presented, discussed and ultimately refined. RESULTS: The Med Diet 4.0 provides a conceptual multidimensional framework to characterize the Mediterranean diet as a sustainable diet model, by applying principles of sustainability to the Mediterranean diet. CONCLUSIONS: By providing a broader understanding of the many sustainable benefits of the Mediterranean diet, the Med Diet 4.0 can contribute to the revitalization of the Mediterranean diet by improving its current perception not only as a healthy diet but also a sustainable lifestyle model, with country-specific and culturally appropriate variations. It also takes into account the identity and diversity of food cultures and systems, expressed within the notion of the Mediterranean diet, across the Mediterranean region and in other parts of the world. Further multidisciplinary studies are needed for the assessment of the sustainability of the Mediterranean diet to include these new dimensions.

Mediterranean diet pyramids: towards the Italian model.

There is a long history to the representation of the Mediterranean Diet Pyramid which may be seen as a form of cultural--culinary evolution as each country applies the foods best suited to its national diet. Different Mediterranean Diet pyramids have been designed for the population of Greece, Spain and Italy, tailored for their different food habits. These refer variously to portion sizes and frequency of consumption--daily, weekly and monthly and are not standardized. The 3rd CIISCAM Conference held in Parma, Italy was devoted to highlight the overall biodiversity and nutritional well being values and the sustainable benefits of the Mediterranean diet, recognised as one of the healthiest dietary pattern, and to reduce the rapid erosion of "lifestyle and food habits. It is necessary, therefore, to refer more to a Mediterranean Lifestyle of which diet is only a part. It should include physical and social activity, recreation and rest. It may be possible to construct a Mediterranean food lifestyle index both to assess such a holistic aspect and to correlate with improved morbidity & mortality.

2-Arachidonoylglycerol as a possible treatment for anorexia nervosa in animal model in mice.

We have investigated the effects of 0.001mg/kg 2-arachidonoylglycerol (2-AG) administered in combination with compounds present in the body alongside 2-AG like 2-palmitoylglycerol and 2-linoleylglycerol (also termed "entourage"), on cognitive function,food intake, and neurotransmitter levels in the hippocampus and hypothalamus of mice under diet restriction. Young female Sabra mice were treated with vehicle, 2-AG, 2-AG+entourage, 2-AG+entourage+5-(4-Chlorophenyl)-1-(2,4-dichloro-phenyl)- 4-methyl-N-(piperidin-1-yl)-1H-pyrazole-3-carboxamide (SR141716A, a CB1 antagonist) and SR141716A. The mice were fed for 2.5h a day for 14days. Cognitive function was evaluated by the eight arm maze test, and neurotransmitter (norepinephrine, dopamine, L-DOPA and serotonin) levels were measured in the hippocampus and hypothalamus by high-performance liquid chromatography-electrochemical detection. Food intake was increased by 2-AG and, to an even greater extent, by 2-AG+entourage. SR141716A reversed the effect of 2-AG+entourage. The administration of 2-AG+entourage improved cognitive function compared to the vehicle mice, and this improvement was blocked by SR141716A. 2-AG+entourage-treated mice showed an increase in norepinephrine (NE), dopamine and L-DOPA levels in the hippocampus. SR141716A normalized NE and L-DOPA levels. There were no significant changes in hypothalamic neurotransmitter levels. The use of very low doses of the endocannabinoid 2-AG+entourage can improve cognitive function by elevating norepinephrine and L-DOPA levels in the hippocampus, without cannabinomimetic side effects. These findings may have implications for cognitive enhancement in anorexia nervosa.

Dietary fat, adipose tissue composition, and the development of carcinoma of the colon.

Dietary fat and plasma lipids have been implicated in the development of carcinoma of the colon. Because of the difficulties in obtaining accurate dietary histories, subcutaneous adipose tissue fatty acids were analyzed to compare fat intake in 3 groups of patients undergoing colonoscopy: patients with carcinoma of the colon (n = 53; average age, 64 yr; 47% male), patients with neoplastic polyps (n = 34; age 63 yr; 71% male), and patients with normal findings (controls; n = 68; age 58 yr; 40% male). The groups were similar with regard to body mass index and coffee and egg consumption. One-way analysis of variance of the plasma total cholesterol, triglycerides, high-density lipoprotein cholesterol, 9 adipose fatty acids, groups of polyunsaturated fatty acids (vegetable origin), saturated fatty acids (animal origin), or the ratio of polyunsaturated to saturated fatty acids did not show any significant differences across the 3 groups. The quality of dietary fat does not appear to be associated with the development of carcinoma of the colon or of neoplastic polyps in this population.

Preferential metabolism by macrophages of conditioned rabbit hypercholesterolemic remnant lipoproteins.

Rabbits were fed a diet containing 1% cholesterol, and lipoproteins were isolated from their plasma by sequential ultracentrifugation. Lipoprotein remnants (d = 1.019-1.063) were conditioned by incubation with bovine aortic smooth muscle cells for 24 h and then incubated for 4 h with J774 cells or mouse peritoneal macrophages. Conditioning of remnants and low-density lipoproteins resulted in enhancement of their uptake and metabolism by the macrophages in culture. The macrophages metabolized conditioned remnant lipoproteins more extensively than controls at all concentrations tested. Addition of 10% safflower oil or 10% butter to the 1% cholesterol diet resulted in a molar ratio of linoleic/oleic acid of 1.62 and 0.62 in plasma neutral lipids and of 5.7 and 2.5 in plasma phospholipids. Conditioned remnants, derived after safflower oil feeding, were metabolized more extensively by macrophages than those obtained after butter feeding. This was also true for control remnants (preincubated without cells). Thiobarbituric acid-reactive substances were higher in remnants from safflower oil-fed than butter-fed rabbit plasma prior to and after conditioning. Mouse peritoneal macrophages metabolized remnant lipoproteins more extensively than low-density lipoproteins. The present results indicate that modification of remnant lipoproteins, the major atherogenic fraction of cholesterol-fed rabbit plasma, results in their enhanced metabolism by macrophages, and that an increase in the linoleic/oleic acid ratio in these lipoproteins might enhance their susceptibility to peroxidative modification.

Modification of cellular fatty acid composition of Hep-G2 cells: effect of antioxidants on cholesterol esterification and secretion.

Modification of fatty acid composition of Hep-G2 cells was achieved by 7-9 days of supplementation of culture medium with palmitic, oleic or linoleic acid. Cholesterol release into serum-free culture medium during 24 h of incubation was significantly lower in cells supplemented with linoleic acid, when compared to those supplemented with palmitic, oleic or no additional fatty acid. In cells cultured in the presence of linoleic acid, less [3H]cholesterol was esterified to cholesteryl ester and the mass of cholesteryl ester was significantly lower than in cells cultured with palmitic acid or with no additional fatty acid. The reduction in [3H]cholesterol secretion and the impairment in cholesterol esterification in linoleic acid-treated cells was prevented by addition of butylated hydroxytoluene or probucol concurrently with the fatty acid. The antioxidants also increased esterification and [3H]cholesterol release in cells supplemented with the other fatty acids. It is suggested that cholesterol secretion and esterification are sensitive to peroxidation.

Prevalence of obesity in Israel.

Israel is a multiethnic society and offers an ongoing 'experiment' concerning the cultural determinants of obesity. The First Israeli National Health and Nutrition Survey 1999-2001 (MABAT) measured a representative population of 2782 adults (49% men) aged 25-64 years (mean 43 years); it showed a prevalence of overweight in 39.3% and obesity in 22.9%. Overweight is more common in men and obesity is more prevalent in women; the Israeli Arab population is more obese than the Jewish one.

Poststreptococcal neprhitis and acute rheumatic fever in two adults.

In two adult subjects who suffered acute episodes of rheumatic fever, sever kidney involvement developed with proteinuria and renal insufficiency. The clinical and histologic picture was typical of poststreptococcal (infectious) glomerulonephritis. During a follow-up period of more than three years, no clinical or biochemical abnormalities have been detected; thus, it is likely that both patients have recovered from their renal diseases. The coexistence of rheumatic fever and acute glomerulonephritis, which is uncommon even in your age groups, may be observed in adult subjects.

Spontaneous remission of protein-losing gastropathy associated with Menetrier's disease. A plea for conservative management.

Spontaneous remission of the protein-losing gastropathy of Menetrier's disease occurred after four months of disease activity. Because the natural history and cause of Menetrier's disease is unclear, we suggest a more conservative approach to the management of this condition, despite recent publications to the contrary.

Bulimia. An underlying behavioral disorder in hyperlipidemic pancreatitis: a prospective multidisciplinary approach.

Between 1978 and 1985, we conducted a prospective study of 21 patients who survived several attacks of pancreatitis and were diagnosed as having primary hyperlipidemia. None of the patients suffered from chronic alcoholism, primary diabetes, or cholelithiasis or was receiving prolonged steroid therapy. Lowering of plasma lipid values toward normal was achieved in all patients following a program of combined dietary and drug (bezafibrate) therapy. Five patients had recurrent episodes of pancreatitis during the treatment program. These patients were diagnosed subsequently as suffering from bulimia and were all given cognitive behavioral therapy. One patient died following an attack of pancreatitis. An underlying eating disorder should be suspected in patients who relapse after treatment for pancreatitis and hyperlipidemia. Multidisciplinary treatment should be used in these patients to improve therapeutic efficacy and uncover behavioral patterns that have a direct impact on their life expectancy.

Temporal concentrations of cortisol and LH in virgin ewes acutely exposed to rams during the transition into the breeding season.

The objectives of this study were to determine if exposing seasonally anovular ewes to rams would alter patterns of cortisol concentrations, and if these changes are associated with changes in characteristics of LH concentrations. Seasonally anestrous ewes were assigned to be exposed to rams (RE; n=11) or wethers (NE; n=12). Blood samples were collected at 15-min intervals beginning 120 min before introduction of males (time=0 min), and continued for 360 min after male exposure. Characteristics of cortisol and LH concentrations included: mean and baseline concentrations, pulse amplitude, duration, frequency, and time to first pulse. Mean and baseline cortisol concentrations, and cortisol pulse amplitude, frequency, and time to first pulse after male exposure did not differ between RE and NE ewes. Cortisol pulse duration was longer (P<0.05) in RE ewes than in NE ewes. Mean LH and LH pulse amplitude, duration, and time to first pulse after male exposure did not differ between RE and NE ewes. Baseline LH concentrations and LH pulse frequency were greater (P<0.05) in RE than in NE ewes. In RE ewes, but not NE ewes, LH pulse frequency tended to increase (P=0.06) as pulse frequency of cortisol decreased. In conclusion, exposing ewes to mature rams during the transition into the breeding season increased LH pulse frequency which hastened ovulatory activity. However, the results do not support the hypothesis that changes in cortisol concentrations plays a significant role in the 'ram effect'.

Significant weight reduction in obese subjects enhances carbamazepine elimination.

Single-dose (200 mg) carbamazepine pharmacokinetics was evaluated in six obese, otherwise healthy subjects, before and after a mean +/- SEM weight reduction of 30.0 +/- 5.0 kg over 11.3 +/- 1.2 months. After weight loss the mean +/- SEM plasma elimination half-life (t1/2) of carbamazepine was significantly shortened (60.3 +/- 3.1 versus 30.8 +/- 3.3 hours, p less than 0.01) and the total plasma clearance (CL) increased (20.4 +/- 1.8 versus 31.6 +/- 5.0 ml/min, p less than 0.05). The apparent volume of distribution (Varea) decreased (106.2 +/- 9.9 versus 77.7 +/- 4.5 L, p less than 0.01); however, no difference was evident when carbamazepine Varea was corrected for body weight. In addition, weight loss coincided in all participants with a complete sonographic disappearance of the initial fatty liver infiltration noted on enrollment. In conclusion, obesity associated with fatty liver presents an enlarged carbamazepine Varea, prolonged carbamazepine t1/2, and reduced carbamazepine CL. Whenever carbamazepine is initiated in obese subjects, steady-state concentrations should be expected only after twice the time required to achieve steady state in lean subjects. Thus carbamazepine maintenance dose should be reduced, dose interval prolonged, and monitoring of carbamazepine plasma levels provided.

Evaluation of plasma low molecular weight antioxidant capacity by cyclic voltammetry.

The low molecular weight antioxidants (LMWA) of biological samples include many compounds and contribute to the total antioxidant capacity of the system. They act as direct chemical scavengers neutralizing, reactive oxygen-derived species (ROS), and contribute to the ability of the sample to cope with oxidative stress. We propose cyclic voltammetry (CV) as a new method for evaluating the antioxidant capacity of plasma-LMWA and the severity of oxidative stress exerted on the plasma. It is based on the reducing properties of these molecules. CV has been proven to be a simple, sensitive and reliable method. Its tracing does not change during storage of frozen plasma for up to six months. We analyzed the CV tracings by the oxidation potential E1/2, and the current heights Ia of its anodic wave(s). E1/2 indicates the specific component of the LMWA and its ability to donate electron(s); Ia indicates the concentration of this component. Two anodic waves have been identified in human plasma, at E1/2 = 420 +/- 25 and 920 +/- 25 mV. Ascorbate (AA) and urate (UA) were identified as major LMWA components of the first anodic wave, and were confirmed by HPLC-electrochemical detection. Ia was shown to depend linearly on the concentration of either of these LMWA, both in buffer and in plasma. Oxidative stress exerted by exposure to peroxyl radicals, copper ions and ionizing irradiation caused marked changes in the CV tracing. These changes represent corresponding alterations particularly in la, rather than in E1/2. The Ia and E1/2 values reflect the antioxidant capacity of the plasma, while the change of Ia value represents the severity of the oxidative stress induced.

Dietary fatty acids in the management of diabetes mellitus.

Dietary fatty acid recommendations for patients with diabetes mellitus may be neither similar to, nor extrapolated from, those for the normal population; some evidence suggests that diabetes prevalence may be correlated with the dietary ratio of n-6 to n-3 fatty acids. In human experiments, n-3 fatty acids may improve many of the metabolic sequelae of insulin resistance by lowering blood pressure and triacylglycerol concentrations. In animals, n-3 fatty acids may cause less weight gain than other fats; however, they may raise low-density-lipoprotein concentrations, increase hepatic glucose output, and decrease insulin secretion in non-insulin-dependent diabetes mellitus. In a minority of patients with insulin-dependent diabetes mellitus, glycemic control may be adversely affected n-6 Fatty acids lower plasma cholesterol but may increase lipoprotein oxidation. Glucose in the presence of transition metals may produce free radicals and result in pancreatic damage and the formation of glycosylation products that inhibit nitric oxide-mediated smooth muscle relaxation; fish oil may counter these effects. High-carbohydrate, low-fat diets, once recommended for diabetes mellitus, appear to aggravate hypertriglyceridemia and are inferior to diets high in monounsaturated fatty acids (MUFAs) if saturated fats are kept to a minimum. MUFA-rich diets improve lipid profiles and may also have antioxidant properties. However, high-fat diets-whatever their composition-promote obesity. Current advice individualizes carbohydrate and fat requirements to optimize blood glucose and lipid concentrations in a lifestyle program to control obesity, exercise, smoking, and blood pressure. Fatty acid modifications may fine-tune the diet if proper balance is kept between the different long-chain polyunsaturated fatty acids and antioxidant requirements.

Does dietary linolenic acid influence blood pressure?

Short-term intervention studies have shown that diets rich in polyunsaturated fats have hypotensive properties. We have studied the long-term effects of dietary fat on blood pressure (BP) using adipose-tissue, fatty acid composition analysis in 399 free-living male subjects (average age, 47 yr). Stepwise-regression analysis showed that adipose linoleic acid (18:2 n-6) was not associated with BP, whereas an absolute 1% increase in linolenic acid (18:3 n-3) was associated with a decrease of 5 mm Hg in the systolic, diastolic, and composite mean arterial BP. Linolenic acid (18:3) comprised only one-eighth the amount of linoleic acid (18:2)--the major polyunsaturate in adipose tissue and hence in the diet (2% vs 16%)--and yet it had a disproportionate association with BP. This may be related to its role as a precursor for the production of prostaglandins and/or other vasoregulators. Dietary manipulation with n-3 fatty acids may be helpful in the treatment and prevention of hypertension.

Breast-fed and formula-fed infants do not differ in immunocompetent cell cytokine production despite differences in cell membrane fatty acid composition.

BACKGROUND: Breast-fed and formula-fed infants differ in the amount and type of polyunsaturated fatty acids consumed. The fatty acid composition of cell membranes is related to dietary fatty acids and, in adults, changes in membrane fatty acid composition are accompanied by changes in monocyte cytokine production and hence a modification of the immunologic response. OBJECTIVE: Our objective was to determine whether production by immunocompetent cells of the proinflammatory cytokines interleukin 1 (IL-1) and tumor necrosis factor (TNF) differs between breast-fed and formula-fed infants. DESIGN: Twenty-six healthy infants (13 breast-fed and 13 fed modified cow-milk formula) aged 2-4 mo were studied. The fatty acid composition of red blood cell (RBC) membrane phospholipids was measured by gas-liquid chromatography and IL-1 and TNF release were measured in whole blood culture in bacterial-endotoxin-stimulated and unstimulated cells. RESULTS: The infants' ages, weights, hemoglobin concentrations, and white blood cell counts did not differ significantly between groups. The percentage of n-3 fatty acids of total RBC phospholipid fatty acids was significantly higher in breast-fed than in formula-fed infants (6.31 +/- 2.5% compared with 2.98 +/- 0.97%); docosahexaenoic acid (22:6n-3) concentrations were also markedly higher in breast-fed infants (5.1 +/- 1.2% compared with 2.2 +/- 0.9%, P: < 0.001), but eicosapentaenoic acid (20:5n-3) and docosapentaenoic acid (22:5n-3) concentrations did not differ significantly between groups. The percentage of n-6 fatty acids was not significantly different between groups. The percentage of oleic acid (18:1) was higher in formula-fed than in breast-fed infants (16.2 +/- 0.7% compared with 20.6 +/- 1.1%; P: < 0.001). IL-1 and TNF release in whole blood culture did not differ significantly between groups. CONCLUSION: The release of proinflammatory cytokines by immunocompetent cells does not differ significantly in breast-fed and formula-fed infants despite differences in cell membrane fatty acid composition.

Alterations in adipocyte free fatty acid re-esterification associated with obesity and weight reduction in man.

Using a newly developed in vitro technique, the rate of re-esterification of lipolyzed free fatty acids (FFA) in small fragments of human subcutaneous adipose tissue was measured. When related to simultaneous glycerol release, this measure permits the calculation of the molar ratios of glycerol and FFA leaving the adipocyte. In weight-stable, never-obese control subjects the molar ratio of FFA:glycerol leaving the adipocytes is 1.4:1. During fasting, this ratio climbs to 2.7:1, close to the theoretical maximum of 3.0:1. Adipocytes from weight-stable obese subjects do not differ significantly from adipocytes of control in regard to this ratio. However, the adipocytes of weight-stable reduced-obese (RO) subjects display a significantly higher FFA:glycerol ratio than the adipocytes of either control or obese subjects. The presence of this fasting-like physiology in adipose tissue from weight-stable RO subjects is of particular interest since these same individuals have other systemic metabolic and subjective findings compatible with caloric deprivation.

The relationship of dietary fat to plasma lipid levels as studied by factor analysis of adipose tissue fatty acid composition in a free-living population of middle-aged American men.

We have used adipose tissue biopsies to assess the quality of fat in the diet and its influence on plasma lipid levels in 413 free-living normolipidemic male subjects. Factor analysis identified three factors which separated the fatty acids on the basis of their chemical structure. F1--monounsaturates--animal fats; F2--saturates--carbohydrates; F3--polyunsaturates--vegetable oils. An increase in F1 was associated with an increase in plasma triglycerides (TG), plasma total cholesterol (TC), and VLDL-C: an increase in F2 led to a decrease in VLDL-C. A rise in F3 was associated with lowered TG, VLDL-C, and HDL-C but increased LDL-C. However, the contribution of each of these factors to the variance in TG, TC, LDL-C, and HDL-C was small, namely: 5.48, 1.30, 2.57, and 2.02%, respectively. A special relationship between F3 and VLDL-C was found such that 16.22% of its variance could be attributed to F3. Our conclusion is that adipose tissue composition and, by implication, the type of dietary fat intake, explains only a small proportion (1-19%) of the variance in plasma lipids in normolipidemic subjects.