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The American Heart Association proposed 7 ideal cardiovascular health metrics (Life's Simple 7 [LS7]) namely, not smoking, body mass index <25 kg/m2, healthy diet, moderate physical activity ≥150 min/week, total blood cholesterol <200 mg/dL, blood pressure <120/80 mmHg and fasting blood glucose <100 mg/dL. Our objective was to assess the association between these LS7 metrics and the incidence of atrial fibrillation (AF). A total of 6,479 participants of the PREDIMED study were included. We calculated the participants' baseline LS7 index ranging 0–7 points to categorize them according to their adherence to these LS7 health metrics. Multivariable Cox regression models were used to estimate Hazard Ratios (HR) and their 95% Confidence Intervals (95% CI). After a median follow-up of 4.8 years, we identified 250 incident cases of AF. After adjusting for potential confounders, adherence to LS7 index was not associated with the incidence of AF (adjusted HR 0.90 [95% CI: 0.56–1.45] for highest vs. lowest LS7 categories). Body mass index <25 kg/m2 was the only health metric individually associated with a lower risk of AF (HR 0.36 [95% CI: 0.16–0.78]). In a high cardiovascular risk Spanish population, adherence to American Heart Association's LS7 metrics was not associated with the risk of incident AF. Clinical Trials number: ISRCTN35739639. • Limited understanding of Life's Simple 7 (LS7) with atrial fibrillation (AF) risk in non-US populations. • No significant LS7 index association with AF in high-risk cardiovascular disease participants. • BMI <25 significantly associated to 64% lower AF risk vs. overweight/obese participants. • More research needed to confirm if LS7 metrics lower AF risk in high cardiovascular risk population. [ABSTRACT FROM AUTHOR]

Plasma citric acid cycle (CAC) metabolites might be likely related to cardiovascular disease (CVD). However, studies assessing the longitudinal associations between circulating CAC-related metabolites and CVD risk are lacking. The aim of this study was to evaluate the association of baseline and 1-year levels of plasma CAC-related metabolites with CVD incidence (a composite of myocardial infarction, stroke or cardiovascular death), and their interaction with Mediterranean diet interventions. Case-cohort study from the PREDIMED trial involving participants aged 55–80 years at high cardiovascular risk, allocated to MedDiets or control diet. A subcohort of 791 participants was selected at baseline, and a total of 231 cases were identified after a median follow-up of 4.8 years. Nine plasma CAC-related metabolites (pyruvate, lactate, citrate, aconitate, isocitrate, 2-hydroxyglutarate, fumarate, malate and succinate) were measured using liquid chromatography-tandem mass spectrometry. Weighted Cox multiple regression was used to calculate hazard ratios (HRs). Baseline fasting plasma levels of 3 metabolites were associated with higher CVD risk, with HRs (for each standard deviation, 1-SD) of 1.46 (95%CI:1.20–1.78) for 2-hydroxyglutarate, 1.33 (95%CI:1.12–1.58) for fumarate and 1.47 (95%CI:1.21–1.78) for malate (p of linear trend <0.001 for all). A higher risk of CVD was also found for a 1-SD increment of a combined score of these 3 metabolites (HR = 1.60; 95%CI: 1.32–1.94, p trend <0.001). This result was replicated using plasma measurements after one-year. No interactions were detected with the nutritional intervention. Plasma 2-hydroxyglutarate, fumarate and malate levels were prospectively associated with increased cardiovascular risk. ISRCTN35739639 • Citric acid cycle metabolites (CAC-m) might influence cardiovascular disease (CVD). • Plasma CAC-m metabolites and CVD events were assessed in PREDIMED. • Outcome was the primary trial end-point (myocardial infarction + stroke + CVD death). • Higher CVD risk was found for plasma 2-hydroxyglutarate, fumarate and malate. [ABSTRACT FROM AUTHOR]

Background Arginine-derived metabolites are involved in oxidative and inflammatory processes related to endothelial functions and cardiovascular risks. Objectives We prospectively examined the associations of arginine catabolism metabolites with the risks of atrial fibrillation (AF) or heart failure (HF), and evaluated the potential modifications of these associations through Mediterranean diet (MedDiet) interventions in a large, primary-prevention trial. Methods Two nested, matched, case-control studies were designed within the Prevención con Dieta Mediterránea (PREDIMED) trial. We selected 509 incident cases and 547 matched controls for the AF case-control study and 326 cases and 402 matched controls for the HF case-control study using incidence density sampling. Fasting blood samples were collected at baseline and arginine catabolism metabolites were measured using LC-tandem MS. Multivariable conditional logistic regression models were applied to test the associations between the metabolites and incident AF or HF. Interactions between metabolites and intervention groups (MedDiet groups compared with control group) were analyzed with the likelihood ratio test. Results Inverse association with incident AF was observed for arginine (OR per 1 SD, 0.83; 95% CI: 0.73–0.94), whereas a positive association was found for N1-acetylspermidine (OR for Q4 compared with Q1 1.58; 95% CI: 1.13–2.25). For HF, inverse associations were found for arginine (OR per 1 SD, 0.82; 95% CI: 0.69–0.97) and homoarginine (OR per 1 SD, 0.81; 95% CI: 0.68–0.96), and positive associations were found for the asymmetric dimethylarginine (ADMA) and symmetric dimethlyarginine (SDMA) ratio (OR per 1 SD, 1.19; 95% CI: 1.02–1.41), N1-acetylspermidine (OR per 1 SD, 1.34; 95% CI: 1.12–1.60), and diacetylspermine (OR per 1 SD, 1.20; 95% CI: 1.02–1.41). In the stratified analysis according to the dietary intervention, the lower HF risk associated with arginine was restricted to participants in the MedDiet groups (P -interaction = 0.044). Conclusions Our results suggest that arginine catabolism metabolites could be involved in AF and HF. Interventions with the MedDiet may contribute to strengthen the inverse association between arginine and the risk of HF. This trial was registered at controlled-trials.com as ISRCTN35739639. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background The tryptophan–kynurenine pathway is linked to inflammation. We hypothesize that metabolites implicated in this pathway may be associated with the risk of heart failure (HF) or atrial fibrillation (AF) in a population at high risk of cardiovascular disease. Objectives We aimed to prospectively analyze the associations of kynurenine-related metabolites with the risk of HF and AF and to analyze a potential effect modification by the randomized interventions of the PREDIMED (Prevención con Dieta Mediterránea) trial with Mediterranean diet (MedDiet). Methods Two case–control studies nested within the PREDIMED trial were designed. We selected 324 incident HF cases and 502 incident AF cases individually matched with ≤3 controls. Conditional logistic regression models were fitted. Interactions with the intervention were tested for each of the baseline plasma metabolites measured by LC–tandem MS. Results Higher baseline kynurenine:tryptophan ratio (OR for 1 SD: 1.20; 95% CI: 1.01, 1.43) and higher levels of kynurenic acid (OR: 1.19; 95% CI: 1.01, 1.40) were associated with HF. Quinolinic acid was associated with AF (OR: 1.15; 95% CI: 1.01, 1.32) and HF (OR: 1.25; 95% CI: 1.04, 1.49). The MedDiet intervention modified the positive associations of kynurenine (P interaction = 0.006), kynurenic acid (P interaction = 0.008), and quinolinic acid (P interaction = 0.033) with HF and the association between kynurenic acid and AF (P interaction = 0.02). Conclusions We found that tryptophan–kynurenine pathway metabolites were prospectively associated with higher HF risk and to a lesser extent with AF risk. Moreover, an effect modification by MedDiet was observed for the association between plasma baseline kynurenine-related metabolites and the risk of HF, showing that the positive association of increased levels of these metabolites and HF was restricted to the control group. [ABSTRACT FROM AUTHOR]

Short dietary assessment tools can be useful to estimate food intake and diet quality in large-scale epidemiological studies with time constraints. To determine the concurrent validity of the 17-item energy-restricted Mediterranean Adherence Screener (er-MEDAS) used in the PREDIMED (PREvención con DIeta MEDiterránea)-Plus trial and to analyse its capacity to detect 1-year changes in diet and cardiometabolic risk factors. Validation study nested in the PREDIMED-Plus (n = 6760, 55–75 years). Dietary data were collected by the 17-item er-MEDAS and a 143-item validated semiquantitative food frequency questionnaire (FFQ) at baseline and after 1-year intervention. Cardiometabolic risk markers were measured at both time points. A Mediterranean diet (MedDiet) score was derived from both instruments. Concurrent validity was evaluated by Pearson and intra-class correlation coefficients (ICC) and Bland and Altman limits of agreement. Construct validity was evaluated by assessing 1-year changes in FFQ-reported dietary intake and cardiometabolic profile changes in relation to changes in er-MEDAS. A moderate to good correlation between the MedDiet score calculated by both measurement instruments was found: r = 0.61 and ICC = 0.60 (both p < 0.001). Agreement of each of the er-MEDAS items ranged from 55.4% to 85.0% with a moderate mean concordance (kappa = 0.41). Between baseline and 1-year follow-up, energy intake measured by the FFQ decreased by 242 kcal, while Mediterranean food consumption increased in participants with the highest increase in the er-MEDAS MedDiet score. An increase in the er-MEDAS MedDiet score ratings was associated with a decrease in BMI, waist circumference, triglycerides, fasting glucose, diastolic blood pressure, and triglycerides/HDL-cholesterol ratio (p < 0.001 for all), and with an increase in HDL-cholesterol (p = 0.006). The er-MEDAS shows a modest to good concurrent validity compared with FFQ data. It shows acceptable construct validity, as a greater er-MEDAS score was associated with more favourable dietary and cardiometabolic profiles over time. ISRCTN89898870; registration date, 24 July 2014. https://www.isrctn.com/ISRCTN89898870. [ABSTRACT FROM AUTHOR]

There is limited prospective evidence on the association between physical activity (PA) and inflammation in older adults. Our aim was to assess the associations between changes in PA and changes in the inflammatory profile in older individuals who are overweight or obese. This prospective study included 489 men and women, aged 55–75 years, from the PREDIMED-Plus trial. Levels of interleukin 6 (IL-6), interleukin 8 (IL-8), interleukin 18 (IL-18), monocyte chemo-attractant protein-1 (MCP-1), C-peptide, high-sensitivity C-reactive protein (hs-CRP), leptin, and regulated on activation, normal T-cell expressed and secreted chemokine (RANTES) were obtained from fasting blood samples and a composite inflammatory score based on these biomarkers was calculated. Physical activity was measured by a validated questionnaire. All measures were taken at baseline and one-year follow-up. Multiple linear regression models showed an association between an increase in total PA and a decrease in the inflammatory score (p = 0.012), which was particularly driven by a decrease in C-peptide (p = 0.037). Similarly, the inflammatory score decreased with increasing moderate PA (p = 0.001), and moderate-to-vigorous PA (p = 0.006). Increases in total PA, moderate and moderate-to-vigorous PA were associated with a decrease in the inflammatory profile of obese or overweight older individuals. This finding is relevant for PA recommendations and public health strategies. Clinical trial identifier: International Standard Randomized Controlled Trial 89898870. [ABSTRACT FROM AUTHOR]

Socioeconomic disparities and lifestyle factors are likely to determine the overall quality of the diet. In addition, overeating is compatible with inadequate micronutrient intake and it can lead to adverse health outcomes. To assess adequacy of dietary nutrient intake and to investigate the influence of socioeconomic and lifestyle factors on nutrient density in a large primary cardiovascular prevention trial conducted in healthy participants with metabolic syndrome (MetS) to assess the cardiovascular effects of an energy-restricted Mediterranean diet (PREDIMED-Plus). Baseline cross-sectional analysis of the PREDIMED-Plus trial with 6646 Spanish participants (aged 55–75 years in men and 60–75 years in women) with overweight/obesity and MetS. Energy and nutrient intake (for 10 nutrients) were calculated using a validated 143-item Food Frequency Questionnaire (FFQ) and nutrient density was estimated dividing the absolute nutrient intake by total energy intake. The prevalence of inadequate intake was estimated according to dietary reference intakes. Multivariable linear regression models were fitted to examine associations between socioeconomic status or lifestyle factors and nutrient density. A considerable proportion of the screened participants showed a deficient intake of vitamins A, D, E, B 9 , calcium, magnesium and dietary fibre. Inadequate intake of four or more of the ten nutrients considered was present in 17% of participants. A higher nutrient density was directly and significantly associated with female sex, higher educational level and a better adherence to the Mediterranean diet. Lifestyle factors such as non-smoking and avoidance of sedentary lifestyles were also independently associated with better nutrient density. Patients with MetS, despite being overweight, exhibited suboptimal nutrient intake, especially among men. Low nutrient density diet can be largely explained by differences in socioeconomic and lifestyle factors. These results highlight the importance of focussing on nutritional education in vulnerable populations, taking into account nutrient requirements. [ABSTRACT FROM AUTHOR]

Few studies have compared micronutrient intake and fulfilment of average requirements (EAR) in non-diabetic, pre-diabetic and diabetic adults at high cardiovascular risk. We assessed these variables in a large sample of participants in the PREDIMED-PLUS randomized trial of primary cardiovascular prevention with diet and physical activity. Baseline assessment of nutritional adequacy in n = 5792 men and women, aged 55–75 years, with overweight/obesity and some metabolic syndrome features. Participants were categorised as non-diabetic (n = 2390), pre-diabetic (n = 1322) or diabetic (n = 2080) by standard criteria. Food and nutrient intake were assessed using a validated food frequency questionnaire. Micronutrients examined were vitamins B1, B2, B3, B6, B12, A, C, D, E and folic acid; Ca, K, P, Mg, Fe, Se, Cr, Zn, and iodine. The proportion of micronutrient inadequacy was evaluated using the EAR or adequate intake (AI) cut-offs. Diet quality was also determined using a 17-item energy-restricted Mediterranean diet (MedDiet) questionnaire. Compared to non-diabetic participants, those with pre-diabetes had lower intakes of total carbohydrates (CHO) and higher intakes of total fat and saturated fatty acids (SFA) and were more likely to be below EAR for folic, while diabetic participants had lower intakes of total CHO and higher intakes of protein, total fat, monounsaturated fatty acids, SFA and cholesterol and were less likely to be below EAR for vitamins B2, and B6, Ca, Zn and iodine. Diabetic participants disclosed higher adherence to the MedDiet than the other two groups. Older Mediterranean individuals with metabolic syndrome and diabetes had better nutrient adequacy and adherence to the MedDiet than those with pre-diabetes or no diabetes. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background and Aims: Glutamate, glutamine are involved in energy metabolism, and have been related to cardiometabolic disorders. However, their roles in the development of type-2 diabetes (T2D) remain unclear. The aim of this study was to examine the effects of Mediterranean diet on associations between glutamine, glutamate, glutamine-to-glutamate ratio, and risk of new-onset T2D in a Spanish population at high risk for cardiovascular disease (CVD).Methods and Results: The present study was built within the PREDIMED trial using a case-cohort design including 892 participants with 251 incident T2D cases and 641 non-cases. Participants (mean age 66.3 years; female 62.8%) were non diabetic and at high risk for CVD at baseline. Plasma levels of glutamine and glutamate were measured at baseline and after 1-year of intervention. Higher glutamate levels at baseline were associated with increased risk of T2D with a hazard ratio (HR) of 2.78 (95% CI, 1.43-5.41, P for trend = 0.0002). In contrast, baseline levels of glutamine (HR: 0.64, 95% CI, 0.36-1.12; P for trend = 0.04) and glutamine-to-glutamate ratio (HR: 0.31, 95% CI, 0.16-0.57; P for trend = 0.0001) were inversely associated with T2D risk when comparing extreme quartiles. The two Mediterranean diets (MedDiet + EVOO and MedDiet + mixed nuts) did not alter levels of glutamine and glutamate after intervention for 1 year. However, MedDiet mitigated the positive association between higher baseline plasma glutamate and T2D risk (P for interaction = 0.01).Conclusion: Higher levels of glutamate and lower levels of glutamine were associated with increased risk of T2D in a Spanish population at high risk for CVD. Mediterranean diet might mitigate the association between the imbalance of glutamine and glutamate and T2D risk. This trial is registered at http://www.controlled-trials.com, ISRCTN35739639. [ABSTRACT FROM AUTHOR]

More than 50 years after the Seven Countries Study, a large number of epidemiological studies have explored the relationship between the Mediterranean diet (MD) and health, through observational, case-control, some longitudinal and a few experimental studies. The overall results show strong evidence suggesting a protective effect of the MD mainly on the risk of cardiovascular disease (CVD) and certain types of cancer. The beneficial effects have been attributed to the types of food consumed, total dietary pattern, components in the food, cooking techniques, eating behaviors and lifestyle behaviors, among others. The aim of this article is to review and summarize the knowledge derived from the literature focusing on the benefits of the MD on health, including those that have been extensively investigated (CVD, cancer) along with more recent issues such as mental health, immunity, quality of life, etc. The review begins with a brief description of the MD and its components. Then we present a review of studies evaluating metabolic biomarkers and genotypes in relation to the MD. Other sections are dedicated to observation and intervention studies for various pathologies. Finally, some insights into the relationship between the MD and sustainability are explored. In conclusion, the research undertaken on metabolomics approaches has identified potential markers for certain MD components and patterns, but more investigation is needed to obtain valid measures. Further evaluation of gene-MD interactions are also required to better understand the mechanisms by which the MD diet exerts its beneficial effects on health. Observation and intervention studies, particularly PREDIMED, have provided invaluable data on the benefits of the MD for a wide range of chronic diseases. However further research is needed to explore the effects of other lifestyle components associated with Mediterranean populations, its environmental impact, as well as the MD extrapolation to non-Mediterranean contexts. [ABSTRACT FROM AUTHOR]

Background: During development of cardiovascular disease (CVD), interferon-γ-mediated inflammation accelerates degradation of tryptophan into downstream metabolites. A Mediterranean diet (MedDiet) consisting of a high intake of extra-virgin olive oil (EVOO), nuts, fruits, vegetables, and cereals has been demonstrated to lower the risk of CVD. The longitudinal relation between tryptophan and its downstream metabolites and CVD in the context of a MedDiet is unstudied.Objective: We sought to investigate the relation between metabolites in the tryptophan-kynurenine pathway and CVD in the context of a MedDiet pattern.Methods: We used a case-cohort design nested in the Prevención con Dieta Mediterránea randomized controlled trial. There were 231 CVD cases (stroke, myocardial infarction, cardiovascular death) among 985 participants over a median of 4.7 y of follow-up [mean ± SD age: 67.6 ± 6.1 y; 53.7% women; mean ± SD body mass index (in kg/m2): 29.7 ± 3.7]. We assessed plasma tryptophan, kynurenine, kynurenic acid, 3-hydroxyanthranilic acid, and quinolinic acid concentrations at baseline and after 1 y of intervention with a MedDiet. We combined these metabolites in a kynurenine risk score (KRS) by weighting each metabolite by the adjusted coefficient of its associations with CVD. Cox models were used in the primary analysis.Results: Increases in tryptophan after 1 y were associated with a lower risk of composite CVD (HR per SD: 0.79; 95% CI: 0.63, 0.98). The baseline kynurenic acid concentration was associated with a higher risk of myocardial infarction and coronary artery disease death but not stroke. A higher KRS was more strongly associated with CVD in the control group than in the 2 intervention groups (P-interaction = 0.003). Adjustment for changes in plasma tryptophan attenuated the inverse association between MedDiet+EVOO and CVD.Conclusions: An increase in the plasma tryptophan concentration was significantly associated with a decreased risk of CVD. A MedDiet may counteract the deleterious effects of a high kynurenine risk score. [ABSTRACT FROM AUTHOR]

Summary Background & aims High dietary protein diets are widely used to manage overweight and obesity. However, there is a lack of consensus about their long-term efficacy and safety. Therefore, the aim of this study was to assess the effect of long-term high-protein consumption on body weight changes and death outcomes in subjects at high cardiovascular risk. Methods A secondary analysis of the PREDIMED trial was conducted. Dietary protein was assessed using a food-frequency questionnaire during the follow-up. Cox proportional hazard models were used to estimate the multivariate-adjusted hazard ratio (HR) and 95% confidence intervals (95%CI) for protein intake in relation to the risk of body weight and waist circumference changes, cardiovascular disease, cardiovascular death, cancer death and total death. Results Higher total protein intake, expressed as percentage of energy, was significantly associated with a greater risk of weight gain when protein replaced carbohydrates (HR: 1.90; 95%CI: 1.05, 3.46) but not when replaced fat (HR: 1.69; 95%CI: 0.94, 3.03). However, no association was found between protein intake and waist circumference. Contrary, higher total protein intake was associated with a greater risk of all-cause death in both carbohydrate and fat substitution models (HR: 1.59; 95%CI: 1.08, 2.35; and HR: 1.66; 95%CI: 1.13, 2.43, respectively). A higher consumption of animal protein was associated with an increased risk of fatal and non-fatal outcomes when protein substituted carbohydrates or fat. Conclusions Higher dietary protein intake is associated with long-term increased risk of body weight gain and overall death in a Mediterranean population at high cardiovascular risk. [ABSTRACT FROM AUTHOR]

Background: Higher consumption of some polyphenols has been associated with a reduced risk of diabetes. However, no studies have evaluated the relation between all polyphenol subclasses and the incidence of diabetes.Objective: We aimed to prospectively examine the associations between the intake of total polyphenols and different groups of polyphenols (flavonoids, phenolic acids, stilbenes, lignans, and others) on the risk of incident diabetes in the PREDIMED (Prevención con Dieta Mediterránea) trial.Methods: This was an observational cohort analysis of the nondiabetic participants in the PREDIMED trial. This study was a multicenter, controlled, randomized, parallel-group feeding trial to assess the effects of either a Mediterranean diet that was supplemented with extra-virgin olive oil or nuts or advice to adhere to a low-fat control diet on cardiovascular outcomes in elderly men and women at high cardiovascular disease risk. From the 7447 randomly assigned participants, 3430 were selected because they were free of diabetes at baseline and filled out the food-frequency questionnaires (FFQs). Polyphenol intake was calculated by matching food consumption data from repeated FFQs with the Phenol-Explorer database on the polyphenol content of each reported food. HRs and 95% CIs for diabetes according to tertiles of polyphenol intake were estimated with the use of time-dependent Cox proportional hazards models.Results: Over a mean of 5.51 y of follow-up (18,900 person-years), there were 314 new cases of diabetes. After multivariable adjustment, we observed a 28% reduction in new-onset diabetes in the highest compared with the lowest tertile of total polyphenol intake (HR: 0.72; 95% CI: 0.52, 0.99; P-trend = 0.05). The intake of subclasses of polyphenols also was inversely associated with diabetes risk, including for total flavonoids (HR: 0.67; 95% CI: 0.48, 0.93; P-trend = 0.02), stilbenes (HR: 0.57; 95% CI: 0.38, 0.84; P-trend = 0.003), dihydroflavonols (HR: 0.59; 95% CI: 0.40, 0.88; P-trend = 0.003), and flavanones (HR: 0.69; 95% CI: 0.49, 0.97; P-trend = 0.03).Conclusions: A high intake of total polyphenols, total flavonoids (specifically flavanones and dihydroflavonols), and stilbenes is associated with a reduced risk of diabetes in elderly persons at high risk of cardiovascular disease. This trial was registered at http://www.controlled-trials.com as ISRCTN35739639. [ABSTRACT FROM AUTHOR]

Summary Background & aims There is little evidence on post hoc -derived dietary patterns (DP) and all-cause mortality in Southern-European populations. Furthermore, the potential effect modification of a DP by a nutritional intervention has not been sufficiently assessed. We assessed the association between a posteriori defined baseline major DP and total mortality or cardiovascular events within each of the three arms of a large primary prevention trial (PREDIMED) where participants were randomized to two active interventions with Mediterranean-type diets or to a control group (allocated to a low-fat diet). Design We followed-up 7216 participants for a median of 4.3 years. A validated 137-item food-frequency questionnaire was administered. Baseline DP were ascertained through factor analysis based on 34 predefined groups. Cox regression models were used to estimate multivariable-adjusted hazard ratios (HR) for cardiovascular disease (CVD) or mortality across quartiles of DP within each of the three arms of the trial. Results We identified two major baseline DP: the first DP was rich in red and processed meats, alcohol, refined grains and whole dairy products and was labeled Western dietary pattern (WDP). The second DP corresponded to a “Mediterranean-type” dietary pattern (MDP). During follow-up, 328 participants died. After controlling for potential confounders, higher baseline adherence to the MDP was associated with lower risk of CVD (adjusted HR for fourth vs. first quartile: 0.52; 95% CI (Confidence Interval): 0.36, 0.74; p -trend <0.001) and all-cause mortality (adjusted HR: 0.53; 95% CI: 0.38, 0.75; p -trend <0.001), regardless of the allocated arm of the trial. An increasing mortality rate was found across increasing quartiles of the WDP in the control group (allocated to a low-fat diet), though the linear trend was not statistically significant ( p = 0.098). Conclusions Higher adherence to an empirically-derived MDP at baseline was associated with a reduced risk of CVD and mortality in the PREDIMED trial regardless of the allocated arm. The WDP was not associated with higher risk of mortality or cardiovascular events. [ABSTRACT FROM AUTHOR]

Background: Few observational studies have examined the effect of dietary fiber intake and fruit and vegetable consumption on total mortality and have reported inconsistent results. All of the studies have been conducted in general population and typically used only a single assessment of diet. Objective: We investigated the association of fiber intake and whole-grain, fruit, and vegetable consumption with all-cause mortality in a Mediterranean cohort of elderly adults at high cardiovascular disease (CVD) risk by using repeated measurements of dietary information and taking into account the effect of a dietary intervention. Design: We followed up 7216 men (55-75 y old) and women (60-75 y old) at high CVD risk in the Prevención con Dieta Mediterránea (PREDIMED) trial for a mean of 5.9 y. Data were analyzed as an observational cohort. Participants were initially free of CVD. A 137-item validated food-frequency questionnaire administered by dietitians was repeated annually to assess dietary exposures (fiber, fruit, vegetable, and whole-grain intakes). Deaths were identified through the continuing medical care of participants and the National Death Index. An independent, blinded Event Adjudication Committee adjudicated causes of death. Cox regression models were used to estimate HRs of death during follow-up according to baseline dietary exposures and their yearly updated changes. Results: In up to 8.7 y of follow-up, 425 participants died. Baseline fiber intake and fruit consumption were significantly associated with lower risk of death [HRs for the fifth compared with first fifth: 0.63 (95% CI: 0.46, 0.86; P = 0.015) and 0.59 (95% CI: 0.42, 0.82; P = 0.004), respectively]. When the updated dietary information was considered, participants with fruit consumption >210 g/d had 41% lower risk of all-cause mortality (HR: 0.59; 95% CI: 0.44, 0.78). Associations were strongest for CVD mortality than other causes of death. Conclusion: Fiber and fruit intakes are associated with a reduction in total mortality. PREDIMED was registered at controlled-trials.com as ISRCTN35739639. [ABSTRACT FROM AUTHOR]

International Public Health authorities recommend biomonitoring studies to assess the exposure to chemicals in the general population. The aim of the present study was to analyze the blood concentrations of a total 360 pollutants, including 230 pesticides in current or recent use, 59 persistent organochlorine pollutants (POPs), 11 anticoagulant rodenticides and 60 pharmaceutical active compounds (PhACs), in a cohort of 403 subjects from Cape Verde. The study was performed in the frame of the Pesticide Residues in Vegetables of the Macaronesia project (PERVEMAC-II). A total of 60 out of 360 toxic compounds (16.7%) were detected, at least, in one participant. The three most frequently detected substances were p,p'-DDE (100%), phenanthrene (94.0%) and hexachlobenzene (35.9%). 2-Phenylphenol and imidacloprid were detected in 29.0 and 14.4% of the population. The three substances with the highest serum concentrations were PhACs: naproxen (249.1 ng/mL), metronidazole (115.6 ng/mL) and acetaminophen (25.2 ng/mL). Median blood concentration of p,p'-DDE, HCB and phenanthrene were 1.87, 0.08 and 0.36 ng/mL. Blood concentrations of POPs were influenced by age, although both gender and body mass index may exert an influence in the presence of these substances. Lifestyle has an effect on the concentration of these substances, especially in terms of dietary habits. Both the frequency of detection and the concentration of the studied substances are similar to those of other biomonitored populations. This is the first biomonitoring study carried out in Cape Verde. Our results may be useful for the implementation of public health measures by the competent authorities. [Display omitted] • 360 pollutants were analyzed in blood from 403 subjects from Cape Verde. • 16.7% of toxic elements were detected/quantified. • p,p'-DDE, phenanthrene and HCB were the 3 most frequently detected substances. • Lifestyle has an effect on the concentration of these substances. [ABSTRACT FROM AUTHOR]

Background: Vegetarian diets have been associated with reduced mortality. Because a pure vegetarian diet might not easily be embraced by many individuals, consuming preferentially plant-derived foods would be a more easily understood message. A provegetarian food pattern (FP) emphasizing preference for plant-derived foods might reduce all-cause mortality. Objective: The objective was to identify the association between an a priori--defined provegetarian FP and all-cause mortality. Design: We followed 7216 participants (57% women; mean age: 67 y) at high cardiovascular risk for a median of 4.8 y. A validated 137-item semiquantitative food-frequency questionnaire was administered at baseline and yearly thereafter. Fruit, vegetables, nuts, cereals, legumes, olive oil, and potatoes were positively weighted. Added animal fats, eggs, fish, dairy products, and meats or meat products were negatively weighted. Energy-adjusted quintiles were used to assign points to build the provegetarian FP (range: 12-60 points). Deaths were confirmed by review of medical records and the National Death Index. Results: There were 323 deaths during the follow-up period (76 from cardiovascular causes, 130 from cancer, 117 for noncancer, noncardiovascular causes). Higher baseline conformity with the provegetarian FP was associated with lower mortality (multivariable-adjusted HR for ≥40 compared with <30 points: 0.59; 95% CI: 0.40, 0.88). Similar results were found with the use of updated information on diet (RR: 0.59; 95% CI: 0.39, 0.89). Conclusions: Among omnivorous subjects at high cardiovascular risk, better conformity with an FP that emphasized plant-derived foods was associated with a reduced risk of all-cause mortality. This trial was registered at www.controlled-trials.com as ISRCTN35739639. [ABSTRACT FROM AUTHOR]

Vitamin K has been related to cardiovascular disease and cancer risk. However, data on total mortality are scarce. The aim of the present study was to assess the association between the dietary intake of different types of vitamin K and mortality in a Mediterranean population at high cardiovascular disease risk. A prospective cohort analysis was conducted in 7216 participants from the PREDIMED (Prevención con Dieta Mediterránea) study (median follow-up of 4.8 y). Energy and nutrient intakes were evaluated using a validated 137-item food frequency questionnaire. Dietary vitamin K intake was calculated annually using the USDA food composition database and other published sources. Deaths were ascertained by an end-point adjudication committee unaware of the dietary habits of participants after they had reviewed medical records and linked up to the National Death Index. Cox proportional hazard models were fitted to assess the RR of mortality. Energy-adjusted baseline dietary phylloquinone intake was inversely associated with a significantly reduced risk of cancer and all-cause mortality after controlling for potential confounders (HR: 0.54; 95% CI: 0.30, 0.96; and HR: 0.64; 95% CI: 0.45, 0.90, respectively). In longitudinal assessments, individuals who increased their intake of phylloquinone or menaquinone during follow-up had a lower risk of cancer (HR: 0.64; 95% CI: 0.43, 0.95; and HR: 0.41; 95% CI: 0.26, 0.64, respectively) and all-cause mortality (HR: 0.57; 95% CI: 0.44, 0.73; and HR: 0.55; 95% CI: 0.42, 0.73, respectively) than individuals who decreased or did not change their intake. Also, individuals who increased their intake of dietary phylloquinone had a lower risk of cardiovascular mortality risk (HR: 0.52; 95% CI: 0.31, 0.86). However, no association between changes in menaquinone intake and cardiovascular mortality was observed (HR: 0.76; 95% CI: 0.44, 1.29). An increase in dietary intake of vitamin K is associated with a reduced risk of cardiovascular, cancer, or all-cause mortality in a Mediterranean population at high cardiovascular disease risk. This trial was registered at http://www.controlled-trials.com as ISRCTN35739639. [ABSTRACT FROM AUTHOR]

Background & aims: The aim was to examine the associations between macronutrient intake and the prevalence of chronic kidney disease (CKD) or microalbuminuria (MiA) in individuals at high cardio- vascular risk. Methods: Cross-sectional analyses conducted in 2123 nondiabetic individuals from the PREDIMED study. Dietary data were collected using a food-frequency questionnaire. Analysis of covariance was used to assess associations between quartiles of nutrient intake and estimated glomerular filtration rate (eGFR) or urinary albumin-to-creatinine ratio (ACR). The odds ratio (OR) for the presence of CKD or MiA according to quartiles of nutrient intake was assessed by logistic regression models. Results: Individuals in the highest quartile of n-6 polyunsaturated fatty acid (PUFA) intake showed lower average eGFR. Individuals in the top quartile of fiber intake had a decreased risk of CKD [OR: 0.68; 95% CI: 0.48-0.95]. Conversely, subjects in the highest quartile of n-6 PUFA intake showed an increased risk of CKD [OR: 1.44; 95% Cl: 1.03-2.01]. No significant associations were found between the intake of other macronutrients and eGFR, urinary ACR or risk of CKD or MiA. Conclusions: A high fiber intake was associated with a decreased risk of CKD, while a high n-6 PUF intake was inversely associated with eGFR and directly associated with an increased risk of CKD. [ABSTRACT FROM AUTHOR]

Ensuring the accuracy of dietary assessment instruments is paramount for interpreting diet-disease relationships. The present study assessed the relative and construct validity of the 14-point Mediterranean Diet Adherence Screener (MEDAS) used in the Prevención con Dieta Mediterránea (PREDIMED) study, a primary prevention nutrition-intervention trial. A validated FFQ and the MEDAS were administered to 7146 participants of the PREDIMED study. The MEDAS-derived PREDIMED score correlated significantly with the corresponding FFQ PREDIMED score (r = 0.52; intraclass correlation coefficient = 0.51) and in the anticipated directions with the dietary intakes reported on the FFQ. Using Bland Altman's analysis, the average MEDAS Mediterranean diet score estimate was 105% of the FFQ PREDIMED score estimate. Limits of agreement ranged between 57 and 153%. Multiple linear regression analyses revealed that a higher PREDIMED score related directly (P < 0.001) to HDL-cholesterol (HDL-C) and inversely IP < 0.038) to BMI, waist circumference, TG, the TG:HDL-C ratio, fasting glucose, and the cholesterol:HDL-C ratio. The 10-y estimated coronary artery disease risk decreased as the PREDIMED score increased (P< 0.0011. The MEDAS is a valid instrument for rapid estimation of adherence to the Mediterranean diet and may be useful in clinical practice. [ABSTRACT FROM AUTHOR]

Abstract: Context: Serum levels of Insulin-like growth factor I (IGF-I) play a critical role in children growth and in the pathogenesis of several diseases. In addition, recent studies suggest that DDT-derivative organochlorine pesticides (OC–DDTs) could influence IGF levels in human beings. Objective and design: Because it has been suggested that IGF-I peak levels at puberty could determine IGF-I levels in adulthood, we developed a cross-sectional study of the potential association between serum levels of OC–DDTs and IGF system in 160 serum samples from young people (81 boys and 79 girls) living in the Canary Islands (Spain). Results: Multivariate tests were used adjusting for confounding variables (age, height, and weight) and stratifying by gender and age: IGF-I serum levels were significantly lower in pre-pubertal male children (6–15years) who showed detectable values of p,p′-DDE, and p,p′-DDD than in pre-pubertal male children with undetectable levels of these OC–DDTs-metabolites (p =0.023 and p =0.049, respectively). In addition, in this multivariate model, a non-linear dose–response curve was observed between Total DDT body burden (sum of the three DDT-derivatives measured: p,p′-DDT, p,p′-DDE, and p,p′-DDD) and IGF-I in pre-pubertal male children (6–15years; p =0.043). Conclusion: These findings suggest that OC–DDTs could modulate the IGF-system in a way that is highly influenced by gender and age. Improvements in our understanding of exogenous determinants of the IGF-system may provide new insights into the role played by environmental contaminants in IGF-related diseases. [Copyright &y& Elsevier]

Abstract: Context: Insulin-like growth factor 1 (IGF-I) and organochlorine pesticides (OCs) have been involved in the pathogenesis of several diseases like cancer, diabetes and growth disorders. Objective and design: The potential relationship between the serum levels of various OCs and serum IGF-I was investigated in adults (176 men and 247 women) from a representative sample of the general population of the Canary Islands (Spain). Results: After adjustment for potential confounders, which include body mass index, age, and IGF-binding protein-3 (IGFBP-3), IGF-I levels were significantly lower in the 247 women who showed detectable levels of p,p′-DDD (a DDT-metabolite) than in women who presented non-detectable levels of this pesticide (p =0.030), specially in 36–50 years old women. A similar negative relationship was also found between IGF-I and aldrin (a non-DDT-derivative) in women (p =0.049). In the group of 176 men, aldrin seemed to exert a similar negative effect on IGF-I (p =0.046) and this effect was clearly significant in the oldest group (51–65 years) (p =0.009). A non-linear dose–response curve was observed between Total Cyclodienes Body Burden (Total Cyclodienes; sum of aldrin, dieldrin and endrin) and IGF-I in men (p =0.024). These findings suggest that OCs could modulate the IGF-system in a way that is highly influenced by gender, age and by chemical or combination of chemicals implicated. Such circumstances may contribute to the development of a number of diseases related to IGF-I and should be taken into account in public health decisions. [Copyright &y& Elsevier]

Compares food consumption trends with coronary heart disease mortality in Spain. Risk factors of cardiovascular diseases; Fats and saturated fat consumption; Dietary information from family budget surveys.

Inorganic elements such as heavy metals and other potentially toxic elements are frequently detected in humans. The aim of the present study was to analyze the blood concentrations of 49 inorganic elements in a cohort of 401 subjects from Cape Verde. The study was performed in the frame of the Pesticide Residues in Vegetables of the Macaronesia project (PERVEMAC-II). Concentration of inorganic elements, including elements in the ATSDR's priority pollutant list and rare earth elements (RREs) were measured by ICP-MS in the whole blood of participants. A total of 20 out of 49 elements (40.8%) were detected in ≥20% of participants. Arsenic, copper, mercury, lead, selenium, strontium and zinc were detected in ≥99% of samples. Among the REEs, 7 showed detection frequencies above 20%. The median number of different elements detected was 15. In the present series, 77.0, 99.2 and 33.4% of the participants showed values of arsenic, mercury and lead higher than Reference Values 95%. These percentages were much higher than those reported in similar studies. Niobium and tantalum showed the highest median concentrations: 1.35 and 1.34 ng/mL, suggesting an environmental source of these valuable REEs in Cape Verde. Age appeared as the most important factor influencing the blood levels of inorganic elements. Lifestyle had an effect on the concentration of some of these elements. Those subjects whose water source was pond water had significantly higher arsenic levels. The concentration of ∑REEs was significantly higher among individuals who purchase their food in supermarkets (P = 0.013). These variables are of relevance since they can be controlled individually to reduce exposure to these contaminants. Our results may be useful for the implementation of public health measures by the competent authorities. [Display omitted] • 49 inorganic elements were analyzed in blood from 401 subjects from Cape Verde. • As, Cu, Hg, Pb, Se, Sr and Zn were detected in ≥99% of samples. • Nb and Ta were the most frequently detected RREs and at the highest concentration. • 77, 99 and 33% of the participants had values of As, Hg and Pb higher than RV95s. • Lifestyle has an effect on the concentration of these chemical elements. [ABSTRACT FROM AUTHOR]

Environmental exposure to persistent organic pollutants (POPs) has been reported to be relevant in the population of the Canary Islands (Spain), especially that of organochlorine pesticides. On the other hand, the population of this archipelago presents a high prevalence of type 2 diabetes (T2D), and it has been recently reported that environmental chemical contamination could play a role in the development of this disease. We performed a cross-sectional study in a representative sample from this archipelago to evaluate whether serum levels of selected POPs could be considered as risk factors for diabetes in this population. Serum levels of 30 POPs were determined in 429 adults (9.3% with T2D). We found that serum levels of p , p ′-DDE (DDE), PCB-153 and PCB-118 were significantly higher among subjects having diabetes than in non-diabetic subjects ( p = 0.001, p = 0.046, and p < 0.0001, respectively). We observed a positive correlation between serum p , p ′-DDE and glucose levels. Serum p , p ′-DDE was identified as a risk factor for diabetes in univariate analysis in the whole series, and it remained as an independent risk factor for diabetes in subjects with serum glucose < 126 mg/dL (multivariate analysis, Exp(B) = 1.283, CI 95% (1.023–1.611), p = 0.031). Those normoglycemic subjects that are most exposed to p , p ′-DDE (95th percentile: serum p , p ′-DDE > 5 μg/L) seem to be those people at higher risk. Our results showed that p , p ′-DDE levels were significantly higher among subjects having diabetes. These findings should be considered by public health Authorities to implement measures devoted to minimize human exposure to pollutants that could be harmful to the population. [ABSTRACT FROM AUTHOR]

The level of contamination with persistent organic pollutants (POPs) and dietary habits and food consumption was extensively studied in the population from the Canary Islands (Spain). Because foodstuffs of animal origin are well known to be prominent contributors to these contaminants, the current study aimed to assess the role of the dietary intake of animal products as a probability factor for increased serum POPs. The intake of animal products (dietary variables) as a determining factor for serum POP levels was investigated using multivariate statistical models. Our results showed that while poultry, rabbit, and cheese consumption increases the probability of having high levels of non-DDT-derivative pesticides, sausage, yogurt, lard, and bacon consumption decreases the probability of having high levels of these pesticides. In addition, poultry, rabbit, eggs, cream, and butter consumption increased the probability of having detectable levels of marker PCB, while dairy desserts decreased the probability of having detectable levels of these PCBs. On the contrary, sausage and meat consumption increased the probability of having detectable levels of dioxin-like PCBs (DL-PCBs). The current results confirm that dietary intake of foodstuffs of animal origin is a relevant risk factor for the accumulation of POPs (and therefore their serum levels). Our study indicates that the analysis of dietary patterns may be useful for identifying those individuals that will probably present a high body burden of POPs. Because POPs can exert deleterious effects on human health, the identification of populations at risk of being highly contaminated is mandatory in order to implement policies that minimize the exposure to these compounds. [ABSTRACT FROM AUTHOR]

Objectives: To determine the impact of energy density on diet quality and anthropometric proxy measures for central body fat in young Spaniards. Methods: Data were obtained from a representative national sample of 2513 young Spaniards aged 10 to 24 y. Dietary assessment was performed with a 24-h recall. Adherence to the Mediterranean diet was measured by the KIDMED index. Reduced rank regression analysis was used to identify energy-density dietary patterns. Waist circumferences and height were measured. Results: Pastries and sausages showed the strongest loading for the dietary energy density factor score (DED-FS), with fruits and vegetables at the opposite end of the scale. Multiple linear regression analysis showed a positive association (P < 0.01) of dietary energy density (DED) and the DED-FS with waist circumferences regressed on height and age (WCheight+age) and waist-to-height ratio (WHtR). The adjusted odds ratio for elevated WCheight+age and WHtR increased across quartile distribution of DED (P < 0.001) and DED-FS (P < 0.05). Diet quality characterized by the KIDMED index was negatively associated (P < 0.001) with DED and the DED-FS. Conclusions: Higher DED is a risk for increased central fat distribution and is associated with low adherence to the Mediterranean diet. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Apolipoprotein (Apo)B, ApoA-I, and their ratio could predict coronary heart disease (CHD) risk more accurately than conventional lipid measurements. Our aim was to assess the effect of a traditional Mediterranean diet (TMD) on apolipoproteins. Methods: High-cardiovascular risk subjects (n =551, 308 women and 243 men), aged 55–80 years, were recruited into a large, multicenter, randomized, controlled, parallel-group, clinical trial (The PREDIMED Study) aimed at testing the efficacy of TMD on primary cardiovascular disease prevention. Participants assigned to a low-fat diet (control) (n =177), or TMDs (TMD+virgin olive oil (VOO), n =181 or TMD+nuts, n =193) received nutritional education and either free VOO (ad libitum) or nuts (dose: 30g/day). A 3-month evaluation was performed. Results: Both TMDs promoted beneficial changes on classical cardiovascular risk factors. ApoA-I increased, and ApoB and ApoB/ApoA-I ratio decreased after TMD+VOO, the changes promoting a lower cardiometabolic risk. Changes in TMD+VOO versus low-fat diet were −2.9mg/dL (95% CI, −5.6 to −0.08), 3.3mg/dL (95% CI, 0.84 to 5.8), and −0.03mg/dL (−0.05 to −0.01) for ApoB, ApoA-I, and ApoB/ApoA-I ratio, respectively. Conclusions: Individuals at high-cardiovascular risk who improved their diet toward a TMD pattern rich in virgin olive oil, reduced their Apo B and ApoB/ApoA-I ratio and improved ApoA-I concentrations. [Copyright &y& Elsevier]

Abstract: The human androgen receptor (AR) gene possesses two trinucleotide repeats of CAG and GGN in exon-1. The GGN repeat affects the amount of AR protein translated, while the CAG repeat affects the efficiency of AR transcriptionaly. In this study, we have genotyped these polymorphic tracts in a representative sample of 557 Caucasian adult individuals (314 women and 243 men) from the Canary Islands, Spain (the ENCA Study), and investigated their association with fasting serum levels of lipids, glucose and insulin. The number of CAG repeats in women (expressed as the average length of the two alleles) was inversely correlated with serum levels of LDL-cholesterol (Spearman rho=−0.179; P <0.01). Women with an average number of CAG repeats in the upper tertile showed significantly lower levels of LDL-cholesterol than those grouped in the lower and middle tertile, after adjusting for age, body mass index, waist-to-hip ratio, smoking and alcohol drinking. The number of GGN repeats in men was correlated with fasting insulin levels (Spearman rho=−0.206; P <0.01), the homeostasis model assessment of insulin resistance (HOMA-IR; Spearman rho=−0.230; P <0.01) and the McAuley index of insulin sensitivity (Spearman rho=0.194; P <0.01). Men with a number of GGN repeats in the upper tertile showed lower levels of insulin and HOMA and a higher level of the McAuley index than those grouped in the lower and middle tertile, after adjusting for the variables listed above. These results support the hypothesis that the longer alleles of the CAG and GGN polymorphisms in the exon-1 of the AR gene, indicative of lower androgenic signaling, respectively protect women from developing dyslipemia and men from developing insulin resistance. [Copyright &y& Elsevier]

Abstract: In 1998, one of the largest determinations of organochlorine pesticides in a representative sample of a Spanish population (682 serum samples from the Canary Islands) was made in the context of the “Canary Islands Nutrition Survey” (ENCA). In the Canary Islands, extensive farming areas have been developed in these last decades, with greenhouses dedicated to intensive cultivation using DDT in huge amounts. In Spain, similarly to other European countries, DDT was banned in the late 1970s. The pesticide residues in human serum are indicative of past and present exposure to them. Our objective is to point out the differences of pesticide contamination between islands; and together with this, if a connection could be established with gender, age, or habitat of subjects. Concentration of selected persistent organochlorine pollutants (p,p′-DDT, o,p′-DDT, p,p′-DDE, o,p′-DDE, p,p′-DDD, and o,p′-DDD) was measured with gas chromatography-electron capture detector. Almost all of the samples (99.3%) presented detectable levels of some DDT-derivatives, being p,p′-DDE the most frequently detected organochlorine. The median concentration of total DDT body burden, expressed in ng/g fat, present in the Canary Islands (370 ng/g fat) was similar to that found in other European countries, although it was noteworthy that a fourth of the population showed a total DDT body burden higher than 715 ng/g. Interestingly, statistical significant differences were found in serum levels of organochlorine pesticides between islands, being these levels higher in people from Tenerife and Gran Canaria (415 and 612 ng/g fat, respectively), the islands that present both highest population and highest surface devoted to intensive agriculture. As expected, serum levels of both total DDT body burden and p,p′-DDE increased with age. Statistically significant differences were also found in relation to gender, women showing higher levels of these organochlorine pesticides than men. One of the most relevant findings of this work is the presence of a very high DDT/DDE ratio in people from the Canary Islands, thus indicating a chronic exposure to DDT that persists nowadays. DDT and its derivatives are considered as xenoestrogens, and they have been linked to breast cancer. Having into account that the Canary Islands present high incidence and mortality for breast cancer, our results point to the possibility that these environmental contaminants may be playing a determining role that must be investigated in detail. The high levels of DDT and its derivatives in serum from people living in this Archipelago should be considered a matter of public health concern. [Copyright &y& Elsevier]

• Evidence on "nudge" interventions on diet and physical activity is limited. • The stand-alone use of "nudge" interventions remains ambiguous. • How attributes of "nudge" interventions mediate efficacy requires further research. • Conceptual development, rigorous larger studies and better reporting are needed. "Nudge" policies are increasingly popular, seeking to modify health-related decisions by affecting response to available options. Thus, critical appraisals of the effectiveness of health-related nudging interventions could help health policy makers in making evidence-based decisions with regards to which of these interventions should be incorporated into policy. The aim of the present effort was to systematically appraise the evidence on nudging interventions on healthy diet and physical activity (PA). A systematic review was performed using Pubmed, Web of Science Core Collection citation index and the Cochrane Controlled Register of Trials (CENTRAL). Interventional studies were included if they quantitatively assessed healthy diet and/or PA interventions that were explicitly related to a nudging context. Methodological assessment was performed using the Cochrane collaboration's risk of bias tool and the Research Triangle Institute item bank. Sixty-four studies were included with varying degrees of bias. Sixty studies investigated healthy diet interventions, three studied PA interventions and one studied interventions pertaining to both. Overall, specific types of interventions such as proximity and presentation alterations can be effective in encouraging people towards the adoption of healthier diet choices, whereas labelling, availability, prompting, functional design and sizing "nudge" interventions provide inconclusive results so far. Nudging interventions improving convenience seem to be effective in encouraging people towards making healthier diet choices, whereas evidence on PA is limited. Further conceptual development and research is needed to optimally determine the type, intensity and circumstances that make nudge-related interventions more effective, particularly regarding PA. [ABSTRACT FROM AUTHOR]

Objective The adoption of a Mediterranean diet (MD) pattern of eating is often described as a strategy to help prevent or manage hypertension. However, this dietary regimen has not been reviewed systematically for its efficacy against hypertension. Therefore, the purpose of this study was to analyze the effect of interventions of at least 1 year duration on blood pressure (BP) values through a systematic review and meta-analysis. The focus was on interventions comparing an MD with a low-fat diet. Design The authors accessed and searched PubMed and Scopus databases up to March, 2015. Randomized control trials comparing MD vs low-fat diet were included. The researchers assessed the methodological quality, extracted the valid data, and conducted the meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Results Six trials (more than 7,000 individuals) were identified. Meta-analysis showed that interventions aiming at adopting an MD pattern for at least 1 year reduced both the systolic BP and diastolic BP levels in individuals with normal BP or mild hypertension. The effect was higher for the systolic BP (–1.44 mm Hg) but also consistent for the diastolic BP (–0.70 mm Hg). However, the results have to be interpreted with caution owing to the reduced number of studies eligible for inclusion in this meta-analysis. This situation limited the statistical power of the analyses. Furthermore, in all analyses, the pooled effect estimation showed a high evidence of heterogeneity, which compromises the validity of the pooled estimates. Conclusions and Implications A positive and significant association was found between the MD and BP in adults. However, in all cases the magnitude of the effect was small. Based on this limited group of studies and their heterogeneity, the authors found insufficient convincing evidence to suggest that the MD decreased BP. Further standardized research is urgently needed to reach evidence-based conclusions to clarify the role of MD in BP management, particularly in Europe and other societies where prevalence of cardiovascular diseases is increasing. [ABSTRACT FROM AUTHOR]