Thinking Health-related Behaviors in a Climate Change Context: A Narrative Review.

BACKGROUND: Human activities have changed the environment so profoundly over the past two centuries that human-induced climate change is now posing serious health-related threats to current and future generations. Rapid action from all scientific fields, including behavioral medicine, is needed to contribute to both mitigation of, and adaption to, climate change. PURPOSE: This article aims to identify potential bi-directional associations between climate change impacts and health-related behaviors, as well as a set of key actions for the behavioral medicine community. METHODS: We synthesized the existing literature about (i) the impacts of rising temperatures, extreme weather events, air pollution, and rising sea level on individual behaviors (e.g., eating behaviors, physical activity, sleep, substance use, and preventive care) as well as the structural factors related to these behaviors (e.g., the food system); and (ii) the concurrent positive and negative roles that health-related behaviors can play in mitigation and adaptation to climate change. RESULTS: Based on this literature review, we propose a first conceptual model of climate change and health-related behavior feedback loops. Key actions are proposed, with particular consideration for health equity implications of future behavioral interventions. Actions to bridge the fields of behavioral medicine and climate sciences are also discussed. CONCLUSIONS: We contend that climate change is among the most urgent issues facing all scientists and should become a central priority for the behavioral medicine community.

Patient satisfaction with HIV care service in Spain: results from a cross-sectional patient survey.

Understanding patient satisfaction with healthcare services can help identify patients' unmet needs and increase treatment adherence. This study aimed to evaluate the satisfaction of people living with HIV with overall HIV care service in Navarra, Spain, using a cross-sectional survey. The survey included a patient-reported experience measure (PREMs) consisting of five statements, and participants were also asked to rate the overall care they receive from the HIV service. Chi-square tests were used to detect differences between groups for statements and Kruskal-Wallis rank test was used to detect differences in ranking of the HIV service. The 395 participants gave the HIV service a mean score of 9.3 points out of 10 (standard deviation 1.1). Only 15 (4%) gave a score of under 8 out of 10, and adherence to antiretroviral therapy was associated with higher ranking of the service. Agreement for all five statements ranged from 80% to 96%. Those without stable housing, with mental health problems, and unemployed felt less supported to manage their HIV. These results highlight the need to regularly assess patient satisfaction with the HIV care and that care should account for social and economic factors that could influence health.

Haspin kinase modulates nuclear architecture and Polycomb-dependent gene silencing.

Haspin, a highly conserved kinase in eukaryotes, has been shown to be responsible for phosphorylation of histone H3 at threonine 3 (H3T3ph) during mitosis, in mammals and yeast. Here we report that haspin is the kinase that phosphorylates H3T3 in Drosophila melanogaster and it is involved in sister chromatid cohesion during mitosis. Our data reveal that haspin also phosphorylates H3T3 in interphase. H3T3ph localizes in broad silenced domains at heterochromatin and lamin-enriched euchromatic regions. Loss of haspin compromises insulator activity in enhancer-blocking assays and triggers a decrease in nuclear size that is accompanied by changes in nuclear envelope morphology. We show that haspin is a suppressor of position-effect variegation involved in heterochromatin organization. Our results also demonstrate that haspin is necessary for pairing-sensitive silencing and it is required for robust Polycomb-dependent homeotic gene silencing. Haspin associates with the cohesin complex in interphase, mediates Pds5 binding to chromatin and cooperates with Pds5-cohesin to modify Polycomb-dependent homeotic transformations. Therefore, this study uncovers an unanticipated role for haspin kinase in genome organization of interphase cells and demonstrates that haspin is required for homeotic gene regulation.

Consensus-building around the conceptualisation and implementation of sustainable healthy diets: a foundation for policymakers.

BACKGROUND: Healthy and sustainable diets need to be adopted to reduce the negative impact of food consumption on human and planetary health. Food systems account for a third of greenhouse gas emissions. "Dietary Patterns for Health and Sustainability" is a World Health Organization (WHO) project that aims to build consensus among international food, health, and sustainability experts and policymakers on how to conceptualise healthy and sustainable diets and on the actions and policies that could be implemented in the WHO European Region to promote these diets. METHODS: A qualitative study among European food, health, and sustainability experts and policymakers to elicit their views on multiple dimensions of food sustainability and health was carried out using a three-phase process, including semi-structured interviews, a Nominal Group Technique, and focus groups during a participatory WHO workshop held in Copenhagen. Thematic analysis was used to analyse the three data sources. RESULTS: The workshop resulted in a shared understanding of the interconnected components of sustainable healthy eating habits. As a result of this understanding, a variety of potential solutions were identified, including actions across different policy domains, tools, strategic guidelines, needs, and pathways for sustainable healthy diets. The pathways included the need for a multi-stakeholder approach, as well as the simultaneous execution of an aligned and coherent mix of policies at the local and national levels. CONCLUSIONS: The prioritised actions should be aimed at helping government policymakers promote sustainable healthy diets and make decisions on improving dietary patterns for citizens' health and wellbeing in line with the United Nations Sustainable Development Goals in the European Region.

Effect of Influenza Vaccination in Preventing Laboratory-Confirmed Influenza Hospitalization in Patients With Diabetes Mellitus.

BACKGROUND: People with diabetes are at high risk of severe influenza complications. The influenza vaccination effect among diabetic patients remains inconclusive. We estimated the average effect of influenza vaccination status in the current and prior seasons in preventing laboratory-confirmed influenza hospitalization in diabetic patients. METHODS: Patients attended in hospitals and primary healthcare centers with influenza-like illness were tested for influenza from the 2013-2014 to 2018-2019 seasons in Navarre, Spain. A test-negative case-control design in diabetic inpatients compared the influenza vaccination status in the current and 5 prior seasons between laboratory-confirmed influenza cases and negative controls. Vaccination status of influenza-confirmed cases was compared between diabetic inpatients and outpatients. Influenza vaccination effect was compared between diabetic patients and older (≥ 60 years) or chronic nondiabetic patients. RESULTS: Of 1670 diabetic inpatients tested, 569 (34%) were confirmed for influenza and 1101 were test-negative controls. The average effect in preventing influenza hospitalization was 46% (95% confidence interval [CI], 28%-59%) for current-season vaccination and 44% (95% CI, 20%-61%) for vaccination in prior seasons only in comparison to unvaccinated patients in the current and prior seasons. Among diabetic patients with confirmed influenza, current-season vaccination reduced the probability of hospitalization (adjusted odds ratio, 0.35; 95% CI, .15-.79). In diabetic patients, vaccination effect against influenza hospitalizations was not inferior to that in older or chronic nondiabetic patients. CONCLUSIONS: On average, influenza vaccination of diabetic population reduced by around half the risk of influenza hospitalization. Vaccination in prior seasons maintained a notable protective effect. These results reinforce the recommendation of influenza vaccination for diabetic patients.

Quality of life in people living with HIV in Romania and Spain.

BACKGROUND: Health-related quality of life (HRQoL) is a crucial component in assessing and addressing the unmet needs of people, especially those with chronic illnesses such as HIV. The aim of the study was to examine and compare the health-related quality of life of people living with HIV in Romania and Spain, compared to the general populations of each country. METHODS: A cross-sectional survey was conducted among adults (≥ 18 years) attending for HIV care in Romania and Spain from October 2019 to March 2020. The survey included two validated HRQoL instruments: a generic instrument, EQ-5D-5L, and an HIV-specific instrument, PozQoL, and questions on socio-demographics, HIV-related characteristics, physical and mental health conditions, and substance use. Multivariable linear regression was used to determine factors associated with HRQoL. RESULTS: 570 people living with HIV responded (170 in Romania and 400 in Spain). The median age was 31 (18-67) in Romania and 52 (19-83) in Spain. Anxiety/depression symptoms were frequently reported by people with HIV (Romania: 50% vs 30% in the Romanian population; Spain: 38% vs 15% in Spanish population). Spain reported higher mean EQ-5Dutility scores than Romania (0.88 and 0.85, respectively) but identical PozQoL scores (3.5, on a scale of 0-5). In both countries, health concerns were highlighted as a key issue for people with HIV. In multivariable analysis, two factors were consistently associated with worse HRQoL in people with HIV: bad or very bad self-rated health status and presence of a mental health condition. In Romania, being gay/bisexual and being disabled/unemployed were associated with worse HRQoL. Whereas in Spain, older age and financial insecurity were significant predictors. CONCLUSIONS: Our results indicated a good HRQoL for people living with HIV in Romania and Spain; however, worse HRQoL profiles were characterized by health concerns, poor self-rated health status, and the presence of mental health conditions. This study highlights the importance of monitoring HRQoL in people living with HIV due to the chronic nature of the disease. In this highly-treatment experienced group, disparities were found, particularly highlighting mental health as an area which needs more attention to improve the well-being of people living with HIV.

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.

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.

Dietary fiber intake and mortality in a Mediterranean population: the "Seguimiento Universidad de Navarra" (SUN) project.

PURPOSE: To prospectively assess the association of dietary fiber intake (from different dietary sources) with all-cause mortality in a Mediterranean cohort. METHODS: We assessed 19,703 participants of the SUN (Seguimiento Universidad de Navarra) cohort (mean follow-up: 10.1 years). A validated 136-item FFQ was administered at baseline. We used Cox proportional hazards models adjusted for multiple socio-demographic, anthropometric, lifestyle factors, and prevalent conditions at baseline. RESULTS: We observed 323 deaths during 198,341 person-years of follow-up. A significantly inverse linear trend in Cox models was observed for the association of total dietary fiber intake and all-cause mortality after adjustment for confounders (p for trend 0.017). Each additional intake of 5 g/1000 kcal of dietary fiber was associated with a 9% relative reduction in all-cause mortality risk (HR 0.91, 95% CI 0.84-0.99). Considering separate dietary sources in separate models, a significant inverse trend was apparent for fiber derived from vegetables (p for trend 0.001), but it was non-significant for fiber derived from fruit, legumes, cereals, or other sources. Soluble fiber was significantly inversely associated with all-cause mortality in the fully adjusted model (p for trend 0.007), and insoluble fiber was marginally significant (p for trend 0.08). CONCLUSIONS: A higher intake of total dietary fiber, and particularly fiber from vegetables, was related to a reduced all-cause mortality in our Mediterranean cohort. Dietary messages to increase the consumption of dietary patterns rich in fiber-rich foods should be broadly disseminated to decrease the alarming rate of chronic diseases and its derived mortality.

Does the MIND diet decrease depression risk? A comparison with Mediterranean diet in the SUN cohort.

PURPOSE: To prospectively evaluate the association of the Mediterranean-DASH diet intervention for neurodegenerative delay (MIND) diet and the Mediterranean diet (and their components), and depression risk. METHODS: We followed-up (median 10.4 years) 15,980 adults initially free of depression at baseline or in the first 2 years of follow-up. Food consumption was measured at baseline through a validated food-frequency questionnaire, and was used to compute adherence to the MIND and the Mediterranean diets. Relationships between these two diets and incident depression were assessed through Cox regression models. RESULTS: We identified 666 cases of incident depression. Comparing the highest versus the lowest quartiles of adherence, we found no association of the MIND diet and incident depression. This relation was statistically significant for the Mediterranean diet {hazard ratio (HR) 0.75, [95% confidence interval (95% CI) 0.61, 0.94]; p < 0.01}, although with departure from linearity. A reduced depression risk was associated with higher consumption of both fruits and nuts [HR 0.82 (95% CI 0.69, 0.96); p = 0.02], moderate nuts consumption [HR 0.77 (95% CI 0.64, 0.93); p = 0.01], and avoidance of fast/fried food [HR 0.63 (95% CI 0.41, 0.96); p = 0.03]. CONCLUSIONS: The Mediterranean diet was associated with reduced depression risk, but we found no evidence of such an association for the MIND diet.

Ibf1 and Ibf2 are novel CP190-interacting proteins required for insulator function.

Insulators are DNA-protein complexes that play a central role in chromatin organization and regulation of gene expression. In Drosophila different proteins, dCTCF, Su(Hw), and BEAF bind to specific subsets of insulators most of them having in common CP190. It has been shown that there are a number of CP190-binding sites that are not shared with any other known insulator protein, suggesting that other proteins could cooperate with CP190 to regulate insulator activity. Here we report on the identification of two previously uncharacterized proteins as CP190-interacting proteins, that we have named Ibf1 and Ibf2. These proteins localize at insulator bodies and associate with chromatin at CP190-binding sites throughout the genome. We also show that Ibf1 and Ibf2 are DNA-binding proteins that form hetero-oligomers that mediate CP190 binding to chromatin. Moreover, Ibf1 and Ibf2 are necessary for insulator activity in enhancer-blocking assays and Ibf2 null mutation cause a homeotic phenotype. Taken together our data reveal a novel pathway of CP190 recruitment to chromatin that is required for insulator activity.

The Mediterranean diet, an environmentally friendly option: evidence from the Seguimiento Universidad de Navarra (SUN) cohort.

OBJECTIVE: How food is produced and consumed has consequences for ecosystems, such as resource use and greenhouse gas (GHG) emission among others. The Mediterranean diet (MedDiet) was proposed as a sustainable dietary model, due to its nutritional, environmental, economic and sociocultural dimensions. However, further evidence is needed. Thus, our objective was to evaluate the impact on resource (land, water and energy) use and GHG emission of better adherence to the MedDiet in a Mediterranean Spanish cohort. DESIGN: We analysed the dietary pattern of participants through a validated FFQ. The outcomes were land use, water and energy consumption and GHG emission according to MedDiet adherence. The specific environmental footprints of food item production and processing were obtained from different available life-cycle assessments. SETTING: Spanish university graduates. SUBJECTS: Participants (n 20 363) in the Seguimiento Universidad de Navarra (SUN) cohort. RESULTS: Better adherence to the MedDiet was associated with lower land use (-0·71 (95 % CI -0·76, -0·66) m2/d), water consumption (-58·88 (95 % CI -90·12, -27·64) litres/d), energy consumption (-0·86 (95 % CI -1·01, -0·70) MJ/d) and GHG emission (-0·73 (95 % CI -0·78, -0·69) kg CO2e/d). A statistically significant linear trend (P<0·05) was observed in all these analyses. CONCLUSIONS: In this Mediterranean cohort, better adherence to the MedDiet was an eco-friendly option according to resource consumption and GHG emission.

A Smartphone Intervention to Promote a Sustainable Healthy Diet: Protocol for a Pilot Study.

BACKGROUND: Changing current dietary patterns into sustainable healthy diets (ie, healthy diets with low environmental impact and socioeconomic fairness) is urgent. So far, few eating behavior change interventions have addressed all the dimensions of sustainable healthy diets at once and used cutting-edge methods from the field of digital health behavior change. OBJECTIVE: The primary objectives of this pilot study were to assess the feasibility and effectiveness of an individual behavior change intervention toward the adoption of a more environmentally sustainable healthy diet as a whole and changes in specific relevant food groups, food waste, and obtaining food from fair sources. The secondary objectives included the identification of mechanisms of action that potentially mediate the effect of the intervention on behaviors, identification of potential spillover effects and covariations among different food outcomes, and identification of the role of socioeconomic status in behavior changes. METHODS: We will run a series of ABA n-of-1 trials over a year, with the first A phase corresponding to a 2-week baseline evaluation, the B phase to a 22-week intervention, and the second A phase to a 24-week postintervention follow-up. We plan to enroll 21 participants from low, middle, and high socioeconomic statuses, with 7 from each socioeconomic group. The intervention will involve sending text messages and providing brief individualized web-based feedback sessions based on regular app-based assessments of eating behavior. The text messages will contain brief educational messages on human health and the environmental and socioeconomic effects of dietary choices; motivational messages to encourage the adoption of sustainable healthy diets by participants, providing tips to achieve their own behavioral goals; or links to recipes. Both quantitative and qualitative data will be collected. Quantitative data (eg, on eating behaviors and motivation) will be collected through self-reported questionnaires on several weekly bursts spread through the study. Qualitative data will be collected through 3 individual semistructured interviews before the intervention period, at the end of the intervention period, and at the end of the study. Analyses will be performed at both the individual and group levels depending on the outcome and objective. RESULTS: The first participants were recruited in October 2022. The final results are expected by October 2023. CONCLUSIONS: The results of this pilot study will be useful for designing future larger interventions on individual behavior change for sustainable healthy diets. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/41443.

Knowledge, attitude, and patient advice on sustainable diets among Spanish health professionals.

Current dietary patterns, especially in high-income countries, are unsustainable. Health professionals, due to their credibility and close contact with the general population, could serve as agents of change for the adoption of sustainable diets. The objective of this study was to assess the knowledge and attitude regarding sustainable diets among the health professionals in Spain. A 24-item online questionnaire was designed for this purpose, and sent to health professionals (i.e., dietitians-nutritionists, nurses, physicians, and pharmacists). From September 2021 to May 2022, 2,545 health professionals answered the survey completely. One-fifth of them had never heard the term "sustainable diet", and most of them recognized having limited knowledge about it. They considered promoting sustainable diets when making dietary recommendations important, and pointed out that they would like to be trained on the topic. Indeed, they reported that all health professionals, independent of their career background, should be educated on sustainable diets. Efforts should be stressed on implementing training courses, at university level but also as continuous post-graduate training, providing health professionals in Spain the necessary knowledge to promote the adoption of sustainable diets among the population.

Ultra-processed food intake and animal-based food intake and mortality in the Adventist Health Study-2.

BACKGROUND: Both ultra-processed foods and animal-derived foods have been associated with mortality in some studies. OBJECTIVES: We aimed to examine the association of 2 dietary factors (ultra-processed foods and animal-based foods), adjusted for each other, with all-cause mortality. METHODS: The setting is an observational prospective cohort study in North America, recruited from Seventh-day Adventist churches, comprised of 95,597 men and women, yielding an analytic sample of 77,437 participants after exclusions. The exposure of interest was diet measured by FFQ, in particular 2 dietary factors: 1) proportion of dietary energy from ultra-processed foods (other processing levels and specific substitutions in some models) and 2) proportion of dietary energy from animal-based foods (red meat, poultry, fish, and eggs/dairy separately in some models). The main outcome was all-cause mortality. Mortality data through 2015 were obtained from the National Death Index. Analyses used proportional hazards regression. RESULTS: There were 9293 deaths. In mutually adjusted continuous linear models of both dietary factors (ultra-processed and animal-based foods), the HR for the 90th compared with the 10th percentile of the proportion of dietary energy from ultra-processed food was 1.14 (95% CI: 1.07, 1.21, comparing 47.7% with 12.1% dietary energy), whereas for animal-based food intake (meats, dairy, eggs) it was 1.01 (95% CI: 0.95, 1.07, comparing 25.0% with 0.4% dietary energy). There was no evidence of interaction (P = 0.36). Among animal-based foods, only red meat intake was associated with mortality (HR: 1.14; 95% CI: 1.08, 1.22, comparing 6.2% with 0% dietary energy). CONCLUSIONS: Greater consumption of ultra-processed foods was associated with higher all-cause mortality in this health-conscious Adventist population with many vegetarians. The total of animal-based food consumption (meat, dairy, eggs) was not associated with mortality, but higher red meat intake was. These findings suggest that high consumption of ultra-processed foods may be an important indicator of mortality.

International Analysis of the Nutritional Content and a Review of Health Benefits of Non-Dairy Plant-Based Beverages.

Concerns about environmental impact and sustainability, animal welfare, and personal health issues have fueled consumer demand for dairy alternatives. The aim of this study was to conduct a cross-sectional survey of plant-based non-dairy beverages from three different continents (USA, Australia, and Western Europe) to assess their nutritional content and health profile. A total of 148 non-dairy beverages were analyzed from the nutrition label and ingredients listed on the commercial package or from the information located on the website of the manufacturer or retailer. The different types of beverages were extracts of nuts or seeds (n = 49), grains (n = 38), legumes (n = 36), coconut (n = 10), and mixed blends (n = 15). On average, the plant-based beverages generally scored well in terms of not containing high levels of sodium, saturated fat, or calories. Over half of the beverages were fortified with calcium to levels equal to or greater than that of dairy milk. The protein content varied from 0 to 10 g/serving. Levels of vitamin D and B12 fortification were quite low. Consumers should be informed of the nutritional profile and potential health benefits of plant-based dairy alternatives as the nutritional content can vary greatly between the different types of beverages.

Nutritional Quality of Plant-Based Cheese Available in Spanish Supermarkets: How Do They Compare to Dairy Cheese?

Plant-based cheese is one of the most increasingly consumed dairy alternatives. Evidence is lacking on their nutritional quality. We aimed to evaluate the nutritional composition of the plant-based cheese options available in Spanish supermarkets, and how they compare with dairy cheese. An audit of plant-based cheese alternatives has been conducted in seven of the most common supermarkets. For each product, the nutritional content per 100 g and ingredients were collected. Data on generic dairy cheese were retrieved from the BEDCA website. Descriptive statistics (median, minimum and maximum) were used to characterize the plant-based cheese products, for both all the products and grouped by main ingredients (i.e., coconut oil, cashew nuts and tofu). Mann-Whitney U tests were used for comparisons between dairy and different types of plant-based cheese. The coconut oil-based products (the large majority of plant-based cheese products, n = 34) could not be considered as healthy foods. Their major ingredients were refined coconut oil and starches and were high in saturated fats and salt. The other smaller groups, cashew nut- (n = 4) and tofu-based (n = 2), showed a healthier nutritional profile. Replacing dairy cheese with these groups could be nutritionally beneficial. Future investigations should address the health effects of substituting dairy cheese with these products.

Altitude and SARS-CoV-2 Infection in the First Pandemic Wave in Spain.

After the first pandemic wave, a nationwide survey assessed the seroprevalence of SARS-CoV-2 antibodies in Spain and found notable differences among provinces whose causes remained unclear. This ecological study aimed to analyze the association between environmental and demographic factors and SARS-CoV-2 infection by province. The seroprevalence of SARS-CoV-2 antibodies by province was obtained from a nationwide representative survey performed in June 2020, after the first pandemic wave in Spain. Linear regression was used in the analysis. The seroprevalence of SARS-CoV-2 antibodies of the 50 provinces ranged from 0.2% to 13.6%. The altitude, which ranged from 5 to 1131 m, explained nearly half of differences in seroprevalence (R2 = 0.47, p < 0.001). The seroprevalence in people residing in provinces above the median altitude (215 m) was three-fold higher (6.5% vs. 2.1%, p < 0.001). In the multivariate linear regression, the addition of population density significantly improved the predictive value of the altitude (R2 = 0.55, p < 0.001). Every 100 m of altitude increase and 100 inhabitants/km2 of increase in population density, the seroprevalence rose 0.84 and 0.63 percentage points, respectively. Environmental conditions related to higher altitude in winter-spring, such as lower temperatures and absolute humidity, may be relevant to SARS-CoV-2 transmission. Places with such adverse conditions may require additional efforts for pandemic control.

Hypertension and Related Comorbidities as Potential Risk Factors for COVID-19 Hospitalization and Severity: A Prospective Population-Based Cohort Study.

The independent role of hypertension for COVID-19 outcomes in the population remains unclear. We aimed to estimate the independent effect of hypertension and hypertension-related conditions, i.e., cardiovascular, cerebrovascular and chronic kidney diseases, as potential risk factors for COVID-19 hospitalization and severe COVID-19 (i.e., intensive care unit admission or death) in the population. The risk for severe COVID-19 among hospitalized patients was also evaluated. A Spanish population-based cohort of people aged 25-79 years was prospectively followed from March to May 2020 to identify hospitalizations for laboratory-confirmed COVID-19. Poisson regression was used to estimate the adjusted relative risk (aRR) for COVID-19 hospitalization and severe COVID-19 among the whole cohort, and for severe COVID-19 among hospitalized patients. Of 424,784 people followed, 1106 were hospitalized by COVID-19 and 176 were severe cases. Hypertension was not independently associated with a higher risk of hospitalization (aRR 0.96, 95% CI 0.83-1.12) nor severe COVID-19 (aRR 1.12, 95% CI 0.80-1.56) in the population. Persons with cardiovascular, cerebrovascular and chronic kidney diseases were at higher risk for COVID-19 hospitalization (aRR 1.33, 95% CI 1.13-1.58; aRR 1.41, 95% CI 1.04-1.92; and aRR 1.52, 95% CI 1.21-1.91; respectively) and severe COVID-19 (aRR 1.61, 95% CI 1.13-2.30; aRR 1.91, 95% CI 1.13-3.25; and aRR 1.78, 95% CI 1.14-2.76; respectively). COVID-19 hospitalized patients with cerebrovascular diseases were at higher risk of mortality (aRR 1.80, 95% CI 1.00-3.23). The current study shows that, in the general population, persons with cardiovascular, cerebrovascular and chronic kidney diseases, but not those with hypertension only, should be considered as high-risk groups for COVID-19 hospitalization and severe COVID-19.

Independent Role of Severe Obesity as a Risk Factor for COVID-19 Hospitalization: A Spanish Population-Based Cohort Study.

OBJECTIVES: This study analyzed the association between severe obesity and coronavirus disease 2019 (COVID-19) hospitalization and severe disease. METHODS: The incidence of hospitalization for laboratory-confirmed COVID-19 was evaluated in a prospective population-based cohort of 433,995 persons aged 25 to 79 years in Spain during March and April of 2020. Persons with and without class 3 obesity were compared using Poisson regression to estimate the adjusted relative risk (aRR) from class 3 obesity of COVID-19 hospitalization and of severe disease (intensive care unit admission or death). Differences in the effect by age, sex, and chronic conditions were evaluated. RESULTS: Individuals with class 3 obesity had a higher risk of hospitalization (aRR = 2.20, 95% CI: 1.66-2.93) and developing severe COVID-19 (aRR = 2.30, 95% CI: 1.20-4.40). In people younger than 50 years, these effects were more pronounced (aRR = 5.02, 95% CI: 3.19-7.90 and aRR = 13.80, 95% CI: 3.11-61.17, respectively), whereas no significant effects were observed in those aged 65 to 79 years (aRR = 1.22, 95% CI: 0.70-2.12 and aRR = 1.42, 95% CI: 0.52-3.88, respectively). Sex and chronic conditions did not modify the effect of class 3 obesity in any of the outcomes. CONCLUSIONS: Severe obesity is a relevant risk factor for COVID-19 hospitalization and severity in young adults, having a magnitude similar to that of aging. Tackling the current obesity pandemic could alleviate the impact of chronic and infectious diseases.