Daily time spent on screens and psychological well-being: Cross-sectional association within the SUN cohort.

BACKGROUND: The impact of various lifestyles on psychological well-being (PWB) remains under-studied. We aimed to explore the cross-sectional association between daily screen use (television, tablet and mobile phone) and PWB within the SUN cohort. METHODS: PWB was assessed using the 29-item Ryff scale (ranging from 29 to 174), and participants with scores >75th percentile were considered as having optimal PWB. Participants were categorized based on their self-reported weekly screen usage hours. Postestimation logistic regression models assessing the prevalence likelihood of not achieving optimal PWB were adjusted for sociodemographic, psychological, personality and lifestyles factors. Isotemporal substitution models explored the potential impact on PWB resulting from replacing 1 h/day of screen time with 1 h/day of exercise. RESULTS: The study included 3051 participants (55.8% women, mean age 57.3 ± 11.1 years, mean Ryff's score: 139.1 ± 17.4 points). Daily screen use for ≥2 h was associated with a higher prevalence likelihood of not achieving an optimal PWB (Prevalence Ratio [PR]:1.09; 95% CI:1.01-1.18). Among PWB dimensions, screen use ≥2 h/day was linked to an increased likelihood of not achieving optimal scores in environmental mastery (PR:1.11; 95% CI:1.02-1.20), life purpose (PR:1.10; 95% CI:1.02-1.18), and personal growth (PR:1.09; 95% CI:1.01-1.18). Replacing 1 h of daily screens time with 1 h of exercise may lead to potential improvements in environmental mastery (Odds Ratio [OR]:0.87; 95% CI:0.76-0.99), purpose in life (OR:0.86; 95% CI: 0.76-0.98), personal growth (OR:0.84; 95% CI:0.73-0.96) and positive interpersonal relationships (OR:0.86; 95% CI:0.75-0.99). CONCLUSIONS: These findings highlight the importance of reducing screen use activities and increasing physical exercise for achieving optimal PWB.

Association between the consumption of ultra-processed foods and the incidence of peptic ulcer disease in the SUN project: a Spanish prospective cohort study.

PURPOSE: Consumption of ultra-processed foods (UPF) has increased despite potential adverse health effects. Recent studies showed an association between UPF consumption and some gastrointestinal disorders. We evaluated the association between UPF consumption and peptic ulcer disease (PUD) in a large Spanish cohort. METHODS: We conducted a prospective analysis of 18,066 participants in the SUN cohort, followed every two years. UPF was assessed at baseline and 10 years after. Cases of PUD were identified among participants reporting a physician-made diagnosis of PUD during follow-ups. Cases were only partially validated against medical records. Cox regression was used to assess the association between baseline UPF consumption and PUD risk. Based on previous findings and biological plausibility, socio-demographic and lifestyle variables, BMI, energy intake, Helicobacter pylori infection, gastrointestinal disorders, aspirin and analgesic use, and alcohol and coffee consumption were included as confounders.We fitted GEE with repeated dietary measurements at baseline and after 10 years of follow-up. Vanderweele's proposed E value was calculated to assess the sensitivity of observed associations to uncontrolled confounding. RESULTS: During a median follow-up of 12.2 years, we recorded 322 new PUD cases (1.56 cases/1000 person-years). Participants in the highest baseline tertile of UPF consumption had an increased PUD risk compared to participants in the lowest tertile (HR = 1.52, 95% CI: 1.15, 2.00, Ptrend=0.002). The E-values for the point estimate supported the observed association. The OR using repeated measurements of UPF intake was 1.39 (95% CI: 1.03, 1.87) when comparing extreme tertiles. CONCLUSION: The consumption of UPF is associated with an increased PUD risk.

Tobacco and alcohol co-use: Lifestyle and sociodemographic factors, and personality aspects as potential predictors in the "Seguimiento Universidad de Navarra" cohort.

Tobacco and alcohol co-use are two major lifestyle modifiable risk factors. Understanding the determinants of both behaviors helps to develop interventions to prevent these exposures. However, previous studies have focused on predictors of individual tobacco or alcohol use. This study aims to explore the potential predictors of tobacco and alcohol co-use among Spanish university graduates from the "Seguimiento Universidad de Navarra" (SUN) cohort study. A total of 7175 participants who were co-users of tobacco and alcohol were selected for this cross-sectional analysis. Their mean age was 39.1 years (12.04 SD) and 57.3% were women. Univariate regression models were used to select the potential predictors of tobacco and alcohol co-use, and the areas under the ROC curves (AUC) were calculated. Multivariable logistic regression models were used to create a predictive model. Baseline potential predictors included sociodemographic factors, lifestyle habits, and perceived personality aspects. In the multivariable model, the main significant potential predictors of tobacco and alcohol co-use were driving under the influence of alcohol (odds ratio [OR] = 1.65 [1.43-1.90]), drinking 1-2 cups of coffee daily (OR = 1.50 [1.24-1.84]), drinking three or more cups of coffee daily (OR = 1.61 [1.35-1.91]), and doing more physical activity than recommended (OR = 1.18 [1.02-1.34]) when compared with the reference group. Conversely, those who were married (OR = 0.87 [0.75-0.99], ate at home 7 days a week (OR = 0.69 [0.60-0.80]), or had a high perceived level of competitiveness (OR = 0.83 [0.72-0.95]) had a lower risk of co-use (AUC 0.61 [confidence interval 95% 0.59-0.63]), compared to the reference group. These results could be used by healthcare professionals, especially nurses, to effectively assess patients at higher risk of tobacco and alcohol co-use. [Correction added on 16 February 2024, after first online publication: The abstract section has been revised to provide more clarity in this version.].

Forecasting levels of serum 25-hydroxyvitamin D based on dietary intake, lifestyle and personal determinants in a sample of Southern Europeans.

Vitamin D is an essential nutrient to be consumed in the habitual dietary intake, whose deficiency is associated with various disturbances. This study represents a validation of vitamin D status estimation using a semi-quantitative FFQ, together with data from additional physical activity and lifestyle questionnaires. This information was combined to forecast the serum vitamin D status. Different statistical methods were applied to estimate the vitamin D status using predictors based on diet and lifestyle. Serum vitamin D was predicted using linear regression (with leave-one-out cross-validation) and random forest models. Intraclass correlation coefficients, Lin's agreement coefficients, Bland-Altman plots and other methods were used to assess the accuracy of the predicted v. observed serum values. Data were collected in Spain. A total of 220 healthy volunteers aged between 18 and 78 years were included in this study. They completed validated questionnaires and agreed to provide blood samples to measure serum 25-hydroxyvitamin D (25(OH)D) levels. The common final predictors in both models were age, sex, sunlight exposure, vitamin D dietary intake (as assessed by the FFQ), BMI, time spent walking, physical activity and skin reaction after sun exposure. The intraclass correlation coefficient for the prediction was 0·60 (95 % CI: 0·52, 0·67; P < 0·001) using the random forest model. The magnitude of the correlation was moderate, which means that our estimation could be useful in future epidemiological studies to establish a link between the predicted 25(OH)D values and the occurrence of several clinical outcomes in larger cohorts.

Carbon dioxide (CO2) emissions and adherence to Mediterranean diet in an adult population: the Mediterranean diet index as a pollution level index.

BACKGROUND: Research related to sustainable diets is is highly relevant to provide better understanding of the impact of dietary intake on the health and the environment. AIM: To assess the association between the adherence to an energy-restricted Mediterranean diet and the amount of CO2 emitted in an older adult population. DESIGN AND POPULATION: Using a cross-sectional design, the association between the adherence to an energy-reduced Mediterranean Diet (erMedDiet) score and dietary CO2 emissions in 6646 participants was assessed. METHODS: Food intake and adherence to the erMedDiet was assessed using validated food frequency questionnaire and 17-item Mediterranean questionnaire. Sociodemographic characteristics were documented. Environmental impact was calculated through greenhouse gas emissions estimations, specifically CO2 emissions of each participant diet per day, using a European database. Participants were distributed in quartiles according to their estimated CO2 emissions expressed in kg/day: Q1 (≤2.01 kg CO2), Q2 (2.02-2.34 kg CO2), Q3 (2.35-2.79 kg CO2) and Q4 (≥2.80 kg CO2). RESULTS: More men than women induced higher dietary levels of CO2 emissions. Participants reporting higher consumption of vegetables, fruits, legumes, nuts, whole cereals, preferring white meat, and having less consumption of red meat were mostly emitting less kg of CO2 through diet. Participants with higher adherence to the Mediterranean Diet showed lower odds for dietary CO2 emissions: Q2 (OR 0.87; 95%CI: 0.76-1.00), Q3 (OR 0.69; 95%CI: 0.69-0.79) and Q4 (OR 0.48; 95%CI: 0.42-0.55) vs Q1 (reference). CONCLUSIONS: The Mediterranean diet can be environmentally protective since the higher the adherence to the Mediterranean diet, the lower total dietary CO2 emissions. Mediterranean Diet index may be used as a pollution level index.

Metabolic syndrome criteria and severity and carbon dioxide (CO2) emissions in an adult population.

BACKGROUND: Metabolic syndrome (MetS) has become a growing risk factor of some non-communicable diseases. Increase of greenhouse gas emissions affects the planet. AIMS: To assess the association between MetS severity and amount of carbon dioxide (CO2) emitted in an adult population. DESIGN: Cross-sectional study (n = 6646; 55-76-year-old-men; 60-75-year-old-women with MetS). METHODS: Dietary habits were assessed using a pre-validated semi quantitative 143-item food frequency questionnaire. The amount of CO2 emitted due to the production of food consumed by person and day was calculated using a European database, and the severity of the MetS was calculated with the MetS Severity Score. RESULTS: Higher glycaemia levels were found in people with higher CO2 emissions. The risk of having high severe MetS was related to high CO2 emissions. CONCLUSIONS: Low CO2 emissions diet would help to reduce MetS severity. Advantages for both health and the environment were found following a more sustainable diet. TRIAL REGISTRATION: ISRCTN, ISRCTN89898870 . Registered 05 September 2013.

Integrative development of a short screening questionnaire of highly processed food consumption (sQ-HPF).

BACKGROUND: Recent lifestyle changes include increased consumption of highly processed foods (HPF), which has been associated with an increased risk of non-communicable diseases (NCDs). However, nutritional information relies on the estimation of HPF consumption from food-frequency questionnaires (FFQ) that are not explicitly developed for this purpose. We aimed to develop a short screening questionnaire of HPF consumption (sQ-HPF) that integrates criteria from the existing food classification systems. METHODS: Data from 4400 participants (48.1% female and 51.9% male, 64.9 ± 4.9 years) of the Spanish PREDIMED-Plus ("PREvention with MEDiterranean DIet") trial were used for this analysis. Items from the FFQ were classified according to four main food processing-based classification systems (NOVA, IARC, IFIC and UNC). Participants were classified into tertiles of HPF consumption according to each system. Using binomial logistic regression, food groups associated with agreement in the highest tertile for at least two classification systems were chosen as items for the questionnaire. ROC analysis was used to determine cut-off points for the frequency of consumption of each item, from which a score was calculated. Internal consistency of the questionnaire was assessed through exploratory factor analysis (EFA) and Cronbach's analysis, and agreement with the four classifications was assessed with weighted kappa coefficients. RESULTS: Regression analysis identified 14 food groups (items) associated with high HPF consumption for at least two classification systems. EFA showed that items were representative contributors of a single underlying factor, the "HPF dietary pattern" (factor loadings around 0.2). We constructed a questionnaire asking about the frequency of consumption of those items. The threshold frequency of consumption was selected using ROC analysis. Comparison of the four classification systems and the sQ-HPF showed a fair to high agreement. Significant changes in lifestyle characteristics were detected across tertiles of the sQ-HPF score. Longitudinal changes in HPF consumption were also detected by the sQ-HPF, concordantly with existing classification systems. CONCLUSIONS: We developed a practical tool to measure HPF consumption, the sQ-HPF. This may be a valuable instrument to study its relationship with NCDs. TRIAL REGISTRATION: Retrospectively registered at the International Standard Randomized Controlled Trial Registry ( ISRCTN89898870 ) on July 24, 2014.

Association between pre-conceptional carbohydrate quality index and the incidence of gestational diabetes: the SUN cohort study.

The aim of the study was to investigate the association between pre-gestational carbohydrate quality index (CQI) and the incidence of gestational diabetes mellitus (GDM). Data from the 'Seguimiento Universidad de Navarra' (SUN) cohort were used, which includes 3827 women who notified at least one pregnancy between December 1999 and December 2019. We used a validated semi-quantitative 136-item FFQ to evaluate dietary exposures at baseline and at 10-year follow-up. The CQI was defined by four criteria: glycaemic index, whole-grain/total-grain carbohydrate, dietary fibre intake and solid/total carbohydrate ratio. We fitted generalised estimating equations with repeated measurements of the CQI to assess its relationship with incident GDM. A total of 6869 pregnancies and 202 new cases of incident GDM were identified. The inverse association between the global quality of carbohydrate and the development of GDM was not statistically significant: OR the highest v. the lowest CQI category: 0·67, 95 % CI (0·40, 1·10), Pfor trend = 0·10. Participants at the highest CQI category and with daily carbohydrate amounts ≥50 % of total energy intake had the lowest incidence of GDM (OR = 0·29 (95 % CI (0·09, 0·89)) compared with those with the lowest quality (lowest CQI) and quantity (≤40 %). Further studies are needed to overcome the limitations of our study. Those studies should jointly consider the quality and the quantity of dietary carbohydrates, as the quality might be of importance, especially in women with a higher intake of carbohydrates.

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

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

Associations between exploratory dietary patterns and incident type 2 diabetes: a federated meta-analysis of individual participant data from 25 cohort studies.

PURPOSE: In several studies, exploratory dietary patterns (DP), derived by principal component analysis, were inversely or positively associated with incident type 2 diabetes (T2D). However, findings remained study-specific, inconsistent and rarely replicated. This study aimed to investigate the associations between DPs and T2D in multiple cohorts across the world. METHODS: This federated meta-analysis of individual participant data was based on 25 prospective cohort studies from 5 continents including a total of 390,664 participants with a follow-up for T2D (3.8-25.0 years). After data harmonization across cohorts we evaluated 15 previously identified T2D-related DPs for association with incident T2D estimating pooled incidence rate ratios (IRR) and confidence intervals (CI) by Piecewise Poisson regression and random-effects meta-analysis. RESULTS: 29,386 participants developed T2D during follow-up. Five DPs, characterized by higher intake of red meat, processed meat, French fries and refined grains, were associated with higher incidence of T2D. The strongest association was observed for a DP comprising these food groups besides others (IRRpooled per 1 SD = 1.104, 95% CI 1.059-1.151). Although heterogeneity was present (I2 = 85%), IRR exceeded 1 in 18 of the 20 meta-analyzed studies. Original DPs associated with lower T2D risk were not confirmed. Instead, a healthy DP (HDP1) was associated with higher T2D risk (IRRpooled per 1 SD = 1.057, 95% CI 1.027-1.088). CONCLUSION: Our findings from various cohorts revealed positive associations for several DPs, characterized by higher intake of red meat, processed meat, French fries and refined grains, adding to the evidence-base that links DPs to higher T2D risk. However, no inverse DP-T2D associations were confirmed.

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

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

Intervention for promoting intake of fruits and vegetables in Brazilians: a randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness of a nutritional intervention to promote fruit and vegetable (FV) intake. DESIGN: A randomised controlled community trial was conducted to evaluate the effectiveness of a 7-month nutritional intervention and to promote FV intake, separately and together. All participants attended physical exercise sessions. The intervention was based on the transtheoretical model and Paulo Freire's pedagogy. The interventions included group educational sessions, motivational cards and informational materials. The primary outcome was a change in FV intake (g/d), and secondary outcomes included stages of change, self-efficacy, decisional balance and knowledge on FV. All data were collected face-to-face; and FV intake was assessed using a validated brief questionnaire. SETTING: Health promotion services of Brazilian Primary Health Care. PARTICIPANTS: 3414 users of Brazilian Primary Health Care (1931 in the control group and 1483 in the intervention group (IG)). RESULTS: At baseline, the average daily FV intake was 370·4 g/d (95 % CI 364·2, 376·6). The increase in FV intake (23·4 g/d; 95 % CI 6·7, 40·0) and fruit intake (+17·3 g/d; 95 % CI 5·1, 29·4; P = 0·01) was greater in the IG among participants in the lowest baseline intake. Participants in the IG also showed progression in the stages of change (P < 0·001), increased self-efficacy (P < 0·001) and improved knowledge of FV crops (P < 0·001). CONCLUSIONS: The nutritional intervention was effective in increasing FV intake and fruits intake among individuals with a lower intake at baseline and in maintaining FV intake among those who reported consuming FV as recommended (400 g/d).

Associations of Total Legume, Pulse, and Soy Consumption with Incident Type 2 Diabetes: Federated Meta-Analysis of 27 Studies from Diverse World Regions.

BACKGROUND: The consumption of legumes is promoted as part of a healthy diet in many countries but associations of total and types of legume consumption with type 2 diabetes (T2D) are not well established. Analyses across diverse populations are lacking despite the availability of unpublished legume consumption data in prospective cohort studies. OBJECTIVE: To examine the prospective associations of total and types of legume intake with the risk of incident T2D. METHODS: Meta-analyses of associations between total legume, pulse, and soy consumption and T2D were conducted using a federated approach without physical data-pooling. Prospective cohorts were included if legume exposure and T2D outcome data were available and the cohort investigators agreed to participate. We estimated incidence rate ratios (IRRs) and CIs of associations using individual participant data including ≤42,473 incident cases among 807,785 adults without diabetes in 27 cohorts across the Americas, Eastern Mediterranean, Europe, and Western Pacific. Random-effects meta-analysis was used to combine effect estimates and estimate heterogeneity. RESULTS: Median total legume intake ranged from 0-140 g/d across cohorts. We observed a weak positive association between total legume consumption and T2D (IRR = 1.02, 95% CI: 1.01 to 1.04) per 20 g/d higher intake, with moderately high heterogeneity (I2 = 74%). Analysis by region showed no evidence of associations in the Americas, Eastern Mediterranean, and Western Pacific. The positive association in Europe (IRR = 1.05, 95% CI: 1.01 to 1.10, I2 = 82%) was mainly driven by studies from Germany, UK, and Sweden. No evidence of associations was observed for the consumption of pulses or soy. CONCLUSIONS: These findings suggest no evidence of an association of legume intakes with T2D in several world regions. The positive association observed in some European studies warrants further investigation relating to overall dietary contexts in which legumes are consumed, including accompanying foods which may be positively associated with T2D.

Public support for healthy supermarket initiatives focused on product placement: a multi-country cross-sectional analysis of the 2018 International Food Policy Study.

BACKGROUND: Food retail environments have an influential role in shaping purchasing behavior and could contribute to improving dietary patterns at a population level. However, little is known about the level of public support for different types of initiatives to encourage healthy food choices in supermarkets, and whether this varies across countries or context. The current study aimed to explore the level of support for three potential supermarket initiatives focused on product placement across five countries, and factors that may influence this support. METHODS: A total of 22,264 adults from Australia, Canada, Mexico, the United Kingdom and the United States (US) provided information on support for three supermarket initiatives related to product placement (targeting product positioning: 'checkouts with only healthy products', 'fewer end-of-aisle displays containing unhealthy foods or soft drinks' or availability: 'more shelf space for fresh and healthier foods') as part of the online 2018 International Food Policy Study. The proportion of respondents that supported each initiative was assessed across countries, and multivariable logistic regression analyses were conducted to evaluate the influence of sociodemographic factors on support. RESULTS: The initiative that received the highest support was 'more shelf space for fresh and healthier foods': 72.0% [95% CI 71.3-72.7], whereas 'checkouts with only healthy products' received the lowest support: 48.6% [95% CI 47.8-49.4]. The level of support differed between countries (p < 0.001 for all initiatives), with the US generally showing the lowest support and Mexico the highest. Noteworthy, in the overall sample, there was not much opposition to any of the initiatives (2.5-14.2%), whereas there was a large proportion of neutral responses (25.5-37.2%). Respondents who were older, female, highly educated, and those who reported having more nutrition knowledge tended to be more supportive, with several differences between countries and initiatives. CONCLUSIONS: Most people in the assessed five countries showed a generally high level of support for three placement initiatives in supermarkets to encourage healthy food choices. Support varied by type of initiative (i.e., product positioning or availability) and was influenced by several factors related to country context and sociodemographic characteristics. This evidence could prompt and guide retailers and policy makers to take stronger action to promote healthy food choices in stores.

Mediterranean diet, alcohol-drinking pattern and their combined effect on all-cause mortality: the Seguimiento Universidad de Navarra (SUN) cohort.

PURPOSE: The health benefits of the Mediterranean diet (MedDiet) have been widely studied. However, controversy remains for one of its components: alcohol intake. We aimed to assess the joint effect of adherence to the MedDiet and alcohol-drinking pattern on all-cause mortality. METHODS: We used data from 20,506 subjects from a prospective cohort of Spanish university graduates, the Seguimiento Universidad de Navarra (SUN) cohort. Adherence to the MedDiet was operationalized using four different dietary indexes and then categorized in low or high adherence, according to the median score. Alcohol-drinking pattern was evaluated with the previously defined the Mediterranean alcohol-drinking pattern (MADP), grouped into three categories of adherence (low, moderate and high adherence) and a fourth category for abstainers. The outcome was all-cause mortality. RESULTS: During a median follow-up of 12.1 years, we observed 460 deaths. No statistically significant supra-multiplicative interaction between the two exposures was found. Low adherence to both the MedDiet and MADP was associated with higher all-cause mortality compared to high adherence to both exposures [multivariable-adjusted hazard ratio (HR) = 2.02, 95% confidence interval (CI): 1.33-3.07]. Similar results were found for cancer mortality and cardiovascular mortality. CONCLUSIONS: Although the combined effect of the MedDiet and MADP was not significantly higher than the product of their individual effects, a low adherence to both the MedDiet and MADP was associated with higher rates of all-cause mortality. This report also shows the usefulness of the dietary pattern approach applied to alcohol intake and of including the drinking pattern as another component of the MedDiet.

Promoting exercise, reducing sedentarism or both for diabetes prevention: The "Seguimiento Universidad De Navarra" (SUN) cohort.

BACKGROUND AND AIM: Both physical activity (PA) and sedentary behaviors have demonstrated independent associations with the development of type 2 diabetes mellitus (T2DM). However, the combination of both, has been less explored. We aimed to compare the associations of PA-only versus the simultaneous effect of PA and sedentary behaviors on T2DM in a Mediterranean cohort. METHODS AND RESULTS: Participants (n = 19,524) initially free of T2DM from the SUN Project were followed-up for a median of 10.4 years. Analyses were conducted in 2018. PA and sedentary parameters (TV viewing time and sitting time) were assessed through a validated questionnaire. The amount of each PA was expressed in METs-h/wk. After that, a previously developed 8-item active + sedentary lifestyle score was computed. T2DM was defined according to ADA criteria. To adjust for potential confounders, Cox regression models were adjusted. Among 19,524 participants, 175 cases of new-onset T2DM were observed during follow-up. After multivariable adjustment, higher PA was strongly inversely associated with T2DM, showing highly significant differences between extreme quartiles (HR = 0.51; 95% CI 0.32-0.79 p for trend<0.001). When considering not only PA, but also the more comprehensive active + sedentary lifestyle combined score, even stronger differences were found between the lowest and the highest categories (HR = 0.40; 95%CI 0.20-0.80; p for trend<0.001). CONCLUSION: Sedentary lifestyles, in addition to PA patterns, should be included in the assessment of T2DM risk. Promoting PA should be coupled with the avoidance of a sedentary lifestyle to lower the risk of T2DM.

[Reduction of red and processed meats in the Spanish population: What is its impact on total and cardiovascular mortality?] / Reducción de carnes rojas y procesadas en la población española: ¿cuál es su impacto sobre la mortalidad cardiovascular?

OBJECTIVE: Quantify the impact of reducing the consumption of red/processed meats on cardiovascular mortality and all-cause mortality of the Spanish adult population based in 5 revisions published. PARTICIPANTS AND MAIN MEASUREMENTS: We defined exposure as consumption of ≥3 servings/week of red or processed meats and considered four possible scenarios of exposed population (30%-60%). Based on data from the Spanish National Statistics Institute, we calculated the weighted mortality between 40 and 80years. Using the relative risks (RR) and 95% confidence intervals (CI) published by the referred revisions (RR=0.88; IC95%: 0.84-0.93 for all-cause mortality and RR=0.92; IC95%: 0.90-0.93 for cardiovascular mortality), we calculated the expected mortality rate in both exposed and unexposed categories. By multiplying these rates by the number of exposed individuals, we estimated the attributable number of yearly deaths. RESULTS: If 60% of the population was exposed, with a 95%CI, the number of cardiovascular deaths that could be averted each year if population consumed <3 servings/week of red or processed meats was between 2.112 and 3.055. If was exposed that 30%, the difference in the yearly number of potentially averted deaths was between 1.079 and 1.577. CONCLUSIONS: Even under the most conservative assumption, the benefit, at the population level, of reducing red or processed meats consumption <3 servings/week on cardiovascular mortality is important. The conclusions of the recently published reviews contradicted their own results and contributed to a state of confusion that can create substantial harm for public health.

Oral contraceptives use and development of obesity in a Mediterranean cohort: the SUN (Seguimiento Universidad de Navarra) Project.

BACKGROUND: The use of oral contraceptives (OC) has been suggested to represent a potential risk factor for the development of obesity. However, the available literature assessing the relationship between OC use and the development of obesity is still scarce and characterised by controversial heterogeneity. We prospectively evaluated the association between the use of OC and the development of obesity in female participants of a middle-aged and free-living cohort. METHODS: The study population included 4920 female Spanish university graduates, initially nonobese women, with mean age (standard deviation) 28.2 (5.4) years. The study population was followed up for a mean of 8.6 (3.7) years. Self-reported use of OC and body mass index were assessed at baseline and biennially during follow-up. We used generalized estimating equation models to evaluate the association between exposure to OC and the development of obesity. RESULTS: After adjusting for potential confounders, baseline OC use was associated with higher odds of new-onset obesity during the full follow-up period (multivariable-adjusted odds ratio [OR] = 1.78; 95% Confidence Interval [CI]: 1.01-3.15). The continued use of OC for periods of time longer than 2 years was significantly associated with a higher risk of developing obesity (OR = 2.82, 95% CI: 1.17-6.82). CONCLUSIONS: According to our prospective cohort study, OC use is significantly associated with higher odds of obesity development, especially when the use of OC is steady and extends over periods of more than 2 years.

A three-dimensional dietary index (nutritional quality, environment and price) and reduced mortality: The "Seguimiento Universidad de Navarra" cohort.

Several healthy diet indices have been associated with mortality risk. However, the ideal diet should not only be healthy but also environmentally friendly and affordable. The study aimed to determine if a new Sustainable Diet Index (SDI), which takes into account the nutritional quality, environmental impacts and market price of diets, was associated with all-cause and cause-specific mortality. Using data from the "Seguimiento Universidad de Navarra" Project, a prospective cohort study of Spanish university graduates, the study included 15,492 participants who were recruited between December 1999 and March 2014 and followed-up for a median of 10 years. Cox regression was used to determine the relationship of SDI and its components with all-cause and cause-specific mortality risk. Hazard ratios with adjustment for several confounders were calculated. The weights for the foods contributing to the SDI were assessed with multiple regression analyses and variability with nested regression analyses. The highest quartile of the SDI scores was associated with a 59% relative reduction in all-cause mortality (HR 0.41, 95% CI 0.23-0.75; ptrend < 0.001) and 79% reduction in cardiovascular mortality (HR 0.21, 95% CI 0.05-0.85; ptrend < 0.001). SDI was positively correlated with beans and potato consumption but negatively correlated with red meat intake. Red and processed meats, fatty dairy products and fish consumption accounted for most of the variability in the SDI. Altogether, dietary patterns accounting not only for nutritional quality of the food but also the impact on the environment and affordability could still provide health benefits.

Ultra-processed food consumption and the incidence of depression in a Mediterranean cohort: the SUN Project.

PURPOSE: A growing body of evidence shows that consumption of ultra-processed foods (UPF) is associated with a higher risk of cardiometabolic diseases, which, in turn, have been linked to depression. This suggests that UPF might also be associated with depression, which is among the global leading causes of disability and disease. We prospectively evaluated the relationship between UPF consumption and the risk of depression in a Mediterranean cohort. METHODS: We included 14,907 Spanish university graduates [mean (SD) age: 36.7 year (11.7)] initially free of depression who were followed up for a median of 10.3 years. Consumption of UPF (industrial formulations made mostly or entirely from substances derived from foods and additives, with little, if any, intact food), as defined by the NOVA food classification system, was assessed at baseline through a validated semi-quantitative 136-item food-frequency questionnaire. Participants were classified as incident cases of depression if they reported a medical diagnosis of depression or the habitual use of antidepressant medication in at least one of the follow-up assessments conducted after the first 2 years of follow-up. Cox regression models were used to assess the relationship between UPF consumption and depression incidence. RESULTS: A total of 774 incident cases of depression were identified during follow-up. Participants in the highest quartile of UPF consumption had a higher risk of developing depression [HR (95% CI) 1.33 (1.07-1.64); p trend = 0.004] than those in the lowest quartile after adjusting for potential confounders. CONCLUSIONS: In a prospective cohort of Spanish university graduates, we found a positive association between UPF consumption and the risk of depression that was strongest among participants with low levels of physical activity.