Dietary α-Linolenic Acid, Marine ω-3 Fatty Acids, and Mortality in a Population With High Fish Consumption: Findings From the PREvención con DIeta MEDiterránea (PREDIMED) Study.

BACKGROUND: Epidemiological evidence suggests a cardioprotective role of α-linolenic acid (ALA), a plant-derived ω-3 fatty acid. It is unclear whether ALA is beneficial in a background of high marine ω-3 fatty acids (long-chain n-3 polyunsaturated fatty acids) intake. In persons at high cardiovascular risk from Spain, a country in which fish consumption is customarily high, we investigated whether meeting the International Society for the Study of Fatty Acids and Lipids recommendation for dietary ALA (0.7% of total energy) at baseline was related to all-cause and cardiovascular disease mortality. We also examined the effect of meeting the society's recommendation for long-chain n-3 polyunsaturated fatty acids (≥500 mg/day). METHODS AND RESULTS: We longitudinally evaluated 7202 participants in the PREvención con DIeta MEDiterránea (PREDIMED) trial. Multivariable-adjusted Cox regression models were fitted to estimate hazard ratios. ALA intake correlated to walnut consumption (r=0.94). During a 5.9-y follow-up, 431 deaths occurred (104 cardiovascular disease, 55 coronary heart disease, 32 sudden cardiac death, 25 stroke). The hazard ratios for meeting ALA recommendation (n=1615, 22.4%) were 0.72 (95% CI 0.56-0.92) for all-cause mortality and 0.95 (95% CI 0.58-1.57) for fatal cardiovascular disease. The hazard ratios for meeting the recommendation for long-chain n-3 polyunsaturated fatty acids (n=5452, 75.7%) were 0.84 (95% CI 0.67-1.05) for all-cause mortality, 0.61 (95% CI 0.39-0.96) for fatal cardiovascular disease, 0.54 (95% CI 0.29-0.99) for fatal coronary heart disease, and 0.49 (95% CI 0.22-1.01) for sudden cardiac death. The highest reduction in all-cause mortality occurred in participants meeting both recommendations (hazard ratio 0.63 [95% CI 0.45-0.87]). CONCLUSIONS: In participants without prior cardiovascular disease and high fish consumption, dietary ALA, supplied mainly by walnuts and olive oil, relates inversely to all-cause mortality, whereas protection from cardiac mortality is limited to fish-derived long-chain n-3 polyunsaturated fatty acids. CLINICAL TRIAL REGISTRATION: URL: http://www.Controlled-trials.com/. Unique identifier: ISRCTN35739639.

Nutritional adequacy according to carbohydrates and fat quality.

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

Dietary patterns and total mortality in a Mediterranean cohort: the SUN project.

BACKGROUND: Different dietary patterns have been associated with several health outcomes, including morbidity and mortality. There is little evidence on the association between empirically derived dietary patterns and all-cause mortality in Southern European populations. OBJECTIVE: The aim of our study was to prospectively evaluate the association between an empirically derived dietary pattern and all-cause mortality. DESIGN: The Seguimiento Universidad de Navarra (SUN) Project is an ongoing, multipurpose, prospective and dynamic Spanish cohort. PARTICIPANTS/SETTING: Participants were a prospective cohort of 16,008 middle-aged Spanish adults. All of them were university graduates (alumni) (59.6% women, mean age 38 years). Usual diet was assessed at baseline with a validated semiquantitative food frequency questionnaire. MAIN OUTCOME MEASURES: Deaths were confirmed by review of medical records and of the National Death Index. STATISTICAL ANALYSIS: Dietary patterns were ascertained through a factor (principal component) analysis based on 30 predefined food groups. Participants were classified according to tertiles of adherence to the three main dietary patterns identified with factor analysis. Cox regression models were fitted to estimate multivariable-adjusted hazard ratios and 95% CIs for mortality. RESULTS: Three major dietary patterns were identified. They were labelled Western dietary pattern (rich in red and processed meat, potatoes, and fast food), Mediterranean dietary pattern (rich in vegetables, fish and seafood, fruits, and olive oil), and alcoholic beverages dietary pattern. During follow-up, 148 deaths were reported (mean age at death 54.5 years). After adjustment for potential confounders, the lowest risk of all-cause mortality was found in the tertile of highest adherence to the Mediterranean dietary pattern (adjusted hazard ratio for third vs first tertile 0.53, 95% CI 0.34 to 0.84) (P for trend <0.01). The Western dietary pattern and alcoholic beverages dietary pattern showed no significant association with mortality. CONCLUSIONS: Greater adherence to an empirically derived dietary pattern approaching the traditional Mediterranean diet was associated with a reduction in the risk of all-cause mortality among middle-aged Mediterranean adults.

Mediterranean diet improves cognition: the PREDIMED-NAVARRA randomised trial.

OBJECTIVE: Previous observational studies reported beneficial effects of the Mediterranean diet (MedDiet) on cognitive function, but results were inconsistent. We assessed the effect on cognition of a nutritional intervention using MedDiets in comparison with a low-fat control diet. METHODS: We assessed 522 participants at high vascular risk (44.6% men, age 74.6 ± 5.7 years at cognitive evaluation) enrolled in a multicentre, randomised, primary prevention trial (PREDIMED), after a nutritional intervention comparing two MedDiets (supplemented with either extra-virgin olive oil (EVOO) or mixed nuts) versus a low-fat control diet. Global cognitive performance was examined by Mini-Mental State Examination (MMSE) and Clock Drawing Test (CDT) after 6.5 years of nutritional intervention. Researchers who assessed the outcome were blinded to group assignment. We used general linear models to control for potential confounding. RESULTS: After adjustment for sex, age, education, Apolipoprotein E genotype, family history of cognitive impairment/dementia, smoking, physical activity, body mass index, hypertension, dyslipidaemia, diabetes, alcohol and total energy intake, participants allocated to the MedDiet+EVOO showed higher mean MMSE and CDT scores with significant differences versus control (adjusted differences: +0.62 95% CI +0.18 to +1.05, p=0.005 for MMSE, and +0.51 95% CI +0.20 to +0.82, p=0.001 for CDT). The adjusted means of MMSE and CDT scores were also higher for participants allocated to the MedDiet+Nuts versus control (adjusted differences: +0.57 (95% CI +0.11 to +1.03), p=0.015 for MMSE and +0.33 (95% CI +0.003 to +0.67), p=0.048 for CDT). These results did not differ after controlling for incident depression. CONCLUSIONS: An intervention with MedDiets enhanced with either EVOO or nuts appears to improve cognition compared with a low-fat diet. ISRCTN:35739639.

Predictors of adherence to a Mediterranean-type diet in the PREDIMED trial.

BACKGROUND: Determinants of dietary changes obtained with a nutritional intervention promoting the Mediterranean diet have been rarely evaluated. AIM: To identify predictors of higher success of an intervention aimed to increase adherence to a Mediterranean diet (MeDiet) in individuals at high cardiovascular risk participating in a trial for primary prevention of cardiovascular disease: the PREDIMED (PREvención con DIeta MEDiterránea) trial. Candidate predictors included demographic and socioeconomic characteristics, cardiovascular risk factors, and baseline dietary habits. METHODS: A total of 1,048 asymptomatic subjects aged 55-80 years allocated to the active intervention groups (subjects in the control group were excluded). Participants' characteristics were assessed at baseline among subjects. Dietary changes were evaluated after 12 months. Main outcome measures were: attained changes in five dietary goals: increases in (1) fruit consumption, (2) vegetable consumption, (3) monounsaturated fatty acid (MUFA)/saturated fatty acid (SFA) ratio, and decreases in (4) sweets and pastries consumption, (5) and meat consumption. Univariate and multivariate logistic regression analyses were used to examine associations between the candidate predictors and likelihood of attaining optimum dietary change (improved adherence to a MeDiet). RESULTS: Among men, positive changes toward better compliance with the MeDiet were more frequent among non-diabetics, and among those with worse dietary habits at baseline (higher consumption of meat, higher SFA intake, lower consumption of fruit and vegetables). Among women, marital status (married) and worse baseline dietary habits (high in meats, low in fruits and vegetables) were the strongest predictors of success in improving adherence to the MeDiet. CONCLUSIONS: Some participant characteristics (marital status and baseline dietary habits) could contribute to predicting the likelihood of achieving dietary goals in interventions aimed to improve adherence to a MeDiet, and may be useful for promoting individualized long-term dietary changes and improving the effectiveness of dietary counseling.

A large randomized individual and group intervention conducted by registered dietitians increased adherence to Mediterranean-type diets: the PREDIMED study.

OBJECTIVE: To assess the effectiveness of an intervention aimed to increase adherence to a Mediterranean diet. DESIGN: A 12-month assessment of a randomized primary prevention trial. SUBJECTS/SETTINGS: One thousand five hundred fifty-one asymptomatic persons aged 55 to 80 years, with diabetes or > or =3 cardiovascular risk factors. INTERVENTION: Participants were randomly assigned to a control group or two Mediterranean diet groups. Those allocated to the two Mediterranean diet groups received individual motivational interviews every 3 months to negotiate nutrition goals, and group educational sessions on a quarterly basis. One Mediterranean diet group received free virgin olive oil (1 L/week), the other received free mixed nuts (30 g/day). Participants in the control group received verbal instructions and a leaflet recommending the National Cholesterol Education Program Adult Treatment Panel III dietary guidelines. MAIN OUTCOME MEASURES: Changes in food and nutrient intake after 12 months. STATISTICAL ANALYSES: Paired t tests (for within-group changes) and analysis of variance (for between-group changes) were conducted. RESULTS: Participants allocated to both Mediterranean diets increased their intake of virgin olive oil, nuts, vegetables, legumes, and fruits (P<0.05 for all within- and between-group differences). Participants in all three groups decreased their intake of meat and pastries, cakes, and sweets (P<0.05 for all). Fiber, monounsaturated fatty acid, and polyunsaturated fatty acid intake increased in the Mediterranean diet groups (P<0.005 for all). Favorable, although nonsignificant, changes in intake of other nutrients occurred only in the Mediterranean diet groups. CONCLUSIONS: A 12-month behavioral intervention promoting the Mediterranean diet can favorably modify an individual's overall food pattern. The individual motivational interventions together with the group sessions and the free provision of high-fat and palatable key foods customary to the Mediterranean diet were effective in improving the dietary habits of participants in this trial.