Dietary vitamin D intake, cardiovascular disease and cardiometabolic risk factors: a sex-based analysis from the ATTICA cohort study.

BACKGROUND: The present study aimed to evaluate the association between dietary vitamin D intake and 10-year first fatal/nonfatal cardiovascular disease (CVD), conventional CVD risk factors and surrogate markers related to inflammation, coagulation, insulin resistance, liver and renal function. METHODS: The ATTICA study was conducted during 2001-2012 including 1514 men and 1528 women (aged >18 years) from the greater Athens area, Greece. Dietary assessment was based on a validated semi-quantitative food frequency questionnaire. Daily intake of vitamin D was calculated using a standardised food database. Follow-up (2011-2012) was achieved in 2020 participants (n = 317 cases). RESULTS: Ranking from first to third vitamin D tertile, CVD events were 24%, 17% and 12% for men (P = 0.002) and 14%, 10% and 11% for women (P = 0.59). Inverse associations between vitamin D and CVD in total sample [hazard ratio (HR) = 0.76 95% confidence interval (CI) = 0.60-0.97] and in men (HR = 0.66 95% CI = 0.49-0.89) were observed, and lost after adjusting for inflammation/coagulation markers; for women, no significant trends were observed. Regarding 10-year onset of conventional risk factors, inverse associations of vitamin D with hypertension in men (HR = 0.62 95% CI = 0.39-0.99) and transition to metabolically unhealthy status in women (HR = 0.69 95% CI = 0.51-0.93) were observed. Significant inverse associations for C-reactive protein, interleukin-6 and fibrinogen in both sexes, whereas these were revealed only in women for insulin resistance. CONCLUSIONS: Contradicting the neutral/modest associations in vitamin-D supplementation trials, increased food-generated vitamin D may protect against hard and intermediate CVD endpoints, implying different paths between sexes.

Visceral adiposity index and 10-year cardiovascular disease incidence: The ATTICA study.

BACKGROUND AND AIMS: Visceral adiposity index (VAI) has been proposed as a marker of visceral adipose tissue accumulation/dysfunction. Our aim was to evaluate potential associations between the VAI and the 10-year cardiovascular disease (CVD) incidence. METHODS AND RESULTS: During 2001-2002, 3042 Greek adults (1514 men; age: ≥18 years) without previous CVD were recruited into the ATTICA study, whilst the 10-year study follow-up was performed in 2011-2012, recording the fatal/non-fatal CVD incidence in 2020 (1010 men) participants. The baseline VAI scores for these participants were calculated based on anthropometric and lipid variables, while VAI tertiles were extracted for further analyses. During the study follow-up a total of 317 CVD events (15.7%) were observed. At baseline, the participants' age and the prevalence of hypertension, diabetes, hypercholesterolemia and metabolic syndrome increased significantly across the VAI tertiles. After adjusting for multiple confounders, VAI exhibited a significantly independent positive association with the 10-year CVD incidence (OR = 1.05, 95%CI: 1.01, 1.10), whereas the association of the body mass index (HR = 1.03, 95%CI: 0.99, 1.08), or the waist circumference (HR = 1.01, 95%CI: 0.99, 1.02) was less prominent. Sex-specific analysis further showed that VAI remained significantly predictive of CVD in men alone (HR = 1.06, 95%CI: 1.00, 1.11) but not in women (HR = 1.06, 95%CI: 0.96, 1.10). CONCLUSIONS: Our findings show for the first time in a large-sample, long-term, prospective study in Europe that the VAI is independently associated with elevated 10-year CVD risk, particularly in men. This suggests that the VAI may be utilized as an additional indicator of long-term CVD risk for Caucasian/Mediterranean men without previous CVD.

Amino acid profile and metabolic syndrome in a male Mediterranean population: A cross-sectional study.

BACKGROUND AND AIMS: The metabolic syndrome (MetS) refers to a cluster of clinically relevant factors that increases the risk of cardiovascular diseases and all-cause mortality. Circulating levels of several amino acids and metabolites related to one-carbon metabolism have been associated with cardiometabolic risk factors and MetS. We aimed to identify the amino acid profile that is significantly associated with MetS among an all male Mediterranean population. METHODS AND RESULTS: One hundred middle-aged men (54.6 ± 8.9 years) participated in a cross-sectional study carried out during 2011-2012. The International Diabetes Federation (IDF) criteria were used to define MetS. Fasting plasma levels of 20 common amino acids and 15 metabolites related to amino acid and one-carbon metabolism were measured using gas chromatography (GC-MS/MS) and liquid chromatography tandem mass spectrometry (LC-MS/MS). Principal components analysis was applied. Fifty-six participants fulfilled the IDF criteria for defining MetS. Five factors were extracted from the 35 measured metabolites. The branched-chain amino acids/aromatic amino acids (BCAA/AAA) related pattern and the glutamine/glycine/serine/asparagine (Gln/Gly/Ser/Asn) related pattern were significantly associated with MetS (odds ratio, 95% confidence interval; 6.41, 2.43-16.91, and 0.47, 0.23-0.96, respectively) after adjustment for age, current smoking status, physical activity level and medical treatment for hypertension, dyslipidaemia, type 2 diabetes mellitus. Further adjustment for liver function markers (i.e. glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, and γ-glutamyltransferase), and plasma adiponectin levels did not significantly affect the associations. CONCLUSION: The BCAA/AAA pattern was positively associated, while the Gln/Gly/Ser/Asn pattern was inversely associated with established cardiometabolic risk factors and MetS. Plasma adiponectin levels or markers of liver function did not significantly affect these associations.

Adherence to Mediterranean diet and 10-year incidence (2002-2012) of diabetes: correlations with inflammatory and oxidative stress biomarkers in the ATTICA cohort study.

BACKGROUND: The purpose of this work was to investigate the links between oxidative stress, inflammation and coagulation and their effect on Mediterranean diet-diabetes relationship. METHODS: In 2001-2002, a random sample of 1514 men (18-87 years old) and 1528 women (18-89 years old) was selected to participate in the ATTICA study, where Athens is the major metropolis. A validated questionnaire was used to assess lifestyle and dietary factors. Adherence to Mediterranean diet was recorded using MedDietScore. Among others, oxidative stress and inflammatory biomarkers were recorded. During 2011-2012, the 10-year follow-up was performed. Diabetes incidence was defined according to the American Diabetes Association criteria. RESULTS: A total of 191 incident cases of diabetes were documented, yielding an incidence of 12.9% (13.4% in men and 12.4% in women). Medium and high adherence was found to decrease diabetes risk by 49% (95% CI: 0.30, 0.88) and 62% (95% CI: 0.16, 0.88), respectively, compared with low adherence. A logarithmic trend between Mediterranean diet and diabetes incidence was also revealed (p for trend = 0.042). Individuals with abnormal waist circumference (>94 for men, >80 for women) were benefited the most. Wholegrain cereals, fruits and legumes had the greatest predictive ability. The anti-diabetic effect of Mediterranean diet correlated with measurements of tumour necrosis factor-α, homocysteine and total antioxidant capacity. CONCLUSIONS: The reported results support the role of Mediterranean diet as a promising dietary tool for the primary prevention of diabetes, by attenuating inflammation and fostering total antioxidant capacity. This dietary pattern may have therapeutic potential for many cardiometabolic disorders associated with inflammation and/or oxidative stress.

Metabolic syndrome and 10-year cardiovascular disease incidence: The ATTICA study.

AIMS: To evaluate the influence of metabolic syndrome (MetS) as well as inflammatory and renal markers on cardiovascular disease (CVD) incidence. METHODS AND RESULTS: During 2001-2002, 1514 men and 1528 women (>18 y) without any clinical evidence of CVD or any other chronic disease, at baseline, living in greater Athens area, Greece, were enrolled. In 2011-2012, the 10-year follow-up was performed in 2583 participants (15% of the participants were lost to follow-up). Incidence of fatal or non-fatal CVD was defined according to WHO-ICD-10 criteria. MetS was defined using three definitions, provided by the National Cholesterol Education Program Adult Treatment panel III (revised NCEP ATP III), the International Diabetes Federation (IDF) or the Harmonized definition. Furthermore, the contributory predictive role of C-reactive protein (CRP), inteleukin-6, uric acid and estimated glomerular filtration rate in the aforementioned models was evaluated. History of MetS-NCEP was positively associated with CVD, adjusting for potential confounding factors (OR:1.83, 95%CI:1.24-2.72). Not statistically significant associations with CVD incidence were observed when using the IDF or the Harmonized definition. Additionally, none of the added inflammatory and renal function markers mediated the influence of MetS on CVD incidence (all p's from Sobel test >0.40). C-statistic values for the MetS definitions used exceeded 0.789 (CI:0.751-0.827), indicating fair-to-good predictive probability of the models. CONCLUSION: Results of the present work revealed the negative impact of MetS-NCEP, but not of the other MetS definitions, on CVD incidence, a key-point that may help in better understanding the role of IDF and Harmonized MetS definitions on CVD.

Exclusive olive oil consumption and 10-year (2004-2014) acute coronary syndrome incidence among cardiac patients: the GREECS observational study.

BACKGROUND: The present study evaluated the association between long-term, exclusive olive oil consumption, in cooking preparation or as a dressing, and the 10-year (2004-2014) incidence of acute coronary syndrome (ACS) among cardiac patients. METHODS: From October 2003 to September 2004, a sample of 2172 ACS consecutive patients from six major Greek hospitals were enrolled. During 2013-2014, the 10-year follow-up was performed in 1918 patients (88% participation rate). The development of fatal or nonfatal ACS was recorded through medical records or hospital registries. Among other dietary components, added fats (i.e. olive oil, butter, margarine and seed oils) consumption at baseline examination was assessed using a semi-quantitative food frequency questionnaire. RESULTS: Non-exclusive olive oil consumption on a daily basis was associated with an adverse effect on the ACS incidence after taking into account various potential confounders [odds ratio (OR) = 1.40, 95% confidence interval (CI) = 1.05-1.86, P = 0.024]. However, significant interactions between olive oil consumption and body mass index (BMI) (P = 0.082) and educational level (P = 0.054) led to further stratified analysis. Using BMI as strata (i.e. ≤29.9 versus >29.9 kg m(-2)), the above association remained significant only in obese patients (OR = 1.80, 95% CI = 1.03-3.12, P = 0.038), whereas, on examining the education status (i.e. ≤9 versus >9 years of school), a significant association was observed only among the higher educated patients (OR = 1.83, 95% CI = 1.01-3.32, P = 0.047). CONCLUSIONS: Exclusive use of olive oil, either as a salad dressing or in cooking, should be promoted through the dietary management of ACS patients, with the aim of reducing the likelihood of recurrent cardiac episodes.

Exploring the path of Mediterranean diet on 10-year incidence of cardiovascular disease: the ATTICA study (2002-2012).

BACKGROUND AND AIMS: A Mediterranean diet has been associated with lower all-cause and cardiovascular disease (CVD) morbidity and mortality, but the clinical and behavioral pathway has not been well understood and appreciated. The aim of this work was to explore the path between adherence to a Mediterranean-type diet, lifestyle behaviors, clinical status, and a 10-year incidence of CVD. METHODS AND RESULTS: The ATTICA study was carried out in the Athens area during 2001-2002 and included 3042 participants free of CVD at baseline (49.8% men, aged 18-89). Adherence to a Mediterranean diet was assessed using the MedDietScore (range 0-55). During 2011-2012, 2583 out of the 3042 participants were found during the 10-year follow-up (15% lost to follow-up). Adherence to a Mediterranean diet decreased CVD risk (relative Risk (RR) per 1/55 unit = 0.96, 95% confidence interval (CI): 0.93, 1.00), independently of various sociodemographic, lifestyle, and clinical factors. Subgroup analyses revealed that participants with an unhealthy lifestyle (i.e., smokers, and obese and sedentary persons) remained protected from CVD through a greater adherence to a Mediterranean diet (RR for smokers = 0.92, 95%CI: 0.88, 0.97; RR for obese participants = 0.90, 95%CI: 0.82, 0.979; and RR for sedentary participants = 0.95, 95%CI: 0.90, 0.99). Path analysis revealed that adherence to a Mediterranean diet not only decreases the levels of C-reactive protein and interleukin-6 but also has an independent protective role against CVD risk per se (total effect of the MedDietScore on CVD = -0.003, 95%CI: -0.005 to 0.000). CONCLUSION: Adherence to a Mediterranean diet confers a considerable reduction on CVD risk, independent of various factors. Therefore, even subjects with unhealthy lifestyle behaviors may benefit from adherence to this diet, suggesting another dimension to prevention strategies.

Association between periodontitis and acute myocardial infarction: a case-control study of a nondiabetic population.

BACKGROUND AND OBJECTIVE: Periodontitis and acute myocardial infarction (AMI) are two diseases that share common risk factors. The role of periodontitis as an independent risk factor for cardiovascular disease has been under debate. The aim of this study was to investigate whether an association exists between periodontitis and AMI in a nondiabetic population, using multiple periodontal case definitions. MATERIAL AND METHODS: Periodontal examination was performed in 204 patients with AMI. The control group comprised 102 healthy subjects, without significant coronary disease, confirmed angiographically. Periodontitis was assessed using measurements of clinical attachment loss (CAL), probing depth and number of missing teeth. From these measurements, five different case definitions of periodontitis were generated. RESULTS: Using the continuous forms of periodontal measurements, the odds ratio (95% confidence interval) of the association with incident AMI was 1.74 (1.26-2.50), 1.83 (1.10-3.17) and 1.08 (1.06-1.13) for mean CAL, probing depth and number of missing teeth, respectively. A consistent positive association was observed regardless of the case definition of periodontitis. CONCLUSION: In this nondiabetic population, the association between periodontitis and AMI was consistent across different measurements and/or definitions of periodontitis. The strength of the association increased concomitantly with the robustness of the criteria used to define periodontitis.

Executive summary of the Hellenic Atherosclerosis Society guidelines for the diagnosis and treatment of dyslipidemias - 2023.

Atherosclerotic cardiovascular disease (ASCVD) remains the main cause of death worldwide, and thus its prevention, early diagnosis and treatment is of paramount importance. Dyslipidemia represents a major ASCVD risk factor that should be adequately managed at different clinical settings. 2023 guidelines of the Hellenic Atherosclerosis Society focus on the assessment of ASCVD risk, laboratory evaluation of dyslipidemias, new and emerging lipid-lowering drugs, as well as diagnosis and treatment of lipid disorders in women, the elderly and in patients with familial hypercholesterolemia, acute coronary syndromes, heart failure, stroke, chronic kidney disease, diabetes, autoimmune diseases, and non-alcoholic fatty liver disease. Statin intolerance is also discussed.

A multicomponent lifestyle intervention produces favourable changes in diet quality and cardiometabolic risk indices in hypercholesterolaemic adults.

BACKGROUND: To date, there are no dietary intervention studies available jointly examining the changes produced in cardiometabolic risk indices and diet quality assessed with the Healthy Eating Index 2005 (HEI-2005). The present study aimed to evaluate the effect of a 3-month multicomponent lifestyle intervention on several cardiometabolic risk indices, physical activity levels and diet quality. METHODS: A total sample of 108 hypercholesterolaemic adults (40-60 years old) were randomised to two intervention groups provided with and instructed to consume daily: (i) plain milk (n = 37) or (ii) enriched milk (n = 40) respectively; both groups were attending a 3-month dietary counselling programme. For the needs of the present study both intervention groups were analysed together IG: n = 77) and were compared against a control group following usual diet (CG: n = 31). RESULTS: Regarding diet quality HEI scores for 'milk' (P = 0.021), 'dark green/orange vegetables and legumes' (P = 0.050) and 'total HEI score' (P = 0.045) were improved in the IG compared to the CG. The IG also improved 'whole grains' and 'calories from solid fats, alcoholic beverages and added sugars' scores compared to their baseline values. Both groups improved the 'total vegetable' HEI score. Regarding physical activity levels and cardiometabolic risk indices, the IG significantly increased the daily number of steps (P = 0.005) and decreased body weight (P = 0.021), body mass index (P = 0.019) and waist circumference (P = 0.027) to a higher extent compared to the changes observed in the CG. Moreover, the IG significantly decreased systolic (P = 0.001) and diastolic blood pressure (P = 0.050) compared to baseline values. CONCLUSIONS: The present study revealed that this 3-month lifestyle and nutrition counselling intervention programme appears to have favourable effects on diet quality, physical activity levels, anthropometric and certain cardiometabolic risk indices.

Adherence to the Mediterranean diet and serum uric acid: the ATTICA study.

OBJECTIVE: The present study aimed to explore potential associations between adherence to a Mediterranean diet and serum uric acid (UA) levels. METHODS: The sample consisted of 2380 men and women free of cardiovascular or renal disease who participated in the ATTICA study. Dietary intake was assessed using a food frequency questionnaire (FFQ) and adherence to the Mediterranean diet was evaluated with the MedDietScore. Serum UA was measured and hyperuricaemia was defined as UA concentration > 7.0 mg/dL in men or > 6.0 mg/dL in women. RESULTS: MedDietScore was inversely associated with UA levels (b-coefficient per quartile of the score = -0.07 ± 0.03, p = 0.02) independently of sex, presence of overweight, hypertension, or abnormal glucose metabolism, and alcohol or coffee intake. Those at the fourth quartile of MedDietScore had a 70% lower likelihood of having hyperuricaemia [odds ratio (OR) 0.30, 95% confidence interval (CI) 0.11-0.82] compared to those at the first quartile, after adjustment for several confounders. According to stratified analyses by sex, body mass index (BMI) status, hypertension, abnormal glucose, alcohol and coffee intake, the inverse association between serum UA and MedDietScore remained significant in women (b-coefficient = -0.194 ± 0.055, p < 0.001), overweight subjects (b-coefficient = -0.103 ± 0.047, p = 0.02), in those with normal glucose metabolism (b-coefficient = -0.074 ± 0.037, p = 0.04), and in those abstaining from alcohol (b-coefficient = -0.212 ± 0.073, p = 0.004) and coffee (b-coefficient = -0.221 ± 0.096, p = 0.02). CONCLUSION: Adherence to the Mediterranean diet is associated with lower serum UA levels and lower likelihood of hyperuricaemia. These findings support a potential role of this dietary pattern in the prevention and treatment of hyperuricaemia and gout.

Dietary antioxidant capacity is inversely associated with diabetes biomarkers: the ATTICA study.

BACKGROUND AND AIMS: Elevated dietary antioxidant activity has been regarded as providing potential benefits to health. The present work aimed at evaluating the association of glycemic indices with total dietary antioxidant capacity in healthy adults. METHODS AND RESULTS: The ATTICA study consisted of men and women, randomly selected from all areas of Attica region in Greece. In this work, a random sub-sample from the ATTICA study's database was studied, consisting of 551 men (41 ± 11 years) and 467 women (38 ± 11 years), with complete nutritional and biochemical information. Dietary habits were evaluated using a validated food-frequency questionnaire. The dietary antioxidant capacity was based on published values for Italian foods measured by three different assays: ferric-reducing antioxidant power (FRAP), total radical-trapping antioxidant parameter (TRAP) and Trolox equivalent antioxidant capacity (TEAC). Inverse, age-energy adjusted correlations were observed between FRAP and log-glucose (r = -0.149, p = 0.001), log-insulin (r = -0.221, p = 0.001) and log-HOMA-IR (r = -0.186, p = 0.001) concentration, as well as with TRAP and TEAC. After controlling for age, gender, body mass index, physical activity status, smoking habits and energy intake, multi-adjusted analysis confirmed the previous relationships only among participants who were not on the Mediterranean dietary pattern. CONCLUSIONS: Although more prospective studies are required, the data presented support the view that dietary modification towards higher consumption of antioxidants should be implemented in public health strategies, in order to better control glycemic markers in individuals, and prevent the development of diabetes at the population level.

Mediterranean diet is inversely associated with steatosis and fibrosis and decreases ten-year diabetes and cardiovascular risk in NAFLD subjects: Results from the ATTICA prospective cohort study.

BACKGROUND AND AIMS: We assessed the association of Mediterranean diet with NAFLD and their interaction in predicting ten-year diabetes onset and first fatal/non-fatal cardiovascular disease (CVD) incidence. METHODS: The ATTICA prospective observational study in Athens, Greece included 1,514 men and 1,528 women (>18 years old) free-of-CVD at baseline. Liver steatosis and fibrosis indices were calculated. Mediterranean diet adherence was assessed through MedDietScore. At the ten-year follow-up visit, CVD evaluation was performed in an a priori specified subgroup of n = 2,020 participants and diabetes onset in n = 1,485 free-of-diabetes participants. RESULTS: MedDietScore was inversely associated with steatosis and fibrosis; e.g. in the case of the TyG index the Odds Ratio (OR) of the 3rd vs. 1st MedDietScore tertile was = 0·53, [95% Confidence Interval (95% CI) (0·29, 0·95)] and the associations persisted in multi-adjusted models. NAFLD predicted incident diabetes prospectively over a ten year period [HR = 1·87, 95% CI (0·75, 4·61)] and the association remained significant only in subjects with low MedDietScore (below median) whereas diabetes onset among subjects with higher MedDietScore was not influenced by NAFLD. Similarly, NAFLD predicted CVD [Hazard Ratio (HR) = 3·01, 95%CI(2·28, 3·95)]; the effect remained significant only in subjects with MedDietScore below median [HR = 1·38, 95% CI (1·00, 1·93)] whereas it was essentially null [HR = 1·00,95% CI (0·38, 2·63)] among subjects with higher score. Mediation analysis revealed that adiponectin and adiponectin-to-leptin ratio were the strongest mediators. CONCLUSIONS: We report an inverse association between Mediterranean diet and NAFLD. Mediterranean diet protected against diabetes and CVD prospectively among subjects with NAFLD.

Dietary habits of Greek adults and serum total selenium concentration: the ATTICA study.

PURPOSE: The trace element selenium is an essential micronutrient for human health, and its low levels in serum are implicated in the pathogenesis of several chronic diseases. The determination of total serum selenium levels may contribute to the assessment of the health status of all populations. Since the serum selenium levels are highly affected by diet, we assessed its association with the dietary habits of Greek adults. METHODS: Serum selenium levels were determined with inductively coupled plasma mass spectrometry in a cohort of 506 participants (men: 296, women: 210) aged 18-75 from the ATTICA study. Food consumption was evaluated with a validated food-frequency questionnaire. RESULTS: Evaluation of the relationship between serum total selenium with major food groups and beverages by multi-adjusted analysis revealed that serum selenium was positively correlated with the consumption of red meat (2.37 ± 0.91, p = 0.01) while the consumption of other selenium-containing foods (i.e., fish, cereals, dairy products, vegetables) did not demonstrate such a relationship. Moreover, principal component analysis revealed that the adoption of a vegetarian type of diet is inversely correlated with total selenium (-3.94 ± 2.28, p = 0.08). CONCLUSIONS: Among the dietary habits that were examined, red meat seems to be the major determinant of serum selenium in Greek adults.

Osteoprotegerin and nuclear factor-kappaB ligand are associated with leptin and adiponectin levels, in apparently healthy women.

OBJECTIVES: We investigated the relationship between the major bone turnover markers, i.e., Osteoprotegerin (OPG) and Receptor activator of nuclear factor-kappaB ligand (RANKL) and serum adipokines (leptin, adiponectin) levels in a sample of apparently healthy women. METHODS: A random sample which consisted of 80 females (18-71 years) was studied. Elisa method was used to measure the OPG, RANKL and the leptin, adiponectin levels in females' serum. RESULTS: OPG values were inversely correlated with leptin (rho = -0.38, p = 0.002) and positively correlated with age (rho = 0.27, p=0.01) and body mass index (rho = 0.29, p=0.009). RANKL values were inversely correlated with adiponectin (rho = -0.23, p = 0.06) and age (rho = -0.30, p=0.01). Additionally, OPG was higher in post- as compared to pre-menopausal women. Further data analysis adjusting for potential confounders revealed that the OPG/RANKL ratio was positively associated with adiponectin and inversely associated with leptin levels independent of the effect of age, body mass index and menopausal status. CONCLUSIONS: These results reveal that leptin circulating levels are inversely associated with serum OPG/RANKL ratio among healthy women.

The influence of socio-environmental determinants on hypertension. A spatial analysis in Athens metropolitan area, Greece.

INTRODUCTION: While epidemiological and pathophysiological aspects of hypertension are still being investigated, there is an increased global interest between hypertension and social health determinants and environmental factors that this study aims to examine. METHODS: The sample size used in this work included 2,445 individuals, from Athens metropolitan area, who were randomly enrolled in ATTICA study, during 2001 to 2002. Principal component analysis (PCA), Poisson regression modeling and geographical analysis, based on Geographic Information Systems (GIS) technology, were applied. RESULTS: Geographical analysis and thematic mapping revealed that the West municipalities of Athens had the lowest socio-environmental status. Three components were derived from PCA: high, low and mixed socio-environmental status. Poisson regression analysis showed that high socio-environmental status, educational and economic level were negatively correlated with hypertension in some sectors of Athens (p < 0.05, for all). CONCLUSIONS: Through the use of geospatial surveillance the underlying epidemiology of hypertension, and those at greater risk, can be more precisely determined. This study underlines the need to account for environmental factors when developing public health policies and programs for effective hypertension prevention or reduction.

Dietary patterns and 5-year incidence of cardiovascular disease: a multivariate analysis of the ATTICA study.

BACKGROUND AND AIMS: The 5-year incidence of cardiovascular disease (CVD) in relation to dietary habits, among men and women from Greece, was evaluated. METHODS AND RESULTS: From May 2001 to December 2002, 1514 men and 1528 women (>18 years) without any clinical evidence of CVD, living in the Attica area, Greece, were enrolled in the ATTICA study. In 2006, a group of experts performed the 5-year follow-up (941 of the 3042 participants were lost). Development of CVD (coronary heart disease, acute coronary syndromes, stroke, or other CVD) during the follow-up period was defined according to WHO ICD-10 criteria. Principal components analysis was applied, and 15 dietary patterns were extracted (71% of total information explained) from 26 foods or food groups. The 5-year incidence of CVD was 11.0% in men and 6.1% in women (p<0.001); the case fatality rate was 1.6%. Multi-adjusted analysis revealed that the dietary pattern that was mainly characterized by cereals, small fish, hardtack and olive oil intake, was associated with lower CVD risk (HR per 1 unit=0.72, 95% CI 0.52-1.00); the pattern that was characterized by fruits, vegetables intake and olive oil use in daily cooking was associated with lower CVD risk (HR per 1 unit=0.80, 95% CI 0.66-0.97); while patterns that were mainly characterized by sweets, red meat, margarine, salty nuts intake, and hard cheese, as well as alcohol intake, were associated with higher CVD risk (HR per 1 unit=1.26, 95% CI 1.01-1.56, and HR per 1 unit=1.32, 95% CI 1.05-1.66, respectively). CONCLUSIONS: Multivariate statistical methods revealed dietary patterns based on empirical epidemiological data which were associated with the development of CVD.

Relationship between meat intake and the development of acute coronary syndromes: the CARDIO2000 case-control study.

OBJECTIVE: The aim of the present study was to evaluate the association between meat consumption and the prevalence of a first, non-fatal event of an acute coronary syndrome (ACS), in a Greek sample. DESIGN: Randomized, case-control study. SETTING: Tertiary care. SUBJECTS: A total of 848 out of 956 patients who had been randomly selected from hospitals with first event of an ACS and 1078 population-based controls, age and sex matched. INTERVENTIONS: Detailed information regarding their medical records, alcohol intake, physical activity and smoking habits was recorded. Nutritional habits were evaluated with a semiquantitative food-frequency questionnaire. Multiple logistic regression analysis estimated the odds ratio of having ACS by level of meat intake, after taking into account several confounders. RESULTS: Patients consumed higher quantities of meat compared with controls (6.5+/-2.9 vs 4.9+/-2.1 portions per month, P<0.001). Food-specific analysis showed that red meat consumption was strongly associated with 52% increased odds of ACS (95% confidence interval (CI) 1.47-1.58). On the contrary, white meat consumption seems to be associated with only 18% likelihood of having cardiac events (95% CI 1.11-1.26). Participants who consumed >8 portions red meat and >12 portions white meat per month had 4.9 times and 3.7 higher odds of having ACS, respectively (P<0.001), compared with low meat intake (<4 portions and <8 portions per month, respectively). CONCLUSIONS: Increased red meat consumption showed a strong positive association with cardiac disease risk, whereas white meat consumption showed less prominent results, after controlling for several potential confounding factors.

L-Carnitine/Simvastatin Reduces Lipoprotein (a) Levels Compared with Simvastatin Monotherapy: A Randomized Double-Blind Placebo-Controlled Study.

Lipoprotein (a) [Lp(a)] is an independent risk factor for cardiovascular disease. There are currently limited therapeutic options to lower Lp(a) levels. L-Carnitine has been reported to reduce Lp(a) levels. The aim of this study was to compare the effect of L-carnitine/simvastatin co-administration with that of simvastatin monotherapy on Lp(a) levels in subjects with mixed hyperlipidemia and elevated Lp(a) concentration. Subjects with levels of low-density lipoprotein cholesterol (LDL-C) >160 mg/dL, triacylglycerol (TAG) >150 mg/dL and Lp(a) >20 mg/dL were included in this study. Subjects were randomly allocated to receive L-carnitine 2 g/day plus simvastatin 20 mg/day (N = 29) or placebo plus simvastatin 20 mg/day (N = 29) for a total of 12 weeks. Lp(a) was significantly reduced in the L-carnitine/simvastatin group [-19.4%, from 52 (20-171) to 42 (15-102) mg/dL; p = 0.01], but not in the placebo/simvastatin group [-6.7%, from 56 (26-108) to 52 (27-93) mg/dL, p = NS versus baseline and p = 0.016 for the comparison between groups]. Similar significant reductions in total cholesterol, LDL-C, apolipoprotein (apo) B and TAG were observed in both groups. Co-administration of L-carnitine with simvastatin was associated with a significant, albeit modest, reduction in Lp(a) compared with simvastatin monotherapy in subjects with mixed hyperlipidemia and elevated baseline Lp(a) levels.

Mediterranean diet and prognosis of first-diagnosed Acute Coronary Syndrome patients according to heart failure phenotype: Hellenic Heart Failure Study.

BACKGROUND/OBJECTIVES: Nutrition in secondary prevention of Acute Coronary Syndrome (ACS) is inadequately investigated. We sought to evaluate the role of Mediterranean diet in prognosis of first-diagnosed ACS patients, according to heart failure type. SUBJECTS/METHODS: in 2006-2009, 1000 consecutive patients hospitalized at First Cardiology Clinic of Athens with ACS diagnosis were enrolled in the study. In 2016, 10-year follow-up was performed (75% participation rate). Only n=690 (69%) first-diagnosed ACS patients were included. Adherence to Mediterranean diet was assessed through MedDietScore (range 0-55). Heart failure phenotypes were reduced, mid-range and preserved ejection fraction (that is, HFrEF, HFmrEF and HFpEF, respectively). RESULTS: Ranking from first to third MedDietScore tertile, fewer 1, 2 and 10-year fatal/non-fatal ACS events were observed. Multivariate logistic regression analysis highlighted a significantly inverse association between MedDietScore and long-term ACS prognosis in 1 year (odds ratio (OR)=0.84, 95% confidence interval (CI) (0.71, 1.00), P=0.05), 2 year (OR=0.91, 95% CI (0.82, 1.00), P=0.04) and 10 year (OR=0.93, 95% CI (0.85, 1.00), P=0.05) follow-up. Further analysis revealed that MedDietScore differentially affected patients' prognosis according to heart failure phenotype, with short-term impact in HFrEF and HFmrEF patients yet longer positive outcomes in HFpEF and C-reactive protein potentially mediated these relations. CONCLUSIONS: Mediterranean diet seemed to protect against recurrent cardiac episodes in coronary patients with major ACS complications. Results were more encouraging with regard to patients with preserved left ventricle function. Such findings may possess a cost-effective, supplementary-to-medical, treatment approach in this patient category where evidence concerning their management are inconclusive.European Journal of Clinical Nutrition advance online publication, 23 August 2017; doi:10.1038/ejcn.2017.122.