Mediterranean diet trajectories and 20-year incidence of cardiovascular disease: The ATTICA cohort study (2002-2022).

BACKGROUND AND AIMS: Only few studies have assessed longitudinal dietary trends in relation to cardiovascular disease (CVD) risk. We aimed to evaluate the association between adherence to the Mediterranean diet, both baseline and longitudinal, and 20-year CVD incidence. METHODS AND RESULTS: This was a prospective study among 1988 Greek adults (50% men, age: 45 ± 14years). Adherence to the Mediterranean diet was evaluated at baseline and 10 years through the MedDietScore, based on which longitudinal Mediterranean diet trajectories were identified. CVD incidence was recorded at 20 years. Each one-unit increase in baseline MedDietScore was associated with an 8% reduction in 20-year CVD incidence. Compared to subjects in the lowest tertile of baseline MedDietScore, those in the highest exhibited a 44% lower 20-year CVD risk (relative risk: 0.56, 95% confidence interval: 0.32, 0.97) adjusted for age, sex, baseline body mass index, smoking, physical activity, presence of hypercholesterolemia, hypertension and diabetes mellitus, and family history of CVD; further adjustment for high-sensitivity C-reactive protein, uric acid and estimated glomerular filtration rate attenuated this association. Results were similar in models adjusted for longitudinal changes in body weight, physical activity and smoking, and 10-year medical status. Mediterranean diet trajectory analysis revealed that 24.7%, 8.6%, 45.8% and 20.9% of participants longitudinally sustained a low adherence, moved closer, moved away or sustained a high adherence, respectively; among those, the corresponding CVD incidence was 63.3%, 65.5%, 28.1% and 9.4% (p-value<0.001). CONCLUSION: The Mediterranean diet offers long-term protection against CVD, part of which is mediated by inflammation, uricemia and renal function.

Food Compass Score predicts incident cardiovascular disease: The ATTICA cohort study (2002-2022).

BACKGROUND: The Food Compass Score (FCS) is a novel nutrient profiling system, which evaluates food and diet quality. The present study aimed to prospectively assess the relationship of FCS with short-term (10 years) and long-term (20 years) cardiovascular disease (CVD) incidence and to explore whether this relationship is modified by long-term adherence to a Mediterranean type diet (MTD). METHODS: Volunteers of the ATTICA cohort study, with complete data for the calculation of FCS and incident CVD were included (n = 759). Development of CVD was determined at 10 and 20 years after baseline. Dietary intake was assessed through a validated food frequency questionnaire. The FCS was calculated for each participant based on the published algorithm. Long-term adherence to a MTD was evaluated through MedDietScore. RESULTS: FCS was inversely associated with CVD incidence (hazard ratio [HR] for 20-year follow-up = 0.97, 95% confidence interval [CI] = 0.95-0.99; HR for 10-year follow-up = 0.98, 95% CI = 0.96-1.01) in the total sample, as well as in those with a high baseline adherence to a MTD (HR for 20-year follow-up = 0.96, 95% CI = 0.93-0.99; HR for 10-year follow-up = 0.98, 95% CI = 0.95-1.02). FCS was also inversely associated with CVD risk in those who went away from the MTD (HR = 0.97, 95% CI = 0.96-0.99). CONCLUSIONS: FCS, a novel tool for assessing overall diet quality, was also found to be useful in identifying potential CVD candidates in a long-term period, even in populations with good background dietary habits, such as those following a MTD.

Exploring the Role of Irrational Beliefs, Lifestyle Behaviors, and Educational Status in 10-Year Cardiovascular Disease Risk: the ATTICA Epidemiological Study.

BACKGROUND: Irrational beliefs, maladaptive emotions, and unhealthy lifestyle behaviors can adversely affect health status. However, limited research has examined the association between irrational beliefs and cardiovascular disease (CVD). The aim of this study was to evaluate the association between irrational beliefs and the 10-year CVD incidence among apparently healthy adults, considering the potential moderating or mediating role of particular social and lifestyle factors. METHODS: The ATTICA study is a population-based, prospective cohort (2002-2012), in which 853 participants without a history of CVD [453 men (aged 45 ± 13 years) and 400 women (aged 44 ± 18 years)] underwent psychological evaluations. Among other tools, participants completed the irrational beliefs inventory (IBI, range 0-88), a self-reported measure consistent with the Ellis model of psychological disturbance. Demographic characteristics, detailed medical history, dietary, and other lifestyle habits were also evaluated. Incidence of CVD (i.e., coronary heart disease, acute coronary syndromes, stroke, or other CVD) was defined according to the International Coding Diseases (ICD)-10 criteria. RESULTS: Mean IBI score was 53 ± 2 in men and 53 ± 3 in women (p = 0.88). IBI score was positively associated with 10-year CVD risk (hazard ratio 1.07, 95%CI 1.04, 1.13), in both men and women, and more prominently among those with less healthy dietary habits and lower education status; specifically, higher educational status leads to lower IBI score, and in conjunction they lead to lower 10-year CVD risk (HR for interaction 0.98, 95%CI 0.97, 0.99). CONCLUSIONS: The findings of this study underline the need to build new, holistic approaches in order to better understand the inter-relationships between irrational beliefs, lifestyle behaviors, social determinants, and CVD risk in individuals.

Association Between Family History of Diabetes, Irrational Beliefs, and Health Anxiety with 10-Year Risk of Type 2 Diabetes Mellitus: the ATTICA Epidemiological Study (2002-2012).

BACKGROUND: This study aimed to examine the relationship between family history of diabetes, irrational beliefs, and health anxiety in the development of type 2 diabetes mellitus (T2DM). METHOD: ATTICA is a prospective, cohort study (2002-2012). The working sample included 845 participants (18-89 years), free of diabetes at baseline. Α detailed biochemical, clinical, and lifestyle evaluation was performed, while participants' irrational beliefs and health anxiety were assessed through the Irrational Beliefs Inventory and the Whiteley index scale, respectively. We evaluated the association between the participants' family history of diabetes mellitus with the 10-year risk of diabetes mellitus, both in the total study's sample and separately according to their levels of health anxiety and irrational beliefs. RESULTS: The crude 10-year risk of T2DM was 12.9% (95%CI: 10.4, 15.4), with 191 cases of T2DM. Family history of diabetes was associated with 2.5 times higher odds (2.53, 95%CI 1.71, 3.75) of T2DM compared to those without family history. Among participants with family history of diabetes, the highest likelihood of developing T2DM, regarding their tested psychological features (i.e., low/high irrational beliefs in the entire group, low/high health anxiety in the entire group, and low/high irrational beliefs, low/high healthy anxiety), had people with high irrational beliefs, low health anxiety (OR 3.70, 95%CI 1.83, 7.48). CONCLUSIONS: The findings underline the important moderating role of irrational beliefs and health anxiety in the prevention of T2DM, among participants at increased risk of T2DM.

The association of specific types of vegetables consumption with 10-year type II diabetes risk: Findings from the ATTICA cohort study.

BACKGROUND: The present study aimed to investigate the association between vegetable consumption, in total as well as per type/category, and 10-year type-2 diabetes mellitus (T2DM) incidence. METHODS: The ATTICA study was conducted during 2001-2012 in 3042 apparently healthy adults living in Athens area, Greece. A detailed biochemical, clinical, and lifestyle evaluation was performed; vegetable consumption (total, per type) was evaluated through a validated semi-quantitative food frequency questionnaire. After excluding those with no complete information of diabetes status or those lost at the 10-year follow-up, data from 1485 participants were used for the current analysis. RESULTS: After adjusting for several participants' characteristics, including overall dietary habits, it was observed that participants consuming at least 4 servings/day of vegetables had a 0.42-times lower risk of developing T2DM (hazard ratio [HR] = 0.42; 95% confidence interval [CI] = 0.29-0.61); the benefits of consumption were greater in women (HR = 0.29; 95% CI = 0.16-0.53) compared to men (HR = 0.56; 95% CI = 0.34-0.92). Only 33% of the sample consumed vegetables 4 servings/day. The most significant associations were observed for allium vegetables in women and for red/orange/yellow vegetables, as well as for legumes in men. CONCLUSIONS: The intake of at least 4 servings/day of vegetables was associated with a considerably reduced risk of T2DM, independently of other dietary habits; underlying the need for further elaboration of current dietary recommendations at the population level.

Visceral adipose tissue phenotype and hypoadiponectinemia are associated with aortic Fluorine-18 fluorodeoxyglucose uptake in patients with familial dyslipidemias.

BACKGROUND: The role of adipose tissue (AT) in arterial inflammation in familial dyslipidaemias is poorly studied. We investigated the relationship between AT and arterial inflammation in patients with heterozygous familial hypercholesterolemia (heFH) and familial combined hyperlipidemia (FCH). METHODS AND RESULTS: A total of 40 patients (20 heFH/20 FCH) and a subgroup of 20 of non-heFH/FCH patients were enrolled. Participants underwent blood sampling for serum adipokine measurements and Fluorine-18 fluorodeoxyglucose (18F-FDG) PET/CT imaging. Abdominal visceral (VAT) and subcutaneous (SAT) AT volumes and AT and abdominal aorta 18F-FDG uptake were quantified. FCH patients had increased VAT (pANOVA = 0.004) and SAT volumes (pANOVA = 0.003), lower VAT metabolic activity (pANOVA = 0.0047), and lower adiponectin levels (pANOVA = 0.007) compared to heFH or the control group. Log(Serum adiponectin) levels were correlated with aortic TBR (b = - 0.118, P = 0.038). In mediation analysis, VAT volume was the major determinant of circulating adiponectin, an effect partly mediated via VAT TBR. Clustering of the population of heFH/FCH by VAT volume/TBR and serum adiponectin identified two distinct patient clusters with significant differences in aortic TBR levels (2.11 ± 0.06 vs 1.89 ± 0.05, P= 0.012). CONCLUSIONS: VAT phenotype (increased VAT volume and/or high VAT TBR) and hypoadiponectinemia may account for the observed differences in arterial inflammation levels between heFH and FCH patients.

Quality of plant-based diets in relation to 10-year cardiovascular disease risk: the ATTICA cohort study.

PURPOSE: We prospectively evaluated the association between quality of plant-based diets and 10-year first fatal/non-fatal cardiovascular disease (CVD) incidence. METHODS: ATTICA study was conducted in the greater metropolitan Athens area, Greece, during 2001-2002 studying men and women (aged > 18 years old) free of CVD at baseline. Follow-up CVD assessment (2011-2012) was achieved in n = 2,020 participants (n = 317 cases). Dietary assessment was based on a validated semi-quantitative paper-based food frequency questionnaire. Overall, healthful, and unhealthful plant-based dietary indices (PDI, hPDI and uPDI) were calculated through a standard published procedure. The association between plant-based indices and CVD outcome has been evaluated via Cox regression analysis. RESULTS: The CVD event rate was 15.7% (n = 317) with a median follow-up time of 8.41 years. The highest (3rd PDI tertile) vs. lowest (1st tertile) adherence to plant-based pattern-irrespective to healthfulness of food products consumed-was inversely associated with CVD (hazard ratio (HR) 0.56; 95% confidence interval (95% CI) 0.14, 2.25) yet the CI was wide. Ranking from 1st to 2nd and 3rd hPDI tertile the CVD event rate was 6.4%, 10.5% and 16.2%, respectively (p = 0.003). Multi-variable adjusted analysis revealed that participants assigned in 2nd and 3rd hPDI tertile had 47% (HR 0.53; 95% CI 0.25-1.08) and 68% (HR 0.32; 95% CI 0.16-0.63) lower risk to develop CVD compared with their 1st tertile counterparts. Conversely, a positive association between uPDI and CVD risk was revealed in dose-response analysis (HR(per 5 units increase in uPDI) 1.34; 95% CI 0.95-2.37)). CONCLUSIONS: Quality of plant-based diets is important and needs to be considered, as not all plant-source foods have beneficial cardiovascular effects.

Meat consumption, depressive symptomatology and cardiovascular disease incidence in apparently healthy men and women: highlights from the ATTICA cohort study (2002-2012).

Objectives: To evaluate the association of meat consumption with prevalent depressive symptomatology and cardiovascular disease (CVD) incidence in apparently healthy individuals.Methods: ATTICA study was conducted during 2001-2012 including n = 1514 men and n = 1528 women (aged >18 years old) from the greater Athens area, Greece. At baseline, depressive symptomatology through Zung Self-Rating Depression Scale (range 20-80) and meat consumption (total meat, red, white and processed meat) through validated semi-quantitative food frequency questionnaire were assessed. Follow-up (2011-2012) was achieved in n = 2020 participants (n = 317 cases); n = 845 participants with complete psychological metrics were used for the primary analysis.Results: Ranking from 1st to 3rd total meat consumption (low to high) tertiles, participants assigned in 2nd tertile had the lowest depressive-symptomatology scoring (p<0.001). This trend was retained in multiadjusted logistic regression analysis; participants reporting moderate total and red meat consumption had ∼20% lower likelihood to be depressed (i.e. Zung scale<45) compared with their 1st tertile counterparts (Odds Ratio (OR)total meat 0.82, 95% Confidence Interval (95%CI) (0.60, 0.97) and ORred meat 0.79 95%CI (0.45, 0.96)). Non-linear associations were revealed; 2-3 serving/week total meat and 1-2 servings/week red meat presented the lowest odds of depressive symptomatology (all ps<0.05). These U-shape trends seemed to attenuate the aggravating effect of depressive symptomatology on CVD hard endpoints. All aforementioned associations were more evident in women (all ps for sex-related interaction<0.05).Discussion: The present findings generate the hypothesis that moderate total meat consumption and notably, red meat may be more beneficial to prevent depressed mood and in turn hard CVD endpoints.

Psychological factors in relation to the 10-year incidence of metabolic syndrome: The ATTICA epidemiological study (2002-2012).

BACKGROUND AND AIMS: Various bio-psychological mechanisms underlying the association between mental health problems and metabolic syndrome remain unknown. We investigated the role of irrational beliefs in conjunction with anxiety, depression and hostility in the 10-year metabolic syndrome (MetS) incidence, and the effect of biochemical and socio-behavioral factors on the aforementioned associations. METHODS AND RESULTS: ATTICA is a prospective, cohort study (2002-2012). The sample included 591 participants [51.3% men (aged 41.5 ± 10 years) and 48.7% women (aged 37.5 ± 11.5 years)], free of MetS at baseline. Detailed biochemical, clinical, and lifestyle evaluations were performed, while participants' irrational beliefs, anxiety, depression and hostility were assessed using the Irrational Beliefs Inventory, the Spielberger State-Trait Anxiety Inventory, the Zung Self-Rating Depression Scale and the Hostility and Direction of Hostility Questionnaire, respectively. Multiple logistic regression was applied to estimate the odds ratio (OR) of developing MetS and to control for confounders, as well as stratified logistic regression to detect moderator effects. High irrational beliefs were associated with 1.5-times higher odds of developing MetS than low irrational beliefs. Especially, participants with high irrational beliefs and high anxiety were 96% more likely to develop MetS, compared with those with low irrational beliefs and low or high anxiety (OR = 1.96; 95% CI = 1.01, 3.80). CONCLUSION: The findings of the study underline the important role of irrational beliefs and anxiety in the development of MetS and the need to build new holistic approaches focused on the primary prevention of both mental health and MetS.

Long-term prognostic value of LDL-C, HDL-C, lp(a) and TG levels on cardiovascular disease incidence, by body weight status, dietary habits and lipid-lowering treatment: the ATTICA epidemiological cohort study (2002-2012).

BACKGROUND: The link between blood lipids and cardiovascular disease (CVD) is complex. Our aim was to assess the differential effect of blood lipids on CVD risk according to age, sex, body weight, diet quality, use of lipid-lowering drugs and presence of hypercholesterolemia. METHODS: In this secondary analysis of the ATTICA prospective cohort study, serum blood lipids, i.e., total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG) and liproprotein(a) [Lp(a)], and sociodemographic, anthropometric, lifestyle and clinical parameters were evaluated at baseline (2001/2002) in 2020 CVD-free men and women. CVD incidence was recorded at the 10-year follow-up (2011/2012). RESULTS: All blood lipids assessed were univariately related to CVD risk; however, associations remained significant only for HDL-C and TG in multivariate models adjusted for age, sex, body mass index, smoking, Mediterranean Diet Score, physical activity, presence of hypercholesterolemia, hypertension and diabetes mellitus, use of lipid-lowering drugs, and family history of CVD [RR per 1 mg/dL (95% CI): 0.983 (0.967, 1.000) and 1.002 (1.001, 1.003), respectively]. In stratified analyses, TC and LDL-C predicted CVD risk in younger subjects, normal-weight subjects, and those not on lipid-lowering drugs, while HDL-C and TG were significant predictors in older subjects, those with low adherence to the Mediterranean diet, and hypercholesterolemic subjects; a significant effect on CVD risk was also observed for TG in males, overweight participants and lipid-lowering medication users and for Lp(a) in older subjects and females (all p ≤ 0.050). CONCLUSIONS: The impact of blood lipids on CVD risk differs according to several biological, lifestyle and clinical parameters.

How will the way we live look different in the wake of the COVID-19 pandemic? A nutrition survey in Greece.

Background: As we move towards a post-pandemic society, a question arises: How will the way we live look different in the wake of the COVID-19 pandemic? Aim: The aim of this survey was to evaluate changes in eating habits and other lifestyle behaviours (i.e., exercise and smoking) of people of almost all ages, who live in Greece, during the COVID-19 pandemic. Methods: A web-based survey using conventional sampling was conducted from during December 2020, in Greece. A total of 2258 individuals, aged 17 years and older voluntarily participated (912 (40%) men). Results: 89 (3.94%) of the participants reported that they had, or currently have been diagnosed with COVID-19. Moreover, 36.4% of the participants reported that they have changed their dietary habits during the pandemic towards a healthier diet - those participants had median age of 35 years, were of both sexes, 17% had co-morbidities and 69% with higher education level; moreover, 19% of those participants have started or increased the frequency of receiving dietary supplements that enhance the immune system, 34% of the participants reported that they gained weight during the pandemic period, whereas 19.8% reported that they have lost weight, and 37% of the participants reported that they have started or increased, as compared to the pre-pandemic time, their frequency of physical activities. Conclusions: The COVID-19_pandemic seems to have forced people to discover again habits and traditions towards a more natural and healthier way of living. Long-term consequences and the evolution of these lifestyle changes after the COVID-19 pandemic have to be evaluated relevant to their implications in public health.

The association between serum uric acid levels and 10-year cardiovascular disease incidence: results from the ATTICA prospective study.

Limited data suggests possible gender-specific association between serum uric acid (SUA) and cardiovascular disease (CVD) incidence. The aim of the present analysis was to evaluate the association between SUA levels and 10-year CVD incidence (2002-2012) in the ATTICA study participants. Overall, 1687 apparently healthy volunteers, with SUA measurements, residing in the greater metropolitan Athens area (Greece), were included. Multivariable Cox-regression models were used to estimate the hazard ratios for SUA in relation to 10-year CVD incidence. Receiver operating curve analysis was conducted to detect optimal SUA cut-off values. Participants in the 2nd and 3rd SUA tertile had 29 and 73% higher 10-year CVD incidence compared with those in the 1st tertile (p < 0.001). In gender-specific analysis, only in women SUA was independently associated with CVD incidence; women in the 3rd SUA tertile had 79% greater 10-year CVD event risk compared to their 1st tertile counterparts. Obese in the 3rd SUA tertile had 2-times higher CVD incidence compared to those in the 1st tertile. Similar findings were observed in metabolically healthy (vs. unhealthy) and metabolically healthy obese. SUA thresholds best predicting 10-year CVD incidence was 5.05 and 4.15 mg/dL (0.30 and 0.25 mmol/L) in men and women, respectively. In conclusion, increased SUA levels were independently related to 10-year CVD event rate in women, obese and metabolically healthy individuals. SUA could predict 10-year CVD incidence even at low levels. Further studies are warranted to identify SUA cut-off values that may improve the detection of individuals at higher CVD risk in clinical practice.

Comparison of the Mediterranean diet and the Dietary Approach Stop Hypertension in reducing the risk of 10-year fatal and non-fatal CVD events in healthy adults: the ATTICA Study (2002-2012).

OBJECTIVE: To compare the Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets in deterring 10-year CVD. DESIGN: Prospective cohort (n 2020) with a 10-year follow-up period for the occurrence of combined (fatal or non-fatal) CVD incidence (International Classification of Diseases (ICD)-10). Baseline adherence to the Mediterranean and DASH diets was assessed via a semi-quantitative FFQ according to the MedDietScore and DASH scores, respectively. SETTING: Attica, Greece. PARTICIPANTS: Two thousand twenty individuals (mean age at baseline 45·2 (sd 14·0) years). RESULTS: One-third of individuals in the lowest quartile of Mediterranean diet consumption, as compared with 3·1 % of those in the highest quartile, developed 10-year CVD (P < 0·0001). In contrast, individuals in the lowest and highest DASH diet quartiles exhibited similar 10-year CVD rates (n (%) of 10-year CVD in DASH diet quartiles 1 v. 4: 79 (14·7 %) v. 75 (15·3 %); P = 0·842). Following adjustment for demographic, lifestyle and clinical confounding factors, those in the highest Mediterranean diet quartile had a 4-fold reduced 10-year CVD risk (adjusted hazard ratio (HR) 4·52, 95 % CI 1·76, 11·63). However, individuals with highest DASH diet quartile scores did not differ from their lowest quartile counterparts in developing such events (adjusted HR 1·05, 95 % CI 0·69, 1·60). CONCLUSIONS: High adherence to the Mediterranean diet, and not to the DASH diet, was associated with a lower risk of 10-year fatal and non-fatal CVD. Therefore, public health interventions aimed at enhancing adherence to the Mediterranean diet, rather than the DASH diet, may most effectively deter long-term CVD outcomes particularly in Mediterranean populations.

The impact of socioeconomic and environmental determinants on Mediterranean diet adherence: a municipal-level spatial analysis in Athens metropolitan area, Greece.

The aim of this study was to identify the geographical variability, the socio-economic and the environmental determinants of adherence to the Mediterranean diet in a general population sample. Level of adherence to the Mediterranean diet was estimated by the ATTICA epidemiological study for 2,749 participants, while socio-economic, demographic, and environmental characteristics were provided by official national and international databases. Higher adherence to the Mediterranean diet was detected in areas with a greater proportion of females and older people, with lower unemployment rate and immigrant population, as well as, in areas covered at a greater extent by green and with higher frequency of supermarkets and street markets. The present findings provide evidence for policy makers to better understand how layers of influence intersect to shape individuals' eating habits, while they may also contribute in identifying areas of emerging interventions needed.

Dairy products, surrogate markers, and cardiovascular disease; a sex-specific analysis from the ATTICA prospective study.

BACKGROUND AND AIMS: Dairy products are a very diverse food group with multiple effects on the cardiac health of men and women. The aim of this work was to evaluate the sex-specific association between dairy products (total and subtypes) and 10-year first fatal/nonfatal cardiovascular disease (CVD) incidence. METHODS AND RESULTS: In 2001-2002, n = 1514 men and n = 1528 women (>18 years old) from greater Athens area, Greece, were enrolled. Dietary assessment was based on a validated semi-quantitative food frequency questionnaire. Dairy product consumption was examined in relation to 10-year CVD incidence. Follow-up (2011-2012) was achieved in n = 2020 participants (n = 317 CVD cases). Ranking from lowest (<1 serving/day) to highest (>2 servings/day) total dairy intake, CVD incidence in men was 17.8%, 15.0%, and 10.9% (p = 0.41), while in women it was 14%, 6.0%, and 5.7% (p = 0.02). Multiadjusted analysis revealed that total dairy intake protected against CVD only in women [Hazard Ratio (HR) = 0.48 and 95% Confidence Interval (95% CI) (0.23, 0.90)], irrespective of the fat content. Further analysis revealed that only fermented products (yogurt and cheese), protected against CVD. For per 200 g/day yogurt consumption, CVD risk was 20%-30% lower with this claim being more evident in women, while for per 30 g/day cheese intake, about 5% lower risk was observed particularly in men. As for butter, nonsignificant associations were highlighted. These associations were mainly retained in the case of hepatic steatosis, insulin resistance, and systemic inflammation. CONCLUSIONS: This work provides incentives for researchers to elucidate the diversity of ingredients and mechanisms through which dairy products exert their effect on cardiac health separately for men and women.

Association between lipids and apolipoproteins on type 2 diabetes risk; moderating effects of gender and polymorphisms; the ATTICA study.

BACKGROUND AND AIMS: Type 2 diabetes mellitus (T2DM) is a condition defined by hyperglycaemia, but also often presents with dyslipidaemia and suppressed HDL cholesterol. Mendelian randomization studies have suggested a causal link between low HDL cholesterol and T2DM. However, influences of gender, polymorphisms and lifestyle, all known to influence HDL cholesterol, have not been fully explored in a prospective cohort. METHODS AND RESULTS: In 2001-2002, a random sample of 1514 males (18-87 years old) and 1528 females (18-89 years old) were recruited in the ATTICA study. The 10-year follow-up (2011-2012) included 1485 participants. Lipids and lipoproteins levels, glucose and insulin levels were measured together with apolipoprotein A1 (apoA1) 75 G/A genotype, which is known to influence HDL-cholesterol. In total, 12.9% of the study sample developed T2DM within the 10-year follow-up period. In multivariable models, for each mg/dL increase in apoA1 levels in males, 10-year T2DM risk decreased 1.02%; while every unit increase in apoB/LDL-cholesterol ratio increased risk 4-fold. Finally, for every unit increase in triglycerides/apoA1 ratio, the risk increased 85%. HOMA-IR independently predicted T2DM 10-year incidence only for carriers of GG polymorphism (all, p < 0.05), but not in carriers of the GA polymorphism (all, p > 0.05). CONCLUSION: ApoA1 was associated with decreased T2DM risk and TG/ApoA1 and apoB/LDL were associated with increased risk of T2DM, only in males. ApoA1 polymorphism, which is associated with lower HDL cholesterol, influenced the predictive effects of HOMA-IR on T2DM incidence, which appeared to be moderated by physical activity, suggesting potential scope for more targeted preventative strategies.

Prognostic value of exercise tolerance test for predicting cardiovascular disease in asymptomatic individuals with heterozygous familiar hypercholesterolemia.

Heterozygous familiar hypercholesterolemia (hFH) is an autosomal dominant inherited dyslipidemia, associated with premature cardiovascular disease (CVD). Aim of the study was to define prognostic factors for cardiovascular events (CVE) in asymptomatic individuals with hFH. All participants with recent diagnosis of hFH were recruited from the outpatient lipid clinic from 1987 to 2016, without any previous clinical evidence of CVD. A detailed clinical evaluation and laboratory investigation was obtained. Exercise tolerance test (ETT) was performed until maximum exercise capacity was achieved, without evidence of ischemia. Primary endpoint of the study was the first CVE. Four hundred fifty one participants were followed up for 10 ± 8 years, with 68 recorded cases of CVD (15%). Cumulative incidence of CVD was 15%, 24% and 32% for the 3 decades, respectively. In univariate analysis, male gender (p = 0.016), progression of age (p < 0.001), menopause (p = 0.030), waist-hip ratio (p = 0.043) and increased levels of Lp(α) (p = 0.014) were significantly associated with increased CVD incidence; whereas, exercise capacity (p = 0.025), low variation of heart rate (HR) during all stages of ETT compared to resting state (p = 0.020), maximum systolic (p = 0.014) and diastolic (p < 0.001) blood pressure were inversely associated with CVD. In multi-adjusted analysis, male gender (p < 0.001), duration of ETT (p = 0.023), estimated HR (p = 0.029), variation of HR during ETT compared to resting state (p < 0.05) and maximum diastolic pressure (p = 0.044) were significantly associated with CVD. Parameters of ETT in asymptomatic individuals with hFH, without any evidence of ischemia, may predict CVD in these high-risk patients after decades of observation.

Waist-to-Height Ratio Outperforms Classic Anthropometric Indices in Predicting Successful Aging in Older Adults; an Analysis of the ATTICA and MEDIS Epidemiological Studies.

Background/Study context: The aim of the present work was to investigate the association of Waist-to-Height Ratio (WHtR) with Successful Aging (SA) status and compare it to classic anthropometric indices, among middle-aged and older individuals.Methods: Among various socio-demographic, clinical and lifestyle characteristics, height, weight, waist circumference (WC), Waist-to-Hip Ratio (WHR) and WHtR of the Greek participants, over 50 years old, enrolled in the ATTICA (n = 1,128) and the MEDIS (n = 2,221) in relation to SA; SA was evaluated using the validated Successful Aging Index (SAI, range 0-10) comprising of health-related, social, lifestyle, and clinical parameters.Results: WHtR was inversely associated with SAI with every 0.1-unit increase, lowering SAI by almost 0.5 units (b-coefficient±SE: -4.71 ± 0.26; 95%CI: -5.21, -4.20). Also, WHtR was more strongly associated with SAI (b = -0.352), surpassing the effect of age and sex (b = -0.347 and 0.11, respectively). With respect to the other anthropometric indices (weight, height, WC, WHR), WHtR exhibited the highest explanatory ability (Adjusted R2 = 0.345); the higher the adjusted R2 the higher explanatory ability.Conclusions: WHtR was revealed as the best determinant of successful aging, with respect to other anthropometric indices (weight, height, WC, WHR). The present findings are of significant public health importance for better understanding the role of body mass distribution on the aging process.

Visceral adiposity index outperforms common anthropometric indices in predicting 10-year diabetes risk: Results from the ATTICA study.

BACKGROUND: Visceral adiposity index (VAI) is a novel marker of visceral adipose tissue accumulation and dysfunction. The study aim was to explore the association of VAI with the 10-year type 2 diabetes mellitus (T2DM) incidence in apparently healthy individuals and compare its T2DM predictive ability against common anthropometric indices. METHODS: In 2001 to 2002, the ATTICA study (Greece) recruited a random sample of 1514 and 1528 CVD-free men (18-87 years old) and women (18-89 years old), respectively. Sociodemographic, lifestyle, clinical, and biochemical characteristics of participants were measured at baseline, and the 10-year follow-up was performed during 2011 to 2012. After excluding participants with diabetes at baseline and participants without complete follow-up information regarding diabetes status and/or baseline VAI values, the working sample consisted of 1049 participants. In this sample, the predictive value of baseline VAI value was studied in relation to 10-year diabetes incidence. RESULTS: One hundred thirty-three incident cases of diabetes were documented (10-year incidence: 12.7%). In the fully adjusted model, VAI significantly increased diabetes risk by 22% (OR per 1-unit increase =1.22; 95%CI, 1.09-1.37). Markers of oxidative stress and inflammation were found to, at least partly, mediate this relationship. Also, a moderating effect of menstruation status was revealed among women. VAI showed the highest predictive ability and contributed the most, along with waist-to-height ratio, to the correct classification of participants who developed diabetes. CONCLUSIONS: The present findings suggest that VAI may be a useful index for predicting long-term diabetes development and may exhibit better predictive ability to commonly used anthropometric indices.

Olive oil consumption and 10-year (2002-2012) cardiovascular disease incidence: the ATTICA study.

PURPOSE: Olive oil, being rich in mono-unsaturated fatty acids and anti-inflammatory compounds, may have protective effects against cardiovascular disease (CVD). The aim of the present work was to examine the association of olive oil consumption with the 10-year CVD incidence in adults without pre-existing CVD. METHODS: The ATTICA Study is a prospective, population-based study conducted in the greater metropolitan area of Athens (Attica, Greece). During 2001-2002, 3042 CVD-free adults (1514 men and 1528 women) were voluntarily recruited to the ATTICA study. Among various dietary habits, consumption of olive oil and other fats/oils was assessed at baseline; participants were classified into three groups (no use; mixed use; and exclusive use of olive oil). In 2011-2012, the 10-year study follow-up was performed, recording the fatal/non-fatal CVD incidence in 2020 participants (mean follow-up duration: 8.41 years). RESULTS: After controlling for various covariates, an inverse association between exclusive olive oil use and the risk of developing CVD was observed (relative risk 0.07, 95% CI: 0.01-0.66) compared to those not consuming olive oil. Further adjustment for fibrinogen plasma levels (among various inflammatory markers) showed a significant mediation effect on the previous association. CONCLUSIONS: These findings support exclusive olive oil consumption, a key component of the Mediterranean diet, for the primary CVD prevention, in adults without pre-existing disease. Circulating fibrinogen levels appear to play a mediating role in this relationship.