The SHED Index: a tool for assessing a Sustainable HEalthy Diet.

PURPOSE: Promoting sustainable diets through sustainable food choices is essential for achieving the sustainable development goals set by the United Nations. Establishing a practical tool that can measure and score sustainable and healthy eating is highly important. METHODS: We established a 30-item questionnaire to evaluate sustainable-dietary consumption. Based on the literature and a multidisciplinary advisory panel, the questionnaire was computed by principal component analysis, yielding the Sustainable-HEalthy-Diet (SHED) Index. A rigorous multi-stage process included validation in training-verification sets, across recycling efforts, as an indicator of environmental commitment; and validation across the proportion of animal-protein consumption, as an indicator of adherence to a sustainable and healthy dietary-pattern. The EAT-Lancet reference-diet and the Mediterranean-Diet-score were used to investigate the construct validity of the SHED Index score. Reliability was assessed with a test-retest sample. RESULTS: Three-hundred-forty-eight men and women, aged 20-45 years, completed both the SHED Index questionnaire and a validated Food-Frequency-Questionnaire. Increased dietary animal-protein intake was associated with a lower SHED Index total score (p < 0.001). Higher recycling efforts were associated with a higher total SHED Index score (p < 0.001). A linear correlation was found between the SHED Index score and food-groups of the Eat-Lancet-reference diet. A significant correlation was found between the Mediterranean-Diet-score and the SHED Index score (r = 0.575, p < 0.001). The SHED Index score revealed high reliability in test-retest, high validity in training and verification sets, and internal consistency. CONCLUSION: We developed the SHED Index score, a simple, practical tool, for measuring healthy and sustainable individual-diets. The score reflects the nutritional, environmental and sociocultural aspects of sustainable diets; and provides a tangible tool to be used in intervention studies and in daily practice.

Declining Rate and Severity of Hospitalized Stroke From 2004 to 2013: The National Acute Stroke Israeli Registry.

BACKGROUND AND PURPOSE: Stroke is a leading cause of morbidity and disability. We assessed trends in rates of hospitalized stroke and stroke severity on admission in a prospective national registry of stroke from 2004 to 2013. METHODS: All 6693 acute ischemic strokes and intracerebral hemorrhage in the National Acute Stroke Israeli participants ≥20 years old were included. Data were prospectively collected in 2004 (February-March), 2007 (March-April), 2010 (April-May), and 2013 (March-April). Rates of hospitalized stroke from 2004 to 2013 were studied using generalized linear models assuming a quasi-Poisson error distribution with a log link. Stroke severity on admission was determined using the National Institutes of Health Stroke Scale score and trends were studied. Analysis was performed for stroke overall and by sex and age-group as well as by stroke type. RESULTS: Estimated average annual rates of hospitalized stroke decreased from 24.9/10 000 in 2004 to 19.5/10 000 in 2013. The age and sex-adjusted rates ratio (95% confidence interval) for hospitalized stroke overall was 0.82 (0.76-0.89) for 2007, 0.71 (0.65-0.77) for 2010, and 0.72 (0.66-0.78) for 2013 compared with 2004. Severity on admission decreased over time: rates (95% confidence interval) of severe stroke (National Institutes of Health Stroke Scale score of ≥11) decreased from 27% (25%-29%) in 2004 to 19% (17%-21%) in 2013, whereas rates (95% confidence interval) of minor stroke (National Institutes of Health Stroke Scale score of ≤5) increased from 46% (44%-49%) in 2004 to 60% (57%-62%) in 2013 (P<0.0001). Findings were consistent by sex, age-group, and stroke type. CONCLUSIONS: Based on our national data, rates of hospitalized stroke and severity of stroke on admission have decreased from 2004 to 2013 overall and by stroke type, in men and women. Despite the observed declines in rates and severity, stroke continues to place a considerable burden to the Israeli health system.

Developing a risk score to predict mortality in the first year after implantable cardioverter defibrillator implantation: Data from the Israeli ICD Registry.

INTRODUCTION: Life expectancy of less than 1 year is usually a contraindication for implantable cardioverter defibrillator (ICD) implantation. The aim was to identify patients at risk of death during the first year after implantation. METHODS AND RESULTS: Data were derived from a prospective Israeli ICD Registry. Two groups of patients were compared, those who died and those who were alive 1 year after ICD implantation. Factors associated with 1-year mortality were identified on a derivation cohort. A risk score was established and validated. A total of 2617 patients have completed 1 year of follow-up after ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Age greater than 75 years (hazard ratio [HR], 2.7; 95% confidence interval [95% CI], 1.6 to 4.4), atrial fibrillation (AF; HR, 1.9; 95% CI, 1.12 to 3.17), chronic lung disease (HR, 2.0; 95% CI, 1.1 to 3.76), anemia (HR, 2.3; 95% CI, 1.3 to 3.93) and chronic renal failure (CRF; HR, 3.4; 95% CI, 1.74 to 6.6) were independent risk factors for 1-year mortality. We propose a simple AAACC ("triple A double C") score for prediction of 1-year mortality after ICD implantation: Age greater than 75 years (3 points(pts)), anemia (2 pts), AF (1 pt), CRF (3 pts) and chronic lung disease (1 pt). Mortality risk increased with rising number of points (from 1% with 0 pts to 12.5% with >4 pts). The risk score was evaluated with receiver operating characteristic curve and the area under the curve of the validation curve is 0.71 (95% CI, 0.66 to 0.76). CONCLUSIONS: Age greater than 75, AF, chronic lung disease, anemia, and CRF were independent risk factors for 1-year mortality. AAACC risk score identifies patients at high risk of death during 1 year after ICD implantation.

Antithrombotic Treatment Prior to Intracerebral Hemorrhage: Analysis in the National Acute Stroke Israeli Registry.

BACKGROUND AND PURPOSE: Intracerebral hemorrhage (ICH) is the most disastrous stroke subtype. Prognosis is considered worse with prior antithrombotic treatment. Our aim was to evaluate the association of prior antithrombotic treatment on the radiological and clinical outcome after ICH in a subgroup of patients included in a national registry. METHODS: Based on the National Acute Stroke Israeli (NASIS) registry during 2004, 2007, 2010, and 2013 (2-month periods), characteristics, volumetric parameters, and prognosis of a subgroup of patients with ICH were analyzed. RESULTS: Among the 634 patients with ICH in the NASIS registry, 310 (49%) were not treated previously with antithrombotic medications, 232 (37%) were treated with an antiplatelet agent, and 92 (14.5%) patients were on oral anticoagulant therapy, of them 30 patients (33%) with an international normalised ratio (INR) value below 2, 33 (36%) patients with an INR value of 2-3, and 29 patients (31%) with an INR value above 3 upon admission. Patients with deep hemorrhage on prior anticoagulants treatment had the highest probability for poor outcome at hospital discharge. Patients with low bleeding volume (0-30 cm3), were likely to have admission National Institute of Health Stroke Scale < 10 (62%), while those with higher volumes (30-59 cm3 and > 60 cm3), had only 16.7% and 14.3% chance, respectively. We did not observe a significant difference between prior antithrombotic treatment and functional outcome at discharge, yet prior anticoagulant treatment was associated with higher long-term mortality rates. CONCLUSIONS: Our findings, based on a national registry, support the high mortality and poor outcome of anticoagulant related ICH.

Shifting Perceptions of Risk and Reward: Use of Anticoagulation in Patients With Acute Brain Ischemia and Atrial Fibrillation: Nine-Year Data From a National Acute Stroke Registry (National Acute Stroke Israeli Survey [NASIS]).

BACKGROUND AND PURPOSE: Despite overwhelming evidence for the benefits of anticoagulation in patients with brain ischemia and atrial fibrillation, vast underuse has been reported. METHODS: Use of anticoagulation for secondary stroke prevention was assessed in the National Acute Stroke Israeli Survey registry (NASIS) of hospitalized patients with atrial fibrillation and acute brain ischemia. Logistic regression analysis was performed to evaluate the effects of clinical covariates on anticoagulation therapy at discharge, and anticoagulation use over time was assessed in subgroups of patients with identified barriers to anticoagulation utilization. RESULTS: There were 1254 survivors of acute brain ischemia with atrial fibrillation (mean age 77.2±10.6 years; 57.7% female). Between 2004 and 2013, the proportion of patients discharged on anticoagulation increased from 55% to 76.2%, and among those without perceived contraindications from 70% to 96% (P<0.0001). Older age, greater stroke severity, earlier registry period, and presence of contraindications were independent predictors of withholding therapy. Increased anticoagulation use over the years was observed even in patients with barriers to anticoagulation use, including patients with potential contraindications (P<0.001). CONCLUSIONS: In survivors of acute brain ischemia with atrial fibrillation, we observed a substantial increase in anticoagulation utilization within less than a decade. This change was mainly driven by greater utilization of anticoagulation in subgroups with traditional clinical barriers to anticoagulation use, indicating a shift in physicians' perceptions of the risk-benefit ratio of anticoagulation.

Development and validation of the first robotic scale for the clinical assessment of upper extremity motor impairments in stroke patients.

PURPOSE: We aimed to develop and validate the first robotic-based instrument and procedure for assessing upper extremity motor impairments in patients with stroke and to test its discriminative power. METHODS: The ReoGo robotic rehabilitation platform was used to design a novel, upper limb functionality assessment tool, the Reo Scale Assessment (RSA). We used the RSA to evaluate 100 patients with stroke. The RSA items were tested for internal consistency and submitted to factor analysis. The Fugl-Meyer (FM) motor test, the Wolf Motor Function Test (WMFT), and the Action Research Arm Test (ARAT) were used to examine the validity of the RSA. RSA scores were compared and correlated with the scores of the 3 scales. The discriminative power of the RSA was tested against the FM impairment levels by analysis of variance. RESULTS: The total RSA score correlated closely with the upper extremity scores of the FM, WMFT, and ARAT (r = 0.95, 0.93, and 0.90, respectively). The RSA was able to discriminate between low, moderate, and high functioning patients (86% agreement with FM). Principal component analysis revealed that the RSA coefficients loaded on 3 tested components: proximal, distal, and force. CONCLUSIONS: Our results provide strong evidence that the validity of the RSA is comparable with that of the FM, WMFT, and ARAT. The objective measuring and scoring systems of the robotic RSA make it an efficient tool for assessing motor function of stroke patients in clinical and research settings. Additional studies are needed to test the reliability and sensitivity of the RSA.

A pilot study of a novel therapeutic approach to obesity: CNS modification by N.I.R. H.E.G. neurofeedback.

BACKGROUND & AIMS: Despite the thorough mapping of brain pathways involved in eating behavior, no treatment aimed at modulating eating dysregulation from its neurocognitive root has been established yet. We aimed to evaluate the effect of N.I.R. H.E.G. (Near Infra-Red Hemoencephalography) neurofeedback training on appetite control, weight and food-related brain activity. METHODS: Six healthy male participants with overweight or mild obesity went through 10 N.I.R. H.E.G. neurofeedback sessions designed to practice voluntary activation of the prefrontal cortex. Weight, eating behavior, appetite control and brain activity related to food and self-inhibition based on fMRI were evaluated before and after neurofeedback training. RESULTS: Our study group demonstrated a positive trend of increased self-control and inhibition related to food behavior, reduced weight and increased activation during an fMRI response-inhibition task (Go-No-Go - GNG) in the predefined region of interest (ROI): superior orbitofrontal cortex (sOFC). CONCLUSIONS: N.I.R. H.E.G. holds a promising potential as a feasible neurofeedback platform for modulation of cortical brain circuits involved in self-control and eating behavior and should be further evaluated and developed as a brain modifying device for the treatment and prevention of obesity.

The Association between Mediterranean Diet and the Risk of Falls and Physical Function Indices in Older Type 2 Diabetic People Varies by Age.

BACKGROUND AND AIMS: Diabetes and dysglycemia increase the risk of frailty and decreased physical abilities. Adherence to the Mediterranean Diet (MD) may reduce this risk. We hypothesized that adherence to the MD is associated with physical function in older type-2 diabetic patients and that the association is stratified by age. METHODS AND RESULTS: We recruited type-2 diabetes patients aged >60 years at the Center for Successful Aging with Diabetes at Sheba Medical Center. Health status and demographic data were obtained from medical records. Food Frequency Questionnaire was used for nutritional assessment and calculation of MD score. Physical function indices were determined by a physiotherapist and included: Berg Balance test, Timed Get-Up-and-Go, 6-min walk (6 MW), 10-m walk (10 MW), Four Square Step Test, 30-s chair stand and Grip strength, and activities and instrumental activities of daily living. Among 117 participants (age 70.6 ± 6.5), high adherence to MD was associated with better score on functional tests (low vs. high MD adherence: 9.7% vs. 25%, ANOVA p = 0.02). A significant age by MD interaction was found: a higher adherence to MD was associated with a better 6 MW (low vs. high: 387 ± 35 m vs. 483 ± 26 m; p = 0.001) and higher 10 MW (low vs. high: 1.8 ± 0.16 m/s vs. 2.0 ± 0.13 m/s; p = 0.02) in participants aged >75 years. These associations remained significant after controlling for gender, age, BMI, and physical activity. CONCLUSION: In the current study, we showed relationships between strength, physical performance, and MD among older diabetic patients. Future studies are needed to confirm this association and establish temporal relationships.

Contemporary Determinants of Delayed Benchmark Timelines in Acute Myocardial Infarction in Men and Women.

Treatment delays in patients with acute myocardial infarction (AMI) are related to increased morbidity and mortality. Hence, identifying determinants of delay may help reduce time to treatment. Importantly, limited data suggest that there may be sex-related disparities in benchmark timelines. Although guidelines advocate the use of the first medical contact (FMC) rather than hospital admission as the moment from which delays to treatment should be monitored, the latter is still often used for quality purposes. We aimed to identify factors associated with treatment delays, with an emphasis on sex-related disparities. We reviewed data on 3,658 patients with AMI from 2 contemporary, consecutive multicenter surveys. Measured delays were FMC-to-electrocardiogram >10 minutes in ST-elevation MI (STEMI) and non-STEMI, FMC-to-primary percutaneous coronary intervention >90 minutes in STEMI, and invasive angiography >72 hours after admission in non-STEMI patients. Timely electrocardiogram was performed in 48% of patients with STEMI and in 39.8% of non-STEMI patients without significant sex-related differences. Independent determinants of delay included atypical chest pain (CP) and presentation during daytime. In patients with STEMI, 37.5% had primary percutaneous coronary intervention in less than 90 minutes without significant sex-related disparities. Independent determinants of delay included atypical CP, night presentation, and diabetes. In non-STEMI patients, independent determinants of delayed invasive approach were female sex, age >75 years, atypical CP, and renal failure. In conclusion, significant treatment delays in patients with AMI are still frequent in contemporary practice, highlighting the need for improvement and guidelines implementation. Predictors of delay identified in our study may facilitate targeting of interventions to improve adherence to guidelines.

Impaired Fasting Glucose Is the Major Determinant of the 20-Year Mortality Risk Associated With Metabolic Syndrome in Nondiabetic Patients With Stable Coronary Artery Disease.

BACKGROUND: We wanted to explore the association of metabolic syndrome (MetS) versus its individual components with 20-year all-cause mortality among patients with stable coronary artery disease. METHODS AND RESULTS: The cohort comprised 12 403 nondiabetic patients with stable coronary artery disease who were enrolled in the Bezafibrate Infarction Prevention Registry between February 1990 and October 1992 and followed up through December 2014. The study cohort was divided into 4 groups: patients without MetS or impaired fasting glucose (IFG), patients with IFG but without MetS, patients with MetS but without IFG, and patients with both MetS and IFG. Kaplan-Meier survival analysis showed that at 20 years of follow-up, the rates of all-cause mortality were the highest among patients with both MetS and IFG (66%). Patients with IFG without MetS experienced a significantly higher mortality rate compared with those with MetS without IFG (61% versus 56%; log-rank P<0.001). Multivariable Cox proportional hazard analysis showed that the final Cox model demonstrated that the additive effect of MetS (hazard ratio, 1.13; 95% confidence interval, 1.1-1.16; P=0.02) and IFG (hazard ratio, 1.54; 95% confidence interval, 1.46-1.62; P<0.001) on 20 years mortality was nonsignificant (hazard ratio, 1.01; 95% confidence interval, 0.93-1.11; P=0.69). IFG was associated with the most pronounced increase in mortality risk among the individual components (hazard ratio, 1.22; 95% confidence interval, 1.14-1.3; P<0.001). CONCLUSIONS: Our findings suggest that IFG alone is a major independent predictor of long-term mortality among patients with stable coronary artery disease versus other components of the MetS.

Community Resilience throughout the Lifespan--The Potential Contribution of Healthy Elders.

An increase in the exposure and predisposition of civilian populations to disasters has been recorded in the last decades. In major disasters, as demonstrated recently in Nepal (2015) and previously in Haiti (2010), external aid is vital, yet in the first hours after a disaster, communities must usually cope alone with the challenge of providing emergent lifesaving care. Communities therefore need to be prepared to handle emergency situations. Mapping the needs of the populations within their purview is a trying task for decision makers and community leaders. In this context, the elderly are traditionally treated as a susceptible population with special needs. The current study aimed to explore variations in the level of community resilience along the lifespan. The study was conducted in nine small to mid-size towns in Israel between August and November 2011 (N = 885). The Conjoint Community Resiliency Assessment Measure (CCRAM), a validated instrument for community resilience assessment, was used to examine the association between age and community resilience score. Statistical analysis included spline and logistic regression models that explored community resiliency over the lifespan in a way that allowed flexible modeling of the curve without prior constraints. This innovative statistical approach facilitated identification of the ages at which trend changes occurred. The study found a significant rise in community resiliency scores in the age groups of 61-75 years as compared with younger age bands, suggesting that older people in good health may contribute positively to building community resiliency for crisis. Rather than focusing on the growing medical needs and years of dependency associated with increased life expectancy and the resulting climb in the proportion of elders in the population, this paper proposes that active "young at heart" older people can be a valuable resource for their community.

Vitamin D Status and Quality of Life in Healthy Male High-Tech Employees.

While low vitamin D status has been shown to be associated with decreased quality of life in unhealthy populations and women, only limited data are available regarding healthy adult men. Our aim was to evaluate the associations between health-related quality of life (QoL) and vitamin D status in adult men. High-tech employees aged 25-65 year were recruited from an occupational periodic examination clinic at Rambam Health Campus. QoL was assessed using the Centers for Disease Control and Prevention (CDC) Health-related quality of life questionnaire (HRQOL-4). Serum 25-hydroxyvitamin D (25(OH)D) and Body Mass Index (BMI) were measured; further information was collected about physical activity, education, sun exposure, sick-days, and musculoskeletal pain severity (visual analog scale). Three hundred and fifty-eight men were enrolled in the study; mean serum 25(OH)D level was 22.1 ± 7.9 ng/mL (range 4.6-54.5 ng/mL). In a multivariate logistic regression model, 25(OH)D was a significant independent determinant of self-rated health; Odds Ratio (OR) for self-rated health was 0.91 (95% confidence interval (CI) 0.85-0.97, p = 0.004), adjusted for age, BMI, pain severity, physical activity, and sun exposure. Every 1 ng/mL increase of 25(OH)D was associated with 9% reduction in the odds of reporting self-rated health as fair or poor. Poisson regression model demonstrated an association between physically unhealthy days and 25(OH)D levels (rate ratio 0.95, p < 0.001). In conclusion, serum levels of 25(OH)D were associated with self-rated health and with physically unhealthy days of HRQOL in healthy high-tech male workers. Future intervention studies are required to test the impact of vitamin D supplementation on QoL.

Predictors of serum 25(Oh)D increase following bimonthly supplementation with 100,000IU vitamin D in healthy, men aged 25-65 years.

UNLABELLED: Vitamin D replenishment therapy typically entails standard dosages, but related increases in serum 25(OH)D levels vary between individuals. This study was aimed to identify factors that affect the efficacy of vitamin D supplementation. SUBJECTS AND METHODS: 79 healthy men aged 25-65 with 25(OH)D<20ng/ml participated in a vitamin D supplementation study. All participants received 100,000IU vitamin D bimonthly, e.g., 1666IU/day. Personal and demographic information, physical activity and sun-exposure questionnaires were completed by the participants. Weight, height, and waist circumference were recorded. Serum calcium, creatinine, 25(OH)D, PTH, lipid profile, and liver-enzyme levels were assessed. All measurements were repeated after 6 and 12 months. The difference between baseline serum 25(OH)D and 12-month measurements was calculated (delta). Linear regression was performed to identify predictors for increases in 25(OH)D levels. RESULTS: Mean serum 25(OH)D level increases according to BMI were 12.6±5.29ng/ml for BMI≤25, 10.12±4.95ng/ml for 2530, which differed significantly from the other BMI categories (p=0.003). In a regression model to predict 25(OH)D increase, BMI was the main predictor (p<0.001), explaining 21.6% of the variance in serum 25(OH)D (inverse association). Age, sun-exposure, serum cholesterol, physical-activity, baseline 25(OH)D levels and seasonality were insignificant. The full model explained 27.9% of the variance in serum 25(OH)D. CONCLUSION: This study's main findings are that BMI affect vitamin D response in healthy men. Quantitative supplementation adjustments may be warranted in obese men, for whom the dose may need to be doubled. This article is part of a special issue entitled '16th Vitamin D Workshop'.

Adherence to mediterranean diet and decline in walking speed over 8 years in community-dwelling older adults.

OBJECTIVES: To determine the association between Mediterranean diet (MedDiet) score and 20-m walking speed over 8 years. DESIGN: Health, Aging and Body Composition Study (Health ABC) beginning in 1997/98. SETTING: Community. PARTICIPANTS: Two thousand two hundred twenty-five well-functioning individuals aged 70 and older. MEASUREMENTS: Walking speed was assessed in relation to low, medium, and high adherence to the MedDiet (0-2, 3-5, 6-9 points, respectively). RESULTS: Individuals in the highest MedDiet adherence group were more likely to be male; less likely to smoke; and more likely to have lower body mass index, higher energy intake, and greater physical activity (P < .05). Usual and rapid 20-m walking speed were highest in the high MedDiet adherence group than in the other groups (high, 1.19 ± 0.19 m/s; medium, 1.16 ± 0.21 m/s; low, 1.15 ± 0.19 m/s, P = .02, for usual speed; high, 1.65 ±0.30 m/s; medium, 1.59 ± 0.32 m/s; low, 1.55 ± 0.30 m/s, P = .001, for rapid speed). Over 8 years, usual and rapid 20-m walking speed declined in all MedDiet adherence groups. Higher MedDiet adherence was an independent predictor of less decline in usual 20-m walking speed (P = .049) in generalized estimating equations adjusted for age, race, sex, site, education, smoking, physical activity, energy intake, health status, depression and cognitive score. The effect decreased after adding total body fat percentage to the model (P = .13). Similar results were observed for MedDiet adherence and rapid 20-m walking speed; the association remained significant after adjustment for total body fat percentage (P = .01). The interaction between time and MedDiet adherence was not significant in any of the models. CONCLUSION: Walking speed over 8 years was faster in those with higher MedDiet adherence at baseline. The differences remained significant over 8 years, suggesting a long-term effect of diet on mobility performance with aging.