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.

Association between a new dietary protein quality index and micronutrient intake adequacy: a cross-sectional study in a young adult Spanish Mediterranean cohort.

PURPOSE: There is no evidence of a dietary index that measures not only the quantity but also the quality of protein. The aim is to investigate the association between a new dietary protein quality index (PQI) and micronutrient intake adequacy in a Mediterranean cohort. DESIGN: We assessed 17,535 participants' diet at baseline using a semi-quantitative FFQ. The PQI was calculated according to the ratio of protein (g/d) sources: [fish, seafood, lean meat, pulses, eggs, nuts, low-fat dairy, and whole grains]/[red and ultra-processed meats, whole-fat or semi-skimmed dairy, potatoes and refined grains]. Participants were classified into quintiles of PQI. We evaluated the intakes of Fe, Cr, I, K, Mg, Ca, P, Na, Se, Zn and vitamins A, B1, B2, B3, B6, B12, C, E and folic acid. Micronutrient adequacy was evaluated using DRIs. Logistic regression analysis was used to assess the micronutrient adequacy according to quintiles of PQI. RESULTS: In this cross-sectional analysis, a total of 24.2% and 4.3% participants did not to meet DRIs in ≥ 4 and ≥ 8 micronutrients, respectively. The odds of failing to meet ≥ 4 and ≥ 8 DRI were lower in participants in the highest quintile of protein quality (OR = 0.22; IC 95% = 0.18, 0.26; P-trend < 0.001; and OR = 0.08; IC 95% = 0.05, 0.14; P-trend < 0.001, respectively) as compared to participants in the lowest quintile. CONCLUSION: Higher PQI was found to be strongly associated with better micronutrient intake adequacy in this Mediterranean cohort. The promotion of high-quality protein intake may be helpful for a more adequate intake of micronutrients. The odds of failing to meet certain numbers of DRIs were lower rather than saying lower risk.

Association between an oxidative balance score and mortality: a prospective analysis in the SUN cohort.

PURPOSE: We aimed to prospectively investigate the association of an overall oxidative balance score (OBS) with all-cause death and cause-specific mortality among participants in the Seguimiento Universidad de Navarra (SUN) Study, a Mediterranean cohort of Spanish graduates. METHODS: Using baseline information on 12 a priori selected dietary and non-dietary lifestyle pro- and antioxidants exposures-vitamins C and E, ß-carotenes, selenium, zinc, heme iron, polyphenols, total antioxidant capacity, body mass index, alcohol, smoking, and physical activity-we constructed an equally weighted OBS categorized into quartiles, with higher scores representing greater antioxidant balance. Cox proportional hazards models were fitted to evaluate the association between the OBS and mortality. RESULTS: A total of 18,561 participants (mean [SD] age, 38.5 [12.4] years; 40.8% males) were included in the analysis. During a median follow-up of 12.2 years (interquartile range 8.3-14.9), 421 deaths were identified, including 80 deaths from cardiovascular disease (CVD), 215 from cancer, and 126 from other causes. After adjustment for potential confounders, the hazard ratios and 95% confidence interval (CIs) between the highest quartile (predominance of antioxidants) vs. the lowest quartile (reference category) were 0.35 (95% CI 0.22-0.54, P-trend < 0.001) for all-cause mortality, 0.18 (95% CI 0.06-0.51, P-trend = 0.001) for CVD mortality, 0.35 (95% CI 0.19-0.65, P-trend = 0.002) for cancer mortality, and 0.45 (95% CI 0.20-1.02, P-trend = 0.054) for other-cause mortality. CONCLUSION: Our findings suggest a strong inverse association between the OBS and all-cause, CVD, and cancer mortality. Individuals exposed to both antioxidant dietary and lifestyle factors may potentially experience the lowest mortality risk. STUDY REGISTRY NUMBER: Dynamic Mediterranean Prospective Cohort: the SUN Project; NCT02669602. https://clinicaltrials.gov/ct2/show/NCT02669602 . https://proyectosun.es.

Do healthy doctors deliver better messages of health promotion to their patients?: Data from the SUN cohort study.

BACKGROUND: Healthy lifestyle adherence is associated with lower chronic disease morbidity/mortality. The role of doctors, as counselors and role models, is essential. Among physicians participating in a prospective cohort, we investigated the behavioral counseling on diet and lifestyle provided to their patients in association with their own personal behaviors. METHODS: We assessed 890 doctors aged ≤65 years participating in the 'Seguimiento Universidad de Navarra' (SUN) cohort, who replied to an online questionnaire regarding their practices on behavioral counseling and drug prescription to their patients. Data were combined with previous baseline information on their personal healthy habits. RESULTS: Among doctors, 31% reported <10 min per visit; 73% counseled 60-100% of their patients on smoking cessation, 58% on physical activity, 54% on weight control, 51% on healthy nutrition, 44% on alcohol avoidance/reduction and 28% recommended alcohol moderate consumption. The percentage of doctors that counseled 100% of their patients about lifestyle was 43% for smoking cessation, 15% for exercise and 13% for weight control and nutrition. Better doctor's adherence to the Mediterranean dietary pattern was associated with more frequent and longer nutrition counseling. Higher practice of physical activity was associated with longer time on counseling about exercise to their patients. Among doctors both current and former smoking were inversely associated with the frequency and duration of their smoking cessation/avoidance counseling practices. CONCLUSIONS: Personal behavioral changes among doctors and better training of medical doctors on a personal healthy diet and lifestyle are likely to contribute to improve the behavioral counseling given to patients.

Adherence to the 2015 Dietary Guidelines for Americans and mortality risk in a Mediterranean cohort: The SUN project.

The 2015-2020 Dietary Guidelines for Americans (DGA) was issued in early 2016. It remains untested if adherence to these guidelines could reduce mortality risk. Using a modified version of the 2015 Dietary Guidelines for American Index (2015 DGAI), we investigated if adherence to the new DGA is associated with mortality in a Spanish (the Seguimiento Universidad de Navarra, SUN) cohort. We assessed the habitual diet of 16,866 participants of this cohort recruited between 1999 and 2014 and calculated their adherence scores to the new DGA using the modified 2015 DGAI (0-21points). Mortality data was determined from the yearly National Death Index reports. After adjusting for demographic and lifestyle confounders, high adherence scores (fourth quartile) were found to be associated with reduced all-cause, cardiovascular and cancer mortality risk, hazard ratios (HR) (95% confidence intervals [CI]) 0.42 (0.25-0.70), 0.30 (0.10-0.90) and 0.46 (0.22-0.96), respectively, compared to low adherence scores (first quartile). A 2-point increase in the 2015 DGAI score was linearly inversely associated with all-cause mortality (HR [95% CI] 0.78 [0.67-0.92]). Main sources of variability in the adherence scores were whole-fat dairy products, red/orange vegetables, fresh fruits, red meat, and dark green vegetables. In conclusion, higher adherence to 2015-2020 Dietary Guidelines for Americans was inversely associated with total, cardiovascular and cancer mortality risk in a Spanish cohort.

Association between pre-pregnancy consumption of meat, iron intake, and the risk of gestational diabetes: the SUN project.

PURPOSE: We assessed the association of total meat, processed, and unprocessed red meat and iron intake with the risk of developing gestational diabetes mellitus (GDM) in pregnant women. METHODS: We conducted a prospective study among 3298 disease-free Spanish women participants of the SUN cohort who reported at least one pregnancy between December 1999 and March 2012. Meat consumption and iron intake were assessed at baseline through a validated, 136-item semi-quantitative, food frequency questionnaire. We categorized total, red, and processed meat consumption and iron intake into quartiles. Logistic regression models were used to adjust for potential confounders. RESULTS: We identified 172 incident cases of GDM. In the fully adjusted analysis, total meat consumption was significantly associated with a higher risk of GDM [OR = 1.67 (95% CI 1.06-2.63, p-trend 0.010)] for the highest versus the lowest quartile of consumption. The observed associations were particularly strong for red meat consumption [OR = 2.37 (95% CI 1.49-3.78, p-trend < 0.001)] and processed meat consumption [OR = 2.01 (95% CI 1.26-3.21, p-trend 0.003)]. Heme iron intake was also directly associated with GDM [OR = 2.21 (95% CI 1.37-3.58, p-trend 0.003)], although the association was attenuated and lost its statistical significance when we adjusted for red meat consumption [OR = 1.57 (95% CI 0.91-2.70, p-trend 0.213)]. No association was observed for non-heme and total iron intake, including supplements. CONCLUSIONS: Our overall findings suggest that higher pre-pregnancy consumption of total meat, especially red and processed meat, and heme iron intake, are significantly associated with an increased GDM risk in a Mediterranean cohort of university graduates.

Adherence to the Mediterranean Dietary Pattern and Incidence of Nephrolithiasis in the Seguimiento Universidad de Navarra Follow-up (SUN) Cohort.

BACKGROUND: Diet plays an important role in the pathogenesis of nephrolithiasis. Limited data are available to investigate the association between a Mediterranean dietary pattern and risk for nephrolithiasis. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 16,094 men and women without a history of nephrolithiasis who participated in the Seguimiento Universidad de Navarra Follow-up (SUN) Project. PREDICTORS: A validated 136-item food frequency questionnaire was used to assess baseline adherence to a Mediterranean dietary pattern that is high in fruits, vegetables, nuts, fish, and legumes, but moderate in alcohol and low in meats, saturated fats, and sugars. A Mediterranean dietary pattern score was calculated and categorized into 3 groups (0-3, 4-6, and 7-9 points). Additional factors included in statistical models were sex, age, body mass index, smoking, physical activity, time spent watching television, following a medical nutritional therapy, water and energy intake, calcium and vitamin D supplementation, and history of hypertension or diabetes. OUTCOMES: Incidence of nephrolithiasis. Participants were classified as having incident nephrolithiasis if they reported a physician-made diagnosis of nephrolithiasis during follow-up. RESULTS: After a mean follow-up of 9.6 years, 735 new cases of nephrolithiasis were identified. The multivariable HRs of nephrolithiasis for the 2 highest categories of adherence to the Mediterranean dietary pattern, using the lowest category as the reference, were 0.93 (95% CI, 0.79-1.09) and 0.64 (95% CI, 0.48-0.87); P for trend=0.01. The risk for nephrolithiasis was lower with greater consumption of dairy products and vegetables and greater with higher monounsaturated fatty acid to saturated fatty acid ratio. LIMITATIONS: No information for kidney stone composition. CONCLUSIONS: Greater adherence to a Mediterranean dietary pattern was associated with reduced risk for incident nephrolithiasis. Additional longitudinal studies are needed.

Beneficial changes in food consumption and nutrient intake after 10 years of follow-up in a Mediterranean cohort: the SUN project.

BACKGROUND: The assessment of changes in dietary habits provides interesting information on whether or not the observed trends are in line with accepted nutritional guidelines. The objective was to evaluate within-subject longitudinal changes in food consumption and nutrient intake and in a 10-year follow-up study. METHODS: The SUN (Seguimiento Universidad de Navarra) project is a prospective Spanish cohort study. Diet was assessed using a 136-item food-frequency questionnaire (FFQ), previously validated in Spain. The participants were 3036 university graduates (55.8 % women) of Spain and the main outcome measures the changes in dietary quality and in food consumption and nutrient intake. Paired t-tests and conditional logistic regression models were used to evaluate within-subject longitudinal dietary changes and the risk of inadequacy respectively, after 10 years of follow-up. RESULTS: During follow-up, participants showed a relevant and significant increase (p < 0.001) in the consumption of fruits (7.4 %), vegetables (8.6 %), low-fat dairy products (35.2 %), lean meat (12.4 %), fish (2.9 %), whole grains (53.2 %), nuts (52.4 %) and a significant decrease in legumes (-7.4 %), whole-fat dairy products (-44.2 %), red meat (-17.6 %), sugar-sweetened beverages (-58.7 %) and wine (-11.9 %). With respect to nutrients, we found a higher proportion of carbohydrates (3.6 %) and fiber (7.4 %) and a decrease in total energy intake (2.7 %), total fat (-4.5 %), SFA (-9.4 %), MUFA (-4.9 %), PUFA (-12.7 %), w-3 and w-6 fatty acids (-9.1 and -20.5 % respectively) and cholesterol (-9.6 %). CONCLUSIONS: In this Mediterranean cohort study, mainly beneficial changes in the consumption of most foods and macronutrients were observed after 10 years of follow-up.

Dietary inflammatory index, cardiometabolic conditions and depression in the Seguimiento Universidad de Navarra cohort study.

Only one prospective study has analysed the relationship between the inflammatory properties of diet and risk of depression thus far. The aim of this study was to assess the association between the dietary inflammatory index (DII) and the incidence of depression. In a cohort study of 15 093 university graduates, participants completed a validated FFQ at baseline and after 10 years of follow-up. The DII was calculated based on the FFQ. Each of the twenty-eight nutrients or foods received a score based on findings from the peer-reviewed literature reporting on the relationships between diet and inflammatory biomarkers (IL-1ß, IL-4, IL-6, IL-10, TNF-α and C-reactive protein). Participants were classified as having depression if they reported a new clinical diagnosis of depression by a physician, antidepressant drugs, or both. Multivariable Cox regression models were used to estimate hazard ratios (HR) of depression according to quintiles of the DII. After a median 8·5 years of follow-up, we observed 1051 incident cases of depression. The HR for participants in the highest quintile of DII (strongly pro-inflammatory) was 1·47 (95% CI 1·17, 1·85) compared with those in the bottom quintile, with a significant dose-response relationship (P trend=0·01). In the subgroup analyses, the association between DII and depression was stronger among participants >55 years and among those with cardiometabolic comorbidities (HR 2·70; 95% CI 1·22, 5·97 and HR 1·80; 95% CI 1·27, 2·57, respectively). A pro-inflammatory diet was associated with a significantly higher risk of depression in a Mediterranean population. This association was stronger among older subjects and subjects with cardiometabolic diseases.

Association between dietary carbohydrate intake quality and micronutrient intake adequacy in a Mediterranean cohort: the SUN (Seguimiento Universidad de Navarra) Project.

Epidemiological research confirms that the prevalence of suboptimal micronutrient intakes across Europe is an emerging concern in terms of public health. The aim of the present study was to investigate the association between a new index of carbohydrate (CHO) quality and micronutrient intake adequacy in the 'Seguimiento Universidad de Navarra (SUN)' cohort. The baseline assessment extended from 1999 to March 2012. We assessed 16,841 participants who completed a validated 136-item semi-quantitative FFQ at baseline. We created a new index to evaluate CHO quality for the following four criteria: dietary fibre intake; glycaemic index; whole grains:total grains ratio; solid CHO:total CHO ratio. The subjects were classified into quintiles according to this index. We evaluated the intakes of Zn, I, Se, Fe, Ca, K, P, Mg, Cr and vitamins B1, B2, B3, B6, B12, C, A, D, E and folic acid. The probability of intake adequacy was evaluated using the estimated average requirement cut-point approach and the probabilistic approach. Logistic regression analysis was used to assess the nutritional adequacy according to the CHO quality index (CQI). Participants in the highest quintile of CQI were found to have the lowest prevalence of inadequacy. A higher quality of CHO intake was found to be associated with a lower risk of nutritional inadequacy in comparison with the lowest quintile of CQI (adjusted OR 0·06, 95 % CI 0·02, 0·16; P for trend < 0·001). A higher CQI was found to be strongly associated with better micronutrient intake adequacy in the young Mediterranean cohort, stressing the importance of focusing nutritional education not only on CHO quantity, but also on quality.

Glycemic load, glycemic index, bread and incidence of overweight/obesity in a Mediterranean cohort: the SUN project.

BACKGROUND: To evaluate prospectively the relationship between white, or whole grain bread, and glycemic index, or glycemic load from diet and weight change in a Mediterranean cohort. METHODS: We followed-up 9 267 Spanish university graduates for a mean period of 5 years. Dietary habits at baseline were assessed using a semi-quantitative 136-item food-frequency questionnaire. Average yearly weight change was evaluated according to quintiles of baseline glycemic index, glycemic load, and categories of bread consumption. We also assessed the association between bread consumption, glycemic index, or glycemic load, and the incidence of overweight/obesity. RESULTS: White bread and whole-grain bread were not associated with higher weight gain. No association between glycemic index, glycemic load and weight change was found.White bread consumption was directly associated with a higher risk of becoming overweight/obese (adjusted OR (≥2 portions/day) versus (≤1 portion/week): 1.40; 95% CI: 1.08-1.81; p for trend: 0.008). However, no statistically significant association was observed between whole-grain bread, glycemic index or glycemic load and overweight/obesity. CONCLUSIONS: Consumption of white bread (≥2 portions/day) showed a significant direct association with the risk of becoming overweight/obese.

Nut consumption and incidence of metabolic syndrome after 6-year follow-up: the SUN (Seguimiento Universidad de Navarra, University of Navarra Follow-up) cohort.

OBJECTIVE: To assess the long-term relationship between tree nut consumption and the risk of developing metabolic syndrome (MetS). DESIGN: Nut consumption was collected using a validated 136-item FFQ. The MetS was defined according to the International Diabetes Federation and American Heart Association/National Heart, Lung, and Blood Institute harmonizing definition. The association between nut consumption and MetS was assessed with logistic regression models adjusting for potential confounders. We compared the incidence of MetS between extreme categories of nut intake (> or = 2 servings/week v. never/almost never) after 6 years of follow-up. SETTING: The SUN Project (Seguimiento Universidad de Navarra, University of Navarra Follow-up) is a prospective cohort study, formed of Spanish university graduates. Information is gathered by mailed questionnaires collected biennially. Nut consumption and MetS information was collected by self-reported data. SUBJECTS: Participants (n 9887) initially free of MetS or diabetes and followed up for a minimum of 6 years were included. RESULTS: We observed 567 new cases of MetS during follow-up. Participants who consumed nuts > or = 2 servings/week presented a 32% lower risk of developing MetS than those who never/almost never consumed (adjusted OR = 0.68, 95% CI 0.50, 0.92). The inverse association was stronger among participants who were health professionals. CONCLUSIONS: Nut consumption was significantly associated with lower risk of developing MetS after a 6-year follow-up period in a cohort of Spanish graduates.

Predictors of total mortality and their differential association on premature or late mortality in the SUN cohort.

Several studies have tried to analyse the association between all-cause mortality and different risk factors, (especially those which are modifiable, such as smoking, diet or exercise), to develop public health preventive strategies. However, a specific analysis of predictors of premature and late mortality is needed to give more precise recommendations. Considering that there are risk factors which exert an influence on some diseases and not on others, we expect that, similarly, they may have a different impact depending on the timing of mortality, separating premature (≤65 years) from late mortality (>65 years). Thus, we prospectively followed-up during a median of 12 years a cohort of 20,272 university graduates comprising an ample range of ages at inception. Time-dependent, covariate-adjusted Cox models were used to estimate adjusted hazard ratios (HR) and their 95 % confidence intervals (CI) for each predictor. The strongest independent predictor of mortality at any age was physical activity which was associated with reduced risk of total, premature and late mortality (range of HRs when comparing the highest vs. the lowest level: 0.24 to 0.48). Specific strong predictors for premature mortality were smoking, HR: 4.22 (95 % CI: 2.42-7.38), and the concurrence of ≥2 metabolic conditions at baseline, HR: 1.97 (1.10-3.51). The habit of sleeping a long nap (≥30 min/d), with HR: 2.53 (1.30-4.91), and poor adherence to the Mediterranean Diet (≤3 points in a 0 to 8 score vs. ≥6 points), with HR: 2.27 (1.08-4.76), were the strongest specific predictors for late mortality. Smoking, diet quality or lifestyles, probably should be differentially assessed as specific predictors for early and late mortality. In the era of precision medicine, this approach will allow tailored recommendations appropriate to each person's age and baseline condition.

Physicians' characteristics and practices associated with the provision of cancer screening advice to their patients: the Spanish SUN cohort study.

OBJECTIVES: To evaluate the association between cancer screening counselling provided by medical doctors to their patients and each doctor's own anthropometrics, lifestyle, cancer screening practices, and personal and family history of cancer. DESIGN: Prospective cohort study. SETTING: Substudy including physicians participating in a Spanish cohort study with open enrolment. PARTICIPANTS: Among 22 800 participants in the cohort as of May 2018, there were 2371 physicians who had replied to the cohort baseline questionnaire, had an email account and were younger than 65 years (retirement age in Spain). From this subsample, 890 replied to an online questionnaire focused on their clinical practices related to the counselling provided to their patients and to their prescription practices of preventive medications. Their mean age was 51.7 (SD 9.4) years and 48% were women. OUTCOME MEASURES: Frequency of counselling given to their patients on specific practices of breast, colorectal and prostate cancer screenings. RESULTS: Counselling on cancer screening to their patients was provided by 65% of physicians in a scenario of colorectal cancer, 59% for prostate cancer and 58% for breast cancer. More frequent cancer screening counselling was associated with the specialties of family medicine (OR=9.4, 95% CI 5.1 to 17.1) and internal medicine (OR=2.9, 95% CI 1.5 to 5.7) as compared with other specialties. Recommending cancer screening was associated with more frequent counselling on smoking cessation (OR=3.7, 95% CI 2.6 to 5.4), having personally attended colorectal cancer screening (OR=2.2, 95% CI 1.1 to 4.7) and prescribing blood pressure medication more often than their colleagues (OR=2.1, 95% CI 1.2 to 3.7). CONCLUSIONS: Among medical doctors, cancer screening counselling was provided to their patients more frequently for doctors with family medicine or internal medicine specialties and for physicians who regularly offered counselling on certain lifestyle behaviours, and those having personally attended colorectal cancer screening. Doctors' own personal practices and knowledge of healthy lifestyles may help doctors to more frequently provide counselling on cancer screening to their patients.

Olive oil consumption is associated with a lower risk of cardiovascular disease and stroke.

BACKGROUND & AIMS: The specific association of olive oil consumption with coronary heart disease (CHD) or stroke has not been totally established. OBJECTIVE: to examine whether olive oil consumption is associated with subclinical atherosclerosis, the risk of total cardiovascular disease (CVD), CHD, and stroke. METHODS: Three cohorts were included: AWHS (2318 men), SUN Project (18,266 men and women), and EPIC-Spain (39,393 men and women). Olive oil consumption was measured at baseline using validated questionnaires. RESULTS: In the AWHS, 747 participants had a positive coronary artery calcium score (CACS>0), and the OR (95% CI) was 0.89 (0.72, 1.10) in those with virgin olive oil consumption ≥30 g/day (v. <10 g/day). In the SUN Project (follow-up 10.8 years) 261 total CVD cases occurred, and the HR was 0.57 (0.34, 0.96) for consumptions ≥30 g/day (v. <10 g/day). In the EPIC-Spain (follow-up 22.8 years) 1300 CHD cases and 938 stroke cases occurred; the HRs for stroke according, 0 to <10 (ref), 10 to <20, 20 to <30, and ≥30 g/day of olive oil consumption, were 0.84 (0.70, 1.02), 0.80 (0.66, 0.96), 0.89 (0.74, 1.07). A weaker association was observed for CHD. The association was stronger among those consuming virgin olive oil, instead of common (refined). CONCLUSIONS: Olive oil is associated with lower risk of CVD and stroke. The maximum benefit could be obtained with a consumption between 20 and 30 g/day. The association could be stronger for virgin olive oil and might operate from the early stages of the disease.

Low consumption of fruit and vegetables and risk of chronic disease: a review of the epidemiological evidence and temporal trends among Spanish graduates.

OBJECTIVE: To review the evidence on the association between fruit and vegetable (F&V) consumption and risk of chronic disease, and to assess trends in the prevalence of low F&V consumption. DESIGN: Systematic review and cross-sectional analyses of a Mediterranean cohort. SETTING: The Seguimiento University of Navarra (SUN) project (Spanish dynamic cohort of graduates). SUBJECTS: A systematic review of prospective studies aimed to assess the relationship between fruit and/or vegetables consumption and chronic disease incidence was conducted. We also assessed 18 457 university graduates (59·4 % women; mean age = 39 (sd 12) years) enrolled in a dynamic cohort with permanently open recruitment. Baseline data were collected between 1999 and 2010 using a validated 136-item FFQ. Four definitions for low F&V consumption were used (<400 g/d, <200 g/4184 kJ (1000 kcal) per d, ≤2 servings/d and ≤1 serving/d). Multivariate-adjusted cross-sectional associations between the prevalence of low F&V consumption and the year of recruitment were estimated. RESULTS: The systematic review found that a high F&V consumption is inversely associated with CVD incidence and mortality. This association is not so clear for cancer. Inconsistent findings have been reported for diabetes. In all, 13 % of participants in the SUN cohort did not meet the goal of consuming at least 400 g/d of F&V and 2·1 % of them did not reach >1 serving/d. Between 1999 and 2010 the consumption of F&V significantly increased. CONCLUSIONS: Even among health-conscious university graduates, low F&V consumption is fairly prevalent. Although the temporal trends suggest an improvement, preventive strategies addressed to increase F&V consumption are needed.

Diet Quality Indices in the SUN Cohort: Observed Changes and Predictors of Changes in Scores Over a 10-Year Period.

BACKGROUND: Dietary quality indices (DQI) are widely used in nutritional epidemiology. However, how they might change over time in a Mediterranean population is not well understood. OBJECTIVE: To evaluate within-participant longitudinal changes in scores for nine a priori-defined DQIs: Fat Quality Index (FQI), Carbohydrate Quality Index (CQI), Pro-vegetarian Dietary Pattern (PVG), Mediterranean Diet Adherence Screener (MEDAS), Mediterranean Diet Score (MDS), Dietary Approaches to Stop Hypertension (DASH), Mediterranean-DASH Intervention for Neurodegenerative Delay Diet (MIND), Prime Diet Quality Score (PDQS) and Alternate Healthy Eating Index (AHEI-2010) in the "Seguimiento Universidad de Navarra" (SUN) cohort, a well-known Mediterranean cohort of university graduates, and to identify baseline predictors of improvement in MEDAS and AHEI-2010 after 10 years of follow-up. DESIGN: In this longitudinal cohort study, DQI scores were calculated based on responses from a validated semiquantitative food-frequency questionnaire (FFQ). PARTICIPANTS/SETTING: Spanish university graduates enrolled in the SUN cohort before March 2008, who completed the 10-year FFQ and reported total dietary intake at baseline and after 10 years of follow-up, included 2,244 men and 3,271 women, whose mean age at baseline was 36.3 years (standard deviation [SD], 10.7). MAIN OUTCOME MEASURES: Main outcome measures were within-participant longitudinal changes for FQI, CQI, PVG, MEDAS, MDS, DASH, MIND, PDQS, and AHEI-2010. STATISTICAL ANALYSES PERFORMED: Adjusted logistic regression models were used to evaluate within-participant longitudinal changes and to identify baseline predictors of improvements ≥10% in MEDAS and AHEI-2010 scores after 10 years of follow-up. RESULTS: The comparison of the nine scores of DQI calculated at baseline and after 10 years of follow-up showed an improvement in all DQI scores except for PDQS. The greatest changes in DQIs were found for MEDAS (from 6.2 to 7.2, +22.9%) and MDS (from 4.3 to 4.4, +15.4%). The strongest predictors at baseline for ≥10% improvements in MEDAS or AHEI-2010 scores varied across indices. Being female, ≥35 years old, and more physically active at baseline were associated with improvement, whereas snacking between meals was associated with <10% improvements in both indices. CONCLUSIONS: In this cohort, the changes in nine a priori-defined DQI scores suggested modest improvements in diet quality, in which MEDAS and MDS scores showed the largest improvements. Additional longitudinal studies, especially intervention trials with long follow-up, are warranted to establish the most appropriate DQIs to assess long-term changes in diet quality in adult populations.