Association between a new dietary protein quality index and micronutrient intake adequacy: a cross-sectional study in a young adult Spanish Mediterranean cohort.

PURPOSE: There is no evidence of a dietary index that measures not only the quantity but also the quality of protein. The aim is to investigate the association between a new dietary protein quality index (PQI) and micronutrient intake adequacy in a Mediterranean cohort. DESIGN: We assessed 17,535 participants' diet at baseline using a semi-quantitative FFQ. The PQI was calculated according to the ratio of protein (g/d) sources: [fish, seafood, lean meat, pulses, eggs, nuts, low-fat dairy, and whole grains]/[red and ultra-processed meats, whole-fat or semi-skimmed dairy, potatoes and refined grains]. Participants were classified into quintiles of PQI. We evaluated the intakes of Fe, Cr, I, K, Mg, Ca, P, Na, Se, Zn and vitamins A, B1, B2, B3, B6, B12, C, E and folic acid. Micronutrient adequacy was evaluated using DRIs. Logistic regression analysis was used to assess the micronutrient adequacy according to quintiles of PQI. RESULTS: In this cross-sectional analysis, a total of 24.2% and 4.3% participants did not to meet DRIs in ≥ 4 and ≥ 8 micronutrients, respectively. The odds of failing to meet ≥ 4 and ≥ 8 DRI were lower in participants in the highest quintile of protein quality (OR = 0.22; IC 95% = 0.18, 0.26; P-trend < 0.001; and OR = 0.08; IC 95% = 0.05, 0.14; P-trend < 0.001, respectively) as compared to participants in the lowest quintile. CONCLUSION: Higher PQI was found to be strongly associated with better micronutrient intake adequacy in this Mediterranean cohort. The promotion of high-quality protein intake may be helpful for a more adequate intake of micronutrients. The odds of failing to meet certain numbers of DRIs were lower rather than saying lower risk.

Macronutrient quality index and cardiovascular disease risk in the Seguimiento Universidad de Navarra (SUN) cohort.

PURPOSE: To assess the association between a multi-dimensional Macronutrient Quality Index (MQI) and the risk of cardiovascular disease (CVD) in a Mediterranean cohort. METHODS: Prospective analyses among 18,418 participants (mean age 36 years, 60.8% women) of the Seguimiento Universidad de Navarra (SUN) cohort. Dietary intake information was obtained through a validated semi-quantitative food-frequency questionnaire (FFQ). The MQI (expressing high-quality macronutrient intake) was calculated based on three previously reported quality indices: the Carbohydrate Quality Index (CQI), the Fat Quality Index (FQI), and the Healthy Plate Protein source Quality Index (HPPQI). Adherence to the Mediterranean diet (MedDiet) and Provegetarian Diet was evaluated using the Trichopoulou index and the score proposed by Martínez-González, respectively. CVD was defined as new-onset stroke, myocardial infarction, or CVD death. RESULTS: After a median follow-up time of 14 years (211,744 person-years), 171 cases of CVD were identified. A significant inverse association was found between the MQI and CVD risk with multivariable-adjusted HR for the highest vs. the lowest quartile of 0.60 (95% IC, 0.38-0.96; Ptrend = 0.024). CONCLUSION: In this Mediterranean cohort, we found a significant inverse relationship between a multidimensional MQI (expressing high-quality macronutrient intake) and a lower risk of CVD.

A score appraising Paleolithic diet and the risk of cardiovascular disease in a Mediterranean prospective cohort.

PURPOSE: To assess the association between a score appraising adherence to the PaleoDiet and the risk of cardiovascular disease (CVD) in a Mediterranean cohort. METHODS: We included 18,210 participants from the Seguimiento Universidad de Navarra (SUN) cohort study. The PaleoDiet score comprised six food groups promoted within this diet (fruit, nuts, vegetables, eggs, meat and fish) and five food groups whose consumption is discouraged (cereals and grains, dairy products, legumes, culinary ingredients, and processed/ultra-processed foods). CVD was defined as acute myocardial infarction with or without ST elevation, non-fatal stroke and cardiovascular death. Cox proportional hazards models adjusted for potential confounders were fitted to assess the association between the PaleoDiet score and CVD risk, and the PaleoDiet and MedDiet indices to explore differences between both diets. RESULTS: During 12.2 years of follow-up, 165 incident CVD cases were confirmed. A significant inverse association was found between the PaleoDiet score and CVD (HR Q5 vs. Q1: 0.45, 95% CI 0.27-0.76, P for trend = 0.007). A weaker association that became non-significant was observed when the item for low consumption of ultra-processed foods was removed from the score. Joint analysis of PaleoDiet and MedDiet Trichopoulou scores suggested that the inverse association between PaleoDiet and CVD was mainly present when adherence to the MedDiet was also high (HR for high adherence vs low adherence to both diet scores: 0.22, 95% CI 0.08-0.64). CONCLUSIONS: Our findings suggest that the PaleoDiet may have cardiovascular benefits in participants from a Mediterranean country. Avoidance of ultra-processed foods seems to play a key role in this inverse association.

Change to a healthy diet in people over 70 years old: the PREDIMED experience.

PURPOSE: It is difficult to change dietary habits and maintain them in the long run, particularly in elderly people. We aimed to assess whether adherence to the Mediterranean diet (MedDiet) and cardiovascular risk factor were similar in the middle-aged and oldest participants in the PREDIMED study. METHODS: We analyzed participants belonging to the first and fourth quartiles of age (Q1 and Q4, respectively) to compare between-group differences in adherence to the nutritional intervention and cardiovascular risk factor (CRF) control during a 3-year follow-up. All participants underwent yearly clinical, nutritional, and laboratory assessments during the following. RESULTS: A total of 2278 patients were included (1091 and 1187 in Q1 and Q4, respectively). At baseline, mean ages were 59.6 ± 2.1 years in Q1 and 74.2 ± 2.6 years in Q4. In Q4, there were more women, greater prevalence of hypertension and diabetes, and lower obesity and smoking rates than the younger cohort (P ≤ 0.001, all). Adherence to the MedDiet was similar in Q1 and Q4 at baseline (mean 8.7 of 14 points for both) and improved significantly (P < 0.01) and to a similar extent (mean 10.2 and 10.0 points, respectively) during follow-up. Systolic blood pressure, low density-lipoprotein cholesterol, and body weight were similarly reduced at 3 years in Q1 and Q4 participants. CONCLUSION: The youngest and oldest participants showed improved dietary habits and CRFs to a similar extent after 3 years' intervention. Therefore, it is never too late to improve dietary habits and ameliorate CRF in high-risk individuals, even those of advanced age. REGISTRATION: The trial is registered in the London-based Current Controlled Trials Registry (ISRCTN number 35739639).

Healthful and unhealthful provegetarian food patterns and micronutrient intake adequacy in the SUN cohort.

OBJECTIVE: To investigate the association between different versions of a provegetarian food pattern (FP) and micronutrient inadequacy. DESIGN: Cross-sectional analysis. Dietary intake was assessed at baseline through a validated 136-item FFQ. Participants were classified according to groups of different versions of a provegetarian FP: overall, healthful and unhealthful. The prevalence of inadequate intake of vitamins B1, B2, B3, B6, B12, C, A, D, E, folic acid, Zn, I, Se, Fe, Ca, K, P, Mg and Cr was evaluated using the estimated average requirement (EAR) cut-point method and the probabilistic approach. Logistic regression analyses were conducted to estimate the probability of failing to meet EAR for either ≥ 3 or ≥ 6 micronutrients. SETTING: Seguimiento Universidad de Navarra (SUN) cohort. PARTICIPANTS: 17 825 Spanish adults. RESULTS: Overall, subjects in the highest group of the unhealthful provegetarian FP had the highest prevalence of inadequate dietary intake for every vitamin and mineral, compared to those in the lowest group. The adjusted OR of failing to meet ≥ 3 EAR (highest v. lowest group) was 0·65 (0·54, 0·69) for the overall, 0·27 (0·24, 0·31) for the healthful and 9·04 (7·57, 10·4) for the unhealthful provegetarian FP. CONCLUSION: A higher adherence to an overall and healthful provegetarian FP was inversely associated with the risk of failing to meet EAR values, whereas the unhealthful version was directly associated with micronutrient inadequacy. Provegetarian FP should be well planned, prioritising nutrient-dense plant foods and minimising ultra-processed and unhealthy ones.

Higher adherence to an empirically derived Mediterranean dietary pattern is positively associated with telomere length: the Seguimiento Universidad de Navarra (SUN) project.

Telomere integrity is influenced by oxidative stress. Also, inflammation-related factors, including nutritional factors, could modulate telomere integrity. The relationship between a posteriori-derived dietary patterns and telomere length (TL) has been scarcely investigated. Thus, our objective was to examine the association between empirically derived dietary patterns ascertained through principal component analysis (PCA) and TL in an older adult Spanish population. A total of 886 older adults (>55 years old; 645 males and 241 females) from the Seguimiento Universidad de Navarra (SUN) cohort were included in the study. TL was measured by monochrome multiplex real-time quantitative PCR. Age-adjusted TL was used for all analyses. Dietary patterns were identified by PCA based on thirty predefined candidate food groups collected from a validated 136-food items frequency questionnaire. Generalised linear models were fitted to obtain ß-coefficients and their 95 % CI evaluating differences in TL between each of the four upper quintiles of adherence to dietary patterns and the lowest quintile. Sensitivity analyses by rerunning all multiple linear models under different stratifications were performed to evaluate the robustness of our results. Two major dietary patterns were empirically identified, Western dietary pattern (WDP) and Mediterranean dietary pattern (MDP). After adjustment for potential confounders, longer TL was found among subjects in the highest quintile of MDP (ß = 0·064; 95 % CI 0·004, 0·123). The WDP showed no significant association with TL. In conclusion, higher adherence to a posteriori-derived MDP was independently associated with longer telomeres in an older adult Spanish population of the SUN project.

Scoping review of Paleolithic dietary patterns: a definition proposal.

The Paleolithic diet (PaleoDiet) is an allegedly healthy dietary pattern inspired by the consumption of wild foods and animals assumed to be consumed in the Paleolithic era. Despite gaining popularity in the media, different operational definitions of this Paleolithic nutritional intake have been used in research. Our hypothesis is that specific components used to define the PaleoDiet may modulate the association of this diet with several health outcomes. We comprehensively reviewed currently applied PaleoDiet scores and suggested a new score based on the food composition of current PaleoDiet definitions and the theoretical food content of a staple dietary pattern in the Paleolithic age. In a PubMed search up to December 2019, fourteen different PaleoDiet definitions were found. We observed some common components of the PaleoDiet among these definitions although we also found high heterogeneity in the list of specific foods that should be encouraged or banned within the PaleoDiet. Most studies suggest that the PaleoDiet may have beneficial effects in the prevention of cardiometabolic diseases (type 2 diabetes, overweight/obesity, CVD and hyperlipidaemias) but the level of evidence is still weak because of the limited number of studies with a large sample size, hard outcomes instead of surrogate outcomes and long-term follow-up. Finally, we propose a new PaleoDiet score composed of eleven food items, based on a high consumption of fruits, nuts, vegetables, fish, eggs and unprocessed meats (lean meats); and a minimum content of dairy products, grains and cereals, and legumes and practical absence of processed (or ultra-processed) foods or culinary ingredients.

Effect of branched-chain amino acid supplementation, dietary intake and circulating levels in cardiometabolic diseases: an updated review.

PURPOSE OF REVIEW: Branched-chain amino acids (BCAAs) are essential amino acids derived from diet. BCAA supplementation has been recommended in elderly and athletes, but recent studies suggest an association between high dietary BCAAs and blood levels of BCAAs with greater risk of cardiometabolic diseases (CMD). This review aims to integrate current epidemiological evidence analyzing the association between BCAAs and related-CMD risk factors. RECENT FINDINGS: Most epidemiological studies consistently show that dietary BCAAs are associated with higher risk of type-2 diabetes (T2D) whereas there is limited evidence related with other cardiovascular risk factors. Evidence also exists showing an association between higher circulating BCAA levels and risk of T2D and cardiovascular disease, and also probably with metabolic syndrome and overweight/obesity. Several clinical trials suggest beneficial cardiometabolic effect of BCAAs supplementation, although with a small sample size and short follow-up. Studies show a weak correlation between dietary BCAAs and circulating BCAA levels. Protein quality sources and whole dietary pattern are key aspects to improve our understanding of the effect of BCAAs as well as factors associated with higher protein needs, such as age or frailty. SUMMARY: Dietary and circulating BCAAs exhibit possible detrimental cardiometabolic effects, but BCAA supplementation may have some positive influence on target groups with nutritional deficiencies.

Mediterranean diet, physical activity and their combined effect on all-cause mortality: The Seguimiento Universidad de Navarra (SUN) cohort.

The health benefits of the Mediterranean diet (MedDiet) and of physical activity (PA) have been widely documented. However, no longitudinal studies have investigated their combined effect on mortality. We assessed the individual and combined effects of adherence to the MedDiet and PA on all-cause mortality. We used data from 19,467 participants from a prospective cohort of Spanish university graduates, the SUN cohort, followed-up between December 1999 and February 2016. Adherence to the MedDiet was assessed using four different dietary scores, categorizing the quantitative scores into tertiles of adherence. To assess multiple dimensions of PA, an 8-item score was built. Multivariable Cox regression models were used to study the individual and combined relationship of adherence to the MedDiet and PA with all-cause mortality. During a median follow-up of 10.3years, we registered 305 deaths. Compared with the lowest adherence to the MedDiet (<20 in the modified Mediterranean diet score), better adherence (23-30 points) was associated with lower mortality (multivariable-adjusted hazard ratio [HR]=0.66, 95% confidence interval [CI]: 0.46-0.96). Engaging in moderate or high levels of PA (versus lower levels) was associated with 44% and 52% relative reductions in mortality, respectively. High adherence to the MedDiet combined with engaging in higher amounts of PA showed a HR=0.36 (95% CI: 0.19-0.67). We documented that the combined effect of better adherence to the MedDiet and increased PA had multiplicative effects on mortality risk reduction.

Added sugars and sugar-sweetened beverage consumption, dietary carbohydrate index and depression risk in the Seguimiento Universidad de Navarra (SUN) Project.

The association between added sugars or sugar-sweetened beverage consumption and the risk of depression, as well as the role of carbohydrate quality in depression risk, remains unclear. Among 15 546 Spanish university graduates from the Seguimiento Universidad de Navarra (SUN) prospective cohort study, diet was assessed with a validated 136-item semi-quantitative FFQ at baseline and at 10-year follow-up. Cumulative average consumption of added sugars, sweetened drinks and an overall carbohydrate quality index (CQI) were calculated. A better CQI was associated with higher whole-grain consumption and fibre intake and lower glycaemic index and consumption of solid (instead of liquid) carbohydrates. Clinical diagnoses of depression during follow-up were classified as incident cases. Multivariable time-dependent Cox regression models were used to estimate hazard ratios (HR) of depression according to consumption of added sugars, sweetened drinks and CQI. We observed 769 incident cases of depression. Participants in the highest quartile of added sugars consumption showed a significant increment in the risk of depression (HR=1·35; 95 % CI 1·09, 1·67, P=0·034), whereas those in the highest quartile of CQI (upper quartile of the CQI) showed a relative risk reduction of 30 % compared with those in the lowest quartile of the CQI (HR=0·70; 95 % CI 0·56, 0·88). No significant association between sugar-sweetened beverage consumption and depression risk was found. Higher added sugars and lower quality of carbohydrate consumption were associated with depression risk in the SUN Cohort. Further studies are necessary to confirm the reported results.

Micronutrient intake adequacy and depression risk in the SUN cohort study.

PURPOSE: The aim of the study was to prospectively assess the association between micronutrient intake adequacy and risk of depression. METHODS: This dynamic cohort study involves Spanish university graduates (SUN Project). Dietary intake was assessed at baseline and after 10 years of follow-up with a semi-quantitative food frequency questionnaire. Micronutrient intake adequacy for vitamins B1, B2, B3, B6, B12, C, A, D, E, folic acid, zinc, iodine, selenium, iron, calcium, potassium, phosphorus, magnesium and chrome was estimated. Inadequate intake for each nutrient was defined when the intake of the nutrient was below the estimated average requirements (EAR) if available or the adequate intake levels, if EARs were not available. We compared participants with inadequate intake for ≥4 nutrients vs. those with one nutrient. Participants were classified as having incident depression if they had no previous history of depression or antidepressants use at baseline, but they reported during follow-up a new clinical diagnosis of depression by a physician, use of antidepressant drugs, or both. Time-dependent multivariable Cox regression models were fitted. RESULTS: After a median follow-up of 8.5 years, 953 new cases of depression were observed among 13,983 participants. Participants with inadequate intake for ≥4 nutrients showed a significantly higher risk of depression [multivariable hazard ratio (HR) = 1.37; 95% confidence interval (CI) 1.01-1.85]. When the analyses were updated with repeated assessments of intakes, the association was attenuated and it was no longer statistically significant (Multivariable HR = 1.11; 95% CI 0.82-1.51). CONCLUSIONS: Micronutrient inadequacy in four or more micronutrients could exert a moderate role in the development of depression.

Self-perceived level of competitiveness, tension and dependency and depression risk in the SUN cohort.

BACKGROUND: Emerging evidence suggests a possible etiologic role of certain personality traits (not necessary dysfunctional) in the risk of depression, but the longitudinal long-term available evidence is currently scarce. We longitudinally assessed whether 3 common personality traits (competitiveness, tension and dependency) were associated with the risk of depression after a maximum follow-up of 15 years. METHODS: We assessed 15,604 university graduates free of depression at baseline through a self-administered questionnaire including personality traits. Simple, Likert-type, questions with 11 possible answers ranging from 0 to 10 were used at baseline to assess the 3 personality traits. We compared participants with high scores (7-10) versus those with low scores (0-4). New medical diagnoses of depression during follow-up were used as the outcome. RESULTS: During a median follow-up of 10.1 y, we prospectively identified 902 new medical diagnoses of depression. The multivariable-adjusted hazard ratios (95% confidence intervals) for depression were 1.85 (1.52-2.24) for participants with higher baseline tension (7-10 versus 0 to 4), P-trend < 0.001; and 1.23 (1.06-1.44) for high versus low baseline dependence levels, P-trend = 0.004. Higher levels of competitiveness were marginally associated with lower risk of depression, with hazard ratio = 0.78 (0.61-1.01), P-trend = 0.105. CONCLUSION: A simple scoring system of personality traits shows an independent association with the future occurrence of depression. This finding underscores, with now prospective evidence, the importance of personality traits in the aetiology of depression and can provide a clinically useful tool for gathering valid information about depression-related personality traits.

Ten-Year Changes in Healthy Eating Attitudes in the SUN Cohort.

OBJECTIVE: The objective of this study was to assess the within-subject longitudinal changes in self-perceived healthy eating attitudes after 10 years of follow-up and to identify predictors of long-term changes in a middle-aged adult cohort. METHODS: Four thousand five hundred seventy-two participants completed a validated food frequency questionnaire (FFQ) at baseline and after 10 years of follow-up. The FFQ was expanded with a brief 10-item questionnaire about eating attitudes with 2 possible answers: yes or no. A baseline score and a 10-year score were calculated with these 10 items (range from 0 to 10). Participants were categorized into 3 groups according to this score. Linear and logistic regressions were used to examine changes at follow-up and associations between baseline characteristics and improvement in the score. RESULTS: After 10 years of follow-up, a statistically significant favorable change (p < 0.001) was achieved in all questions about eating attitudes, particularly in these items: "Do you try to eat less sweets and pastries?" (12%), "Do you try to eat less meat?" (11.1%), and "Do you try to reduce your fat intake?" (10%). Being female (odds ratio [OR] = 1.19, 95% confidence interval [CI], 1.02-1.39), being 35-50 or ≥ 50 years old (OR = 1.24, 95% CI, 1.07-1.44 and OR = 1.74, 95% CI, 1.38-2.18, respectively), a high level of physical activity (OR for third vs first tertile = 1.20, 95% CI, 1.02-1.41), and a higher Mediterranean diet score (OR for second and third tertiles = 1.18, 95% CI, 1.01-1.37 and OR = 1.26, 95% CI, 1.04-1.52, respectively) were associated with a higher probability of improving the eating attitudes score, while a low body mass index (BMI; OR = 0.71, 95% CI, 0.51-1.00) and snacking between meals (OR = 0.84, 95% CI, 0.73-0.97) were associated with a lower probability of improving their score. CONCLUSIONS: The eating attitudes of the participants in the Seguimiento Universidad de Navarra (SUN) cohort became more favorable after 10 years of follow-up. Certain sociodemographic or clinical variables may predict a positive change.

Healthy-eating attitudes and the incidence of cardiovascular disease: the SUN cohort.

There is an emerging use of brief dietary questionnaires to investigate diet-health relation. We prospectively assess the association between eating attitudes (yes/no) and incident cardiovascular disease (CVD) in 19,138 participants of the Seguimiento Universidad de Navarra (SUN) Cohort. We calculated a baseline healthy-eating attitudes score (in quartiles), positively weighting answers on more fruit, vegetables, fish and fiber and less meat, sweets and pastries, fat, butter, fatty meats and added sugar in drinks. We observed 139 incident cases of CVD. A higher score was associated with a lower risk of CVD [3-5 points Hazard Ratio (HR): 0.38 (95% confidence interval: 0.18-0.81); 6-8 points: 0.57 (0.29-1.12); 9-10 points: 0.31 (0.15-0.67), compared to 0-2 points]. Key contributors were the attitude to increase fruit [HR: 0.59 (0.40-0.87)], vegetables [HR: 0.57 (0.29-1.12)] and fiber intake [HR: 0.69 (0.48-0.98)]. Brief questionnaire on attitudes towards healthy-eating may be a useful tool for the primary prevention of CVD.

Predictors of short- and long-term adherence with a Mediterranean-type diet intervention: the PREDIMED randomized trial.

BACKGROUND: Dietary intervention success requires strong participant adherence, but very few studies have examined factors related to both short-term and long-term adherence. A better understanding of predictors of adherence is necessary to improve the design and execution of dietary intervention trials. This study was designed to identify participant characteristics at baseline and study features that predict short-term and long-term adherence with interventions promoting the Mediterranean-type diet (MedDiet) in the PREvención con DIeta MEDiterránea (PREDIMED) randomized trial. METHODS: Analyses included men and women living in Spain aged 55-80 at high risk for cardiovascular disease. Participants were randomized to the MedDiet supplemented with either complementary extra-virgin olive oil (EVOO) or tree nuts. The control group and participants with insufficient information on adherence were excluded. PREDIMED began in 2003 and ended in 2010. Investigators assessed covariates at baseline and dietary information was updated yearly throughout follow-up. Adherence was measured with a validated 14-point Mediterranean-type diet adherence score. Logistic regression was used to examine associations between baseline characteristics and adherence at one and four years of follow-up. RESULTS: Participants were randomized to the MedDiet supplemented with EVOO (n = 2,543; 1,962 after exclusions) or tree nuts (n = 2,454; 2,236 after exclusions). A higher number of cardiovascular risk factors, larger waist circumference, lower physical activity levels, lower total energy intake, poorer baseline adherence to the 14-point adherence score, and allocation to MedDiet + EVOO each independently predicted poorer adherence. Participants from PREDIMED recruiting centers with a higher total workload (measured as total number of persons-years of follow-up) achieved better adherence. No adverse events or side effects were reported. CONCLUSIONS: To maximize dietary adherence in dietary interventions, additional efforts to promote adherence should be used for participants with lower baseline adherence to the intended diet and poorer health status. The design of multicenter nutrition trials should prioritize few large centers with more participants in each, rather than many small centers. TRIAL REGISTRATION: This study was registered at controlled-trials.com (http://www.controlled-trials. com/ISRCTN35739639). International Standard Randomized Controlled Trial Number (ISRCTN): 35739639. Registration date: 5 October 2005. TRIAL DESIGN: parallel randomized trial.

Association between dietary fibre intake and fruit, vegetable or whole-grain consumption and the risk of CVD: results from the PREvención con DIeta MEDiterránea (PREDIMED) trial.

Prospective studies assessing the association between fibre intake or fibre-rich food consumption and the risk of CVD have often been limited by baseline assessment of diet. Thus far, no study has used yearly repeated measurements of dietary changes during follow-up. Moreover, previous studies included healthy and selected participants who did not represent subjects at high cardiovascular risk. We used yearly repeated measurements of diet to investigate the association between fibre intake and CVD in a Mediterranean cohort of elderly adults at high cardiovascular risk. We followed-up 7216 men (55-80 years) and women (60-80 years) initially free of CVD for up to 7 years in the PREvención con DIeta MEDiterránea study (registered as ISRCTN35739639). A 137-item validated FFQ was repeated yearly to assess diet. The primary end point, confirmed by a blinded ad hoc Event Adjudication Committee, was a composite of cardiovascular death, myocardial infarction and stroke. Time-dependent Cox's regression models were used to estimate the risk of CVD according to baseline dietary exposures and to their yearly updated changes. We found a significant inverse association for fibre (P for trend=0·020) and fruits (P for trend=0·024) in age-sex adjusted models, but the statistical significance was lost in fully adjusted models. However, we found a significant inverse association with CVD incidence for the sum of fruit and vegetable consumption. Participants who consumed in total nine or more servings/d of fruits plus vegetables had a hazard ratio 0·60 (95 % CI 0·40, 0·96) of CVD in comparison with those consuming <5 servings/d.

Nutritional adequacy according to carbohydrates and fat quality.

PURPOSE: To investigate the association between carbohydrate quality, fat quality or adherence to the Mediterranean diet and intake adequacy of 19 micronutrients in the PREDIMED (PREvención con DIeta MEDiterránea) trial, a multicenter, randomized, controlled, parallel group and primary prevention trial conducted in Spain. METHODS: We assessed baseline dietary intake of 6,542 elderly subjects at high cardiovascular risk through a validated food frequency questionnaire (FFQ) and a validated 14-item Mediterranean diet (Med-diet) score. We used a multidimensional carbohydrate quality index (CQI) using four criteria and a fat quality index (FQI) according to the ratio (MUFA + PUFA)/(SFA + TFA). The probability of intake adequacy was calculated comparing the intakes to DRI, and also using the probabilistic approach. Absolute and adjusted probability of having inadequate intake for either ≥6 DRI or ≥8 DRI were estimated to assess nutritional adequacy according to quintiles of each index. RESULTS: The lowest prevalence of inadequate micronutrient intake (≥8 DRI) was found in the highest quintile of CQI or Med-diet score, and in the lowest quintile of FQI (adjusted fold risk: 1.4, 3.4 and 10.2 respectively in comparison with the lowest quintile). P for trend <0.001 in three multivariable models. A higher CQI or Med-Diet score and a lower FQI were significantly associated with a lower fold risk of unmet EAR values. CONCLUSIONS: A multidimensional assessment of CQI can be a useful tool to evaluate the quality of carbohydrates. This score and a 14-item Med-diet score were positively related to overall micronutrient adequacy in elderly participants.

Fat intake in children with autism spectrum disorder in the Mediterranean region (Valencia, Spain).

OBJECTIVE: Children with autism spectrum disorder (ASD) have been found to have alterations in dietary fat intake and fat quality. The fat intakes of the foods consumed by children with and without ASD were compared, and the deficiency and excess of these nutrients were examined. METHODS: In a matched case-control study, 3-day food diaries were completed by 105 children with ASD and 495 typically developing (TD) 6- to 9-year-old children in Valencia (Spain). We used the probabilistic approach and estimated average requirement cut-point to evaluate the risk of inadequate nutrients intakes. These were compared between groups and with Spanish recommendations using linear and logistic regression, respectively. RESULTS: Groups did not differ significantly in age, total dietary intake, Healthy Eating Index, or food variety score. Children with ASD had lower saturated fatty acids (SFAs) and ω-3 polyunsaturated fatty acids (PUFAs) intakes, but their total PUFAs and (PUFAs + monounsaturated fatty acids (MUFAs)/SFAs, PUFAs/SFAs intakes and ω-6/ω-3 ratios were higher than TD children. The total fat and cholesterol intakes of both groups were slightly above Spanish recommendations. Both groups had low ω-6 intakes, very low ω-3 intakes, and high ω-6/ω-3 ratios. CONCLUSION: Further research is required to clarify associations between ASD symptomatology, fat-eating patterns and health status.

Snacking between main meals is associated with a higher risk of metabolic syndrome in a Mediterranean cohort: the SUN Project (Seguimiento Universidad de Navarra).

OBJECTIVE: To evaluate the association of snacking between main meals with the risk of developing metabolic syndrome. DESIGN: A dynamic prospective cohort study (the SUN Project; Seguimiento Universidad de Navarra). Snack consumption was evaluated using the question: 'Do you have the habit of snacking between main meals?' Metabolic syndrome was defined according to the updated harmonizing criteria. We estimated multivariable-adjusted relative risks (RR) of metabolic syndrome and their 95 % confidence intervals using Poisson regression models. An exploratory factor analysis was also used to identify patterns of snacking. SETTING: University of Navarra, Spain. SUBJECTS: The study included 6851 university graduates, initially free of metabolic syndrome, and followed-up them for a median of 8·3 years. RESULTS: Among our participants, 34·6% reported usual snacking between main meals. The cumulative incidence of metabolic syndrome was 5·1 % (9·5% among men and 2·8% among women). Snacking between main meals was significantly associated with higher risk for developing metabolic syndrome after multivariable adjustment (RR=1·44; 95%CI 1·18, 1·77). Higher adherence to an 'unhealthy snacking pattern' was also independently associated with increased incidence of metabolic syndrome (fourth quartile of adherence compared with non-snacking: RR=1·68; 95% CI 1·23, 2·29; P for trend <0·001). CONCLUSIONS: Our findings suggest that avoidance of snacking between main meals can be included among the preventive approaches to reduce the risk of metabolic syndrome development, especially when snacks contain foods of poor nutritional quality.

Beneficial changes in food consumption and nutrient intake after 10 years of follow-up in a Mediterranean cohort: the SUN project.

BACKGROUND: The assessment of changes in dietary habits provides interesting information on whether or not the observed trends are in line with accepted nutritional guidelines. The objective was to evaluate within-subject longitudinal changes in food consumption and nutrient intake and in a 10-year follow-up study. METHODS: The SUN (Seguimiento Universidad de Navarra) project is a prospective Spanish cohort study. Diet was assessed using a 136-item food-frequency questionnaire (FFQ), previously validated in Spain. The participants were 3036 university graduates (55.8 % women) of Spain and the main outcome measures the changes in dietary quality and in food consumption and nutrient intake. Paired t-tests and conditional logistic regression models were used to evaluate within-subject longitudinal dietary changes and the risk of inadequacy respectively, after 10 years of follow-up. RESULTS: During follow-up, participants showed a relevant and significant increase (p < 0.001) in the consumption of fruits (7.4 %), vegetables (8.6 %), low-fat dairy products (35.2 %), lean meat (12.4 %), fish (2.9 %), whole grains (53.2 %), nuts (52.4 %) and a significant decrease in legumes (-7.4 %), whole-fat dairy products (-44.2 %), red meat (-17.6 %), sugar-sweetened beverages (-58.7 %) and wine (-11.9 %). With respect to nutrients, we found a higher proportion of carbohydrates (3.6 %) and fiber (7.4 %) and a decrease in total energy intake (2.7 %), total fat (-4.5 %), SFA (-9.4 %), MUFA (-4.9 %), PUFA (-12.7 %), w-3 and w-6 fatty acids (-9.1 and -20.5 % respectively) and cholesterol (-9.6 %). CONCLUSIONS: In this Mediterranean cohort study, mainly beneficial changes in the consumption of most foods and macronutrients were observed after 10 years of follow-up.