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.

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.

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 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.

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.

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.

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.

Ultra-processed foods and type-2 diabetes risk in the SUN project: A prospective cohort study.

BACKGROUND & AIM: The association between ultra-processed foods (UPF) consumption and the risk of type 2 diabetes (T2D) has not been much explored. We aimed to evaluate the association between consumption of UPF and the incidence of T2D. METHODS: We assessed 20,060 participants (61.5% women) from the SUN project (Seguimiento Universidad de Navarra) followed-up every two years (median follow-up 12 years). Food and drink consumption were evaluated through a validated 136-item food frequency questionnaire and grouped according to their degree of processing by the NOVA classification. Participants were categorized into tertiles of UPF consumption adjusted for total energy intake. We fitted Cox proportional hazard models with repeated dietary measurements at baseline and updating information on food consumption after 10 years of follow-up to minimise the potential effect of diet variation. RESULTS: During 215,149 person-years of follow-up, 175 new-onset T2D cases were confirmed. Participants in the highest baseline tertile (high consumption) of UPF consumption had a higher risk of T2D as compared to those in the lowest tertile (multivariable adjusted hazard ratio [HR] 1.53, 95% confidence interval [CI]: 1.06 to 2.22) with a significant dose-response relationship (p for linear trend = 0.024). The multivariable adjusted HR using repeated measurements of UPF intake was 1.65 (95% CI 1.14-2.38) when comparing extreme tertiles. CONCLUSIONS: In a highly-educated Mediterranean cohort with a low absolute risk, a higher intake of UPF was independently associated with a higher risk for T2D. These results provide more evidence to encourage the limitation of UPF consumption to reduce the population burden of T2D.

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.

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.

Cured ham consumption and incidence of hypertension: The "Seguimiento Universidad de Navarra" (SUN) cohort.

BACKGROUND AND OBJECTIVES: Cured ham is one of the most characteristic foods in the Spanish diet. Because it is a red processed meat and due to its nutritional composition, including high sodium content, a potential association between cured ham consumption and a higher risk of hypertension could be expected. However, epidemiological studies evaluating this association are scarce. We prospectively assessed the association between cured ham consumption and the incidence of hypertension. METHODS: The "Seguimiento Universidad de Navarra" (SUN) study is a cohort of Spanish middle-aged adult university graduates (average age: 38 (SD: 12) years, 60% women). We included 13,900 participants of the SUN cohort free of hypertension at baseline. One serving of cured ham is 50g. They were classified into 4 categories of cured ham consumption: <1; 1; 2-4 and ≥5servs/week. Multivariable-adjusted Cox regression models were fitted to assess the association between cured ham consumption and subsequent hypertension risk using the category of lowest consumption as the reference. RESULTS: After a median follow-up of 10.9 years, 1465 incident self-reported cases of hypertension were identified. After adjusting for potential confounders, including dietary confounders, a high consumption of cured ham (≥5servs/week vs. <1serv/week) was not significantly associated with hypertension risk in this prospective cohort (HR=0.88, 95% CI: 0.70-1.10, p linear trend=0.40). CONCLUSIONS: Our results showed that cured ham consumption was not associated with a significantly higher or lower risk of hypertension in a prospective cohort of Spanish middle-aged adult university graduates. Further longitudinal and experimental studies are needed to disentangle the association between cured ham consumption and the risk of hypertension.

Paper-Based Versus Web-Based Versions of Self-Administered Questionnaires, Including Food-Frequency Questionnaires: Prospective Cohort Study.

BACKGROUND: Web-based questionnaires allow collecting data quickly, with minimal costs from large sample groups and through Web-based self-administered forms. Until recently, there has been a lack of evidence from large-scale epidemiological studies and nutrition surveys that have evaluated the comparison between traditional and new technologies to measure dietary intake. OBJECTIVE: This study aimed to compare results from the general baseline questionnaire (Q_0) and the 10-year follow-up questionnaire (Q_10) in the Seguimiento Universidad de Navarra (SUN) prospective cohort, obtained from different subjects, some of whom used a paper-based version, and others used a Web-based version. Both baseline and 10-year assessments included a validated 136-item semiquantitative food-frequency questionnaire (FFQ), used to collect dietary intake. METHODS: The SUN project is a prospective cohort study (with continuous open recruitment and many participants who were recently recruited). All participants were university graduates. Participants who completed the validated FFQ at baseline (FFQ_0, n=22,564) were selected. The variables analyzed were classified into 6 groups of questions: (1) FFQ (136 items), (2) healthy eating attitudes (10 items), (3) alcohol consumption (3 items), (4) physical activity during leisure time (17 items), (5) other activities (24 items), and (6) personality traits (3 items). Multiple linear and logistic regression models were used to assess the adjusted differences between the mean number of missing values and the risk of having apparently incorrect values for FFQ items or mismatches and inconsistencies in dietary variables. RESULTS: Only 1.5% (339/22564) and 60.71% (6765/11144) participants reported their information using the Web-based version for Q_0 and Q_10, respectively, and 51.40 % (11598/22564) and 100.00% (11144/11144) of participants who completed the Q_0 and Q_10, respectively, had the option of choosing the Web-based version. Sociodemographic, lifestyle, health characteristics, food consumption, and energy and nutrient intakes were similar among participants, according to the type of questionnaire used in Q_10. Less than 0.5% of values were missing for items related to healthy eating attitudes, alcohol consumption, and personality traits in the Web-based questionnaires. The proportion of missing data in FFQ, leisure time physical activity, and other activities was higher in paper-based questionnaires than Web-based questionnaires. In Web-based questionnaires, a high degree of internal consistency was found when comparing answers that should not be contradictory, such as the frequency of fruit as dessert versus total fruit consumption and the frequency of fried food consumptions versus oil consumption. CONCLUSIONS: Incorporating a Web-based version for a baseline and 10-year questionnaire has not implicated a loss of data quality in this cohort of highly educated adults. Younger participants showed greater preference for Web-based questionnaires. Web-based questionnaires were filled out to a greater extent and with less missing items than paper-based questionnaires. Further research is needed to optimize data collection and response rate in Web-based questionnaires.

Association between consumption of ultra-processed foods and all cause mortality: SUN prospective cohort study.

OBJECTIVE: To evaluate the association between consumption of ultra-processed foods and all cause mortality. DESIGN: Prospective cohort study. SETTING: Seguimiento Universidad de Navarra (SUN) cohort of university graduates, Spain 1999-2018. PARTICIPANTS: 19 899 participants (12 113 women and 7786 men) aged 20-91 years followed-up every two years between December 1999 and February 2014 for food and drink consumption, classified according to the degree of processing by the NOVA classification, and evaluated through a validated 136 item food frequency questionnaire. MAIN OUTCOME MEASURE: Association between consumption of energy adjusted ultra-processed foods categorised into quarters (low, low-medium, medium-high, and high consumption) and all cause mortality, using multivariable Cox proportional hazard models. RESULTS: 335 deaths occurred during 200 432 persons years of follow-up. Participants in the highest quarter (high consumption) of ultra-processed foods consumption had a higher hazard for all cause mortality compared with those in the lowest quarter (multivariable adjusted hazard ratio 1.62, 95% confidence interval 1.13 to 2.33) with a significant dose-response relation (P for linear trend=0.005). For each additional serving of ultra-processed foods, all cause mortality relatively increased by 18% (adjusted hazard ratio 1.18, 95% confidence interval 1.05 to 1.33). CONCLUSIONS: A higher consumption of ultra-processed foods (>4 servings daily) was independently associated with a 62% relatively increased hazard for all cause mortality. For each additional serving of ultra-processed food, all cause mortality increased by 18%. STUDY REGISTRATION: ClinicalTrials.gov NCT02669602.

Adherence to dietary guidelines for the Spanish population and risk of overweight/obesity in the SUN cohort.

Dietary guidelines play a key role in setting standards for nutrition policies and promoting healthy eating. Like other public health guidelines, they are often influenced by political and economic factors that could place other concerns ahead of the population's health. In order to determine their effectiveness on obesity prevention, we prospectively examined the association between adherence to the latest available national dietary guidelines and the incidence of overweight/obesity in a Spanish cohort study. A sample of 11,554 participants of the "Seguimiento Universidad de Navarra" (SUN) cohort, initially free of overweight or obesity, was included in the study. The Spanish Society of Community Nutrition (SENC) food pyramid (FP) score was computed based on the ratio of consumed to recommended daily servings of grains, fruits, vegetables, dairy, protein-rich foods, olive oil, red and processed meat, sweets, salty snacks and spreadable fats, fermented alcoholic beverages and water. The same approach was followed to calculate the SENC hydration pyramid (HP) score, considering the intake of water and different kind of beverages. Adherence was calculated at baseline and after 10 years of follow-up. Cox proportional hazards models were used to assess the incidence of overweight/obesity (BMI ≥25 kg/m2). During a median follow-up of 10.3 years, 2320 incident cases were identified. The highest level of adherence to the SENC FP score was modestly associated with a reduced risk of overweight/obesity (multivariable-adjusted HR for the fifth quintile vs. the first quintile = 0.78; 95% CI: 0.67-0.91; p-trend: 0.007). No consistent trends were found for the SENC HP. In a large prospective cohort of Spanish university graduates, we found an inverse linear association between adherence to the SENC FP and overweight/obesity risk, whereas this was not the case for the HP.

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.

Mediterranean Diet and Health Outcomes in the SUN Cohort.

The Mediterranean Dietary (MedDiet) Pattern has been linked to many beneficial health effects. This review summarizes the main findings of a prospective cohort study, the Seguimiento Universidad de Navarra (SUN) cohort, specifically focused on MedDiet and the risk of major chronic disease. It is an open cohort in which 22,786 Spanish university graduates have participated since 1999 until February 2018. Data on diet, lifestyle and clinical diagnosis are collected at baseline and every two years. After reviewing 21 publications from the SUN cohort on the effects of the MedDiet, we conclude that this cohort has provided good evidence that a high MedDiet adherence is associated with a reduced incidence of all-cause mortality, fatal and non-fatal major cardiovascular disease (CVD), type 2 diabetes, weight gain, metabolic syndrome, depression, cognitive decline, and nephrolithiasis. An inverse dose-response relationship was found for many of these associations. The MedDiet was also associated with lower average heart rate, a mitigation of the harmful effects of overweight/obesity on the risk of CVD, and an attenuation of the effects of obesity on type 2 diabetes. A suggestion that the MedDiet may enhance fertility was also found.

Egg consumption and dyslipidemia in a Mediterranean cohort.

INTRODUCTION AND OBJECTIVES: Our aim was to prospectively evaluate the association between egg consumption and dyslipidemia in a Mediterranean cohort. METHODS: We followed-up 13,104 Spanish university graduates for a mean period of 8 years. Dietary habits at baseline were assessed using a validated semi-quantitative 136-item food-frequency questionnaire. Self-reported blood concentrations of total cholesterol, high-density lipoproteins cholesterol (HDL-c) and triglycerides were evaluated according to categories of egg consumption after 6 and 8 years of follow-up. We also assessed the association between baseline egg consumption and the incidence of hypercholesterolemia, low HDL-c concentrations and hypertriglyceridemia during follow-up. RESULTS: We observed a significant inverse association for intermediate levels of egg consumption (2 to 4 eggs/week vs. less than 1 egg/week) and hypertriglyceridemia with OR = 0.71 (95% confidence interval [CI]: 0.54 to 0.93, p < 0.05) in the multivariable-adjusted model. Using HDL-c values after 8-year follow-up, we found an association between higher egg consumption and lower HDL-c levels (p for trend = 0.02) with an adjusted difference of -4.01 mg/dl (-7.42 to -0.61) for > 4 vs. < 1 egg/week. Lower means of triglycerides were found in each of the three upper categories of egg consumption compared to the lowest category (< 1 egg/week) with significant results for some of these categories both after 6 and 8 year follow-up. CONCLUSIONS: Our data do not support that higher egg consumption was associated with abnormal blood levels of total cholesterol or triglycerides; an inverse association with HDL-c as a quantitative variable was found only in one of our analyses.