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Objective: The aim was to examine the association between social frailty and diet quality in adults over 65 years of age, and whether results differed by sex. Design: Population-based cross-sectional study using data from the Spanish National Health Survey. Participants: 5,071 community-dwelling people ≥65 years from Spain. Measurements: Social frailty was deemed to exist when the person both lived alone and had low social support, measured with the Duke-UNC scale. Diet was assessed with the Spanish Healthy Eating Index (S-HEI), ranging from 0 to 100 points (highest diet quality). Means and 95% confidence intervals of the S-HEI score for each social frailty group were calculated using linear regressions, with socially robust people as reference. Analyses were adjusted for main confounders, including sociodemographic, lifestyle and morbidity variables. Results: There were no differences in the S-HEI adjusted mean of socially frail (74.3 points, 95%CI: 73.4−75.2) compared to socially robust older adults (75.4 points; 95%CI: 75.1−75.7). In sex-stratified analyses, the S-HEI adjusted mean of socially frail men (71.9 points; 95%CI: 70.6−73.2) was lower than robust men (74.8 points; 95%CI: 74.4−75.3). Specifically, social frailty was associated with lower consumption of vegetables, fruits, dairy and lower diet variety in men. Differences were not observed according to social frailty among older women. Conclusions: Social frailty was associated with poor diet quality in community-dwelling older men, but not in women in Spain. Gender differences in self-care could partly explain this association. Sex-specific interventions are required to minimize the impact of social frailty on diet quality.

Abstract Background The role of diet quality on malnutrition in older adults is uncertain, due the paucity of the research conducted and the use of use of screening tools that did not consider phenotypic criteria of malnutrition. Objective To evaluate the association of two indices of diet quality, namely the Mediterranean Diet Adherence Screener (MEDAS) and the Alternative Healthy Eating Index (AHEI-2010), with malnutrition among community-dwelling older adults in Spain. Methods Cross-sectional analysis of data from 1921 adults aged ≥ 60 years from the Seniors-ENRICA-1 (SE-1) study, and 2652 adults aged ≥ 65 years from the Seniors-ENRICA-2 (SE-2) study. Habitual food consumption was assessed through a validated diet history. Malnutrition was defined according to the Global Leadership Initiative on Malnutrition (GLIM) phenotypic criteria. Statistical analyses were performed with logistic regression with adjustment for socioeconomic and lifestyle variables as well as for total energy and protein intake. Results The prevalence of malnutrition in the SE-1 study was 9.5% (95% confidence interval: 8.2 to 10.9) and 11.7% (10.5 to 13.9) in the SE-2. Adherence to the MEDAS score was associated with lower prevalence of malnutrition [pooled odds ratio for high (≥ 9 points) vs. low adherence (

Abstract Background Traffic exposure has been associated with biomarkers of increased biological ageing, age-related chronic morbidities, and increased respiratory, cardiovascular, and all-cause mortality. Whether it is associated with functional impairments and unhealthy ageing trajectories is unknown. Methods Nationally representative population-based cohort with 3,126 community-dwelling individuals aged ≥60 years who contributed 8,291 biannual visits over a 10 year period. Unhealthy ageing was estimated with a deficit accumulation index (DAI) based on the number and severity of 52 health deficits, including 22 objectively-measured impairments in physical and cognitive functioning. Differences in DAI at each follow-up across quintiles of residential traffic density (RTD) at 50 and 100 meters, and closest distance to a petrol station, were estimated using flexible marginal structural models with inverse probability of censoring weights. Models were adjusted for sociodemographic and time-varying lifestyle factors, social deprivation index at the census tract and residential exposure to natural spaces. Results At baseline, the mean (SD) age and DAI score of the participants were 69.0 (6.6) years and 17.02 (11.0) %, and 54.0% were women. The median (IQR) RTD at 50 and 100 meters were 77 (31-467) and 509 (182-1802) vehicles/day, and the mean (SD) distance to the nearest petrol station of 962 (1317) meters. The average increase in DAI (95%CI) for participants in quintiles Q2-Q5 (vs Q1) of RTD at 50 meters was of 1.51 (0.50, 2.53), 0.98 (-0.05, 2.01), 2.20 (1.18, 3.21) and 1.98 (0.90, 3.05), respectively. Consistent findings were observed at 100 meters. By domains, most of the deficits accumulated with increased RTD were of a functional nature, although RTD at 50 meters was also associated with worse self-reported health, increased vitality problems and higher incidence of chronic morbidities. Living closer to a petrol station was associated with a higher incidence of functional impairments and chronic morbidities. Conclusions Exposure to nearby residential traffic is associated with accelerated trajectories of unhealthy ageing. Diminishing traffic pollution should become a priority intervention for adding healthy years to life in the old age.

Objectives: Growth differentiation factor 15 (GDF-15) levels increase due to systemic inflammation and chronic disease burden. Since these biological processes are pathogenic factors of malnutrition, we examined the prospective association between GDF-15 serum levels and subsequent malnutrition in older adults. Methods: We used data from 723 women and 735 men aged ≥65 years [mean age (SD): 71.3 (4.18) years] participating in the Seniors-ENRICA-2 cohort, who were followed-up for 2.2 years. Malnutrition was assessed with the Mini Nutritional Assessment-Short form (MNA-SF), where a 12–14 score indicates normal nutritional status, an 8–11 score indicates at risk of malnutrition, and a 0–7 score malnutrition. Associations of GDF-15 and malnutrition were analyzed, separately in women and men, using linear and logistic regression and adjusted for the main potential confounders. Results: The mean (SD) MNA-SF score at baseline was 13.2 (1.34) for women and 13.5 (1.13) for men. Incident malnutrition (combined endpoint “at risk of malnutrition or malnutrition”) over 2.2 years was identified in 55 (9.7%) of women and 38 (5.4%) of men. In women, GDF-15 was linearly associated with a decrease in the MNA-SF score; mean differences (95% confidence interval) in the MNA-SF score were −0.07 (−0.13; −0.01) points per 25% increase in GDF-15, and −0.49 (−0.83; −0.16) for the highest versus lowest quartile of GDF-15. Also in women, GDF-15 was linearly associated with a higher malnutrition incidence, with odds ratio (95% confidence interval) of 1.24 (1.06; 1.46) per 25% increment in GDF-15 and of 3.05 (1.21; 7.65) for the highest versus lowest quartile of GDF-15. Results were similar after excluding subjects with cardiovascular disease and diabetes. No association of GDF-15 with changes in MNA score or malnutrition incidence was found in men. Conclusion: Higher serum GDF-15 concentrations are associated with worsening nutritional status in older women. Further studies should elucidate the reasons for the sex differences in this association and explore the therapeutic potential of modifying GDF-15 to prevent malnutrition.

Abstract Background There is mounting evidence that the Mediterranean diet prevents type 2 diabetes, but little is known about the role of Mediterranean lifestyles other than diet and among non-Mediterranean populations. This work aimed to examine the association between a comprehensive Mediterranean-type lifestyle and type 2 diabetes incidence in a British adult population. Methods We used data from 112,493 individuals free of cardiovascular disease and type 2 diabetes mellitus, aged 40–69 years, from the UK Biobank cohort, who were followed from 2009 to 2010 to 2021. The Mediterranean lifestyle was assessed through the 25-item MEDLIFE index, which comprises three blocks: (a) “Mediterranean food consumption”, (b) “Mediterranean dietary habits”, (c) “Physical activity, rest, social habits, and conviviality”. Diabetes incidence was obtained from clinical records. Cox proportional-hazards regression models were used to analyze associations and adjusted for the main potential confounders. Results After a median follow-up of 9.4 years, 2,724 cases of type 2 diabetes were ascertained. Compared to the first quartile of MEDLIFE adherence, the hazard ratios (95% confidence interval) for increasing quartiles of adherence were 0.90 (0.82–0.99), 0.80 (0.72–0.89) and 0.70 (0.62–0.79) (p-trend

Introduction: The impact of residential green spaces on cardiovascular health in older adults remains uncertain. Methods: Cohort study involving 2114 adults aged ≥ 65 years without cardiovascular disease (CVD), residing in five dense municipalities (Prince et al., 2015) of the Madrid region and with detailed characterization of their socioeconomic background, health behaviors, CVD biological risk factors, and mental, physical, and cognitive health. Greenness exposure was measured using the Normalized Difference Vegetation Index (NDVI) at varying distances from participants' homes. Traffic exposure, neighborhood environment, neighborhood walkability, and socioeconomic deprivation at the census level were also assessed. Serum N-terminal pro-B-type natriuretic peptide (NT-ProBNP), high-sensitivity troponin T (hs-TnT), interleukin 6 (IL-6), and Growth Differentiation Factor 15 (GDF‐15) were measured at baseline, and incident CVD events identified through electronic medical records (International Classification of Primary Care-2 codes K74, K75, K77, K90, and K92). Results: After adjusting for sex, age, educational attainment, financial hardship and socioeconomic deprivation at the census level, an interquartile range (IQR) increase in NDVI at 250, 500, 750, and 1000 m around participants' homes was associated with mean differences in ProBNP of −5.56 % (95 %CI: −9.77; −1.35), −5.05 % (-9.58; −0.53), −4.24 % (-8.19, −0.19), and −4.16 % (-7.59; −0.74), respectively; and mean differences in hs-TnT among diabetic participants of −8.03 % (95 %CI: −13.30; −2.77), −9.52 % (-16.08; −2.96), −8.05 % (-13.94, −2.16) and −5.56 % (-10.75; −0.54), respectively. Of similar magnitude, although only statistically significant at 250 and 500 m, were the observed lower IL-6 levels with increasing greenness. GDF-15 levels were independent of NDVI. In prospective analyses (median follow-up 6.29 years), an IQR increase in residential greenness at 500, 750, and 1000 m was associated with a lower risk of incident CVD. The variables that contributed most to the apparent beneficial effects of greenness on CVD were lower exposure to traffic, improved cardiovascular risk factors, and enhanced physical performance. Additionally, neighborhood walkability and increased physical activity were notable contributors among individuals with diabetes. Conclusion: Increased exposure to residential green space was associated with a moderate reduction in CVD risk in older adults residing in densely populated areas.

AimTo examine the independent relationships of lifestyle and social and economic factors with all-cause and cardiovascular disease (CVD) mortality in a large representative sample of the US adult population. Furthermore, the association between the combination of lifestyle and social and economic factors with mortality was analyzed in detail.MethodsThe sample included 103,314 participants with valid records and eligible for mortality follow-up, and information on lifestyle factors and social and economic disadvantages (NHIS waves 2000, 2005, 2010, and 2015). An unhealthy lifestyle score was constructed using information on physical activity, alcohol consumption, diet, and smoking status. Social and economic disadvantages were assessed using information on education, receipt of dividends, employment, family's home, and access to private health. Information on mortality data was determined by the National Death Index records.ResultsCompared with favorable lifestyle, unfavorable lifestyle was associated with higher all-cause (HR 2.07; 95% CI 1.97–2.19) and CVD (HR 1.84; 95% CI 1.68–2.02) mortality. Higher social and economic disadvantages were also associated with higher all-cause (HR 2.44; 95% CI 2.30–2.59) and CVD mortality (HR 2.44; 95% CI 2.16–2.77), compared to low social and economic disadvantages. In joint associations, participants in the high social and economic disadvantage and unfavorable lifestyle showed a greater risk of all-cause (HR 4.06; 95% CI 3.69–4.47) and CVD mortality (HR 3.98; 95% CI 3.31–4.79).ConclusionLifestyle and social and economic disadvantages are associated with all-cause and CVD mortality. The risk of mortality increases as the number of social and economic disadvantages and unhealthy lifestyles increases.

Objectives: Malnutrition is a global concern in older adults, as it negatively affects morbidity and mortality. While higher animal protein intake may help prevent and treat malnutrition, it might also increase the risk of chronic diseases and death. Conversely, vegetable protein intake might have a lower anabolic effect and not be as effective to improve nutritional status. We studied whether animal and vegetable protein intake are associated with changes in nutritional status in older adults. Design: We used pooled data from two Spanish cohorts: the Seniors-ENRICA 1 and Seniors-ENRICA 2. Settings and participants: 2,965 community-dwelling adults aged 62–92 years. Measurements: Protein intake was estimated at baseline via an electronic, validated diet history. Nutritional status was assessed at baseline and after 2.6 years with the GLIM (Global Leadership Initiative on Malnutrition) phenotypic criteria: weight loss, low body mass index, and reduced muscle mass. The odds of improvements in nutritional status were assessed with logistic regression models, extensively adjusted for potential confounders. Results: Higher animal and vegetable protein intake were associated with improvements in nutritional status [odds ratios (95% confidence intervals) per 0.25 g/kg/day were 1.15 (1.00, 1.32) and 1.77 (1.35, 2.32), respectively]. Cereal protein intake drove most of the latter association [2.07 (1.44, 2.98)]. Replacing 0.25 g/kg/day of total animal protein, meat, or fish protein (but not dairy or egg protein) with vegetable protein was associated with improvements in nutritional status [1.54 (1.13, 2.09), 1.70 (1.20, 2.41), and 1.77 (1.18, 2.64), respectively]. Conclusions: Higher animal and, especially, vegetable protein intake were associated with improvements in nutritional status in older adults. Replacing total animal protein, meat, or fish protein with vegetable protein may help improve malnutrition.

BackgroundDespite the substantial evidence of the relationship between diet and mortality, the role of beverage consumption patterns is not well known. The aim of this study was to assess the association of the adherence to a Healthy Beverage Score (HBS) and all-cause mortality in a representative sample of the Spanish adult population.Methods and findingsWe conducted an observational cohort study using data from the Study on Nutrition and Cardiovascular Risk in Spain (ENRICA), which included 12,161 community-dwelling individuals aged ≥18 years recruited in 2008 to 2010 and followed until January 2022. At baseline, food consumption was collected using a validated diet history. The HBS consists of 7 items, each of which is scored from 1 to 4 (highest adherence). The HBS ranges from 7 to 28 points with a higher score representing a healthier pattern. Adherence was assigned as a higher consumption of low-fat milk, and coffee and tea, a lower consumption of whole-fat milk, no consumption of fruit juice, artificially sweetened beverages, or sugar-sweetened beverages, and no or moderate consumption of alcohol. Total mortality was ascertained by linkage to the Spanish National Death Index. Statistical analyses were performed with Cox models and adjusted for the main confounders, including sociodemographic, lifestyle, dietary variables, and morbidity. After a mean follow-up of 12.5 years (SD: 1.7; range: 0.5 to 12.9), a total of 967 deaths occurred. For all-cause mortality, the fully adjusted hazard ratio (HR) for the highest versus lowest sex-specific quartiles of HBS was 0.72 (95% confidence interval [0.57, 0.91], p linear-trend = 0.015), corresponding to an 8.3% reduction in the absolute risk of death. A linear relationship between the risk of death and the adherence to the HBS was observed using restricted cubic splines. The results were robust to sensitivity analyses. The main limitation was that repeated measurements on beverage consumption were not available and beverage consumption could have changed during follow-up.ConclusionsIn this study, we observed that higher adherence to the HBS was associated with lower total mortality. Adherence to a healthy beverage pattern could play a role in the prevention of premature mortality.

Abstract Background High-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) are biomarkers of myocardial infarction and heart failure, respectively, and indicate cardiovascular risk. Since low physical activity (PA) and sedentary behavior (SB) are also associated with higher cardiovascular risk, and this association could be a consequence of higher levels of cardiac biomarkers, we examined the association of device-measured movement behaviors with hs-cTnT and NT-proBNP in older men and women without major cardiovascular disease (CVD). Methods We used data from 1939 older adults from the Seniors-ENRICA-2 study. Accelerometers were used to assess time spent in sleep, SB, light PA (LPA), and moderate-to-vigorous PA (MVPA). Linear regression models were fitted separately in eight strata defined by sex, by median total PA time, and by the presence of subclinical cardiac damage according to cardiac biomarkers levels. Results In the less active men with subclinical cardiac damage, spending 30 min/day more of MVPA was associated with a mean percentage difference (MPD) (95% confidence interval) in hs-cTnT of − 13.1 (− 18.3, − 7.5); MPDs in NT-proBNP per 30 min/day increment were 5.8 (2.7, 8.9) for SB, − 19.3 (− 25.4, − 12.7) for LPA and − 23.1 (− 30.7, − 14.6) for MVPA. In women with subclinical cardiac damage who were less physically active, 30 min/day more of SB, LPA and MVPA were associated with MPDs in hs-cTnT of 2.1 (0.7, 3.6), − 5.1 (− 8.3, − 1.7) and − 17.5 (− 22.9, − 11.7), respectively, whereas in those more active, LPA and MVPA were associated with MPDs of 4.1 (1.2, 7.2) and − 5.4 (− 8.7, − 2.0), respectively. No associations were found with NT-proBNP in women. Conclusions The relationship between movement behaviors and cardiac biomarkers in older adults without major CVD depends on sex, subclinical cardiac damage and PA level. More PA and less SB were generally related to lower cardiac biomarkers levels among less active individuals with subclinical cardiac damage, with greater benefits for hs-cTnT in women than men and no benefits for NT-proBNP in women.

Abstract Background The Mediterranean diet and other dietary patterns rich in fruits and vegetables have been linked to lower risk of frailty in older adults. However, not all plant‐based diets are necessarily healthful, and no previous study has evaluated the role of the quality of plant‐based dietary patterns in frailty risk. Our aim was to assess the association between plant‐based diet quality and risk of frailty. Methods Prospective cohort consisted with 82 234 women aged ≥60 years from the Nurses' Health Study, who were followed from 1990 through 2014. The dates of analysis were April 14 to June 23, 2021. Dietary data were collected every 4 years using a validated semi‐quantitative food frequency questionnaire. The plant‐based diet quality was assessed with two indices (range 18–90 points): (a) healthful plant‐based diet index (hPDI), where healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils and tea/coffee) received positive scores, while less healthy plant foods (fruit juices, sweetened beverages, refined grains, potatoes, and sweets/desserts) and animal foods received reverse scores; and (b) unhealthful plant‐based diet index (uPDI) where positive scores were given to less healthy plant foods and reverse scores to healthy plant foods and animal foods. Frailty incidence was assessed every 4 years, being defined as having three or more of the following five criteria from the FRAIL scale: fatigue, low strength, reduced aerobic capacity, having ≥5 illnesses and weight loss ≥5%. Multivariable‐adjusted Cox proportional‐hazards models were used to estimate hazard ratios (HRs) and their 95% confidence interval (CI). Results We identified 12 910 incident cases of frailty over 1 176 401 person‐year follow‐up. In the multivariable analysis, the hPDI was inversely associated with the risk of frailty (hazard ratio [HR] for the highest vs. lowest quintile: 0.77, 95% confidence interval: 0.72–0.81; P trend

Abstract Background Frailty and sarcopenia are age‐associated syndromes that have been associated with the risk of several adverse events, mainly functional decline and death, that usually coexist. However, the potential role of one of them (sarcopenia) in modulating some of those adverse events associated to the other one (frailty) has not been explored. The aim of this work is to assess the role of sarcopenia within the frailty transitions and mortality in older people. Methods Data from the Toledo Study of Healthy Aging (TSHA) were used. TSHA is a cohort of community‐dwelling older adults ≥65. Frailty was assessed according with the Frailty Phenotype (FP) and the Frailty Trait Scale‐5 (FTS5) at baseline and at follow‐up. Basal sarcopenia status was measured with the standardized Foundation for the National Institutes of Health criteria. Fisher's exact test and logistic regression model were used to determine if sarcopenia modified the transition of frailty states (median follow‐up of 2.99 years) and Cox proportional hazard model was used for assessing mortality. Results There were 1538 participants (74.73 ± 5.73; 45.51% men) included. Transitions from robustness to prefrailty and frailty according to FP were more frequent in sarcopenic than in non‐sarcopenic participants (32.37% vs. 15.18%, P ≤ 0.001; 5.76% vs. 1.12%; P ≤ 0.001, respectively) and from prefrailty‐to‐frailty (12.68% vs. 4.27%; P = 0.0026). Improvement from prefrail‐to‐robust and remaining robust was more frequent in non‐sarcopenic participants (52.56% vs. 33.80%, P ≤ 0.001; 80.18% vs 61.15%, P ≤ 0.001, respectively). When classified by FTS5, this was also the case for the transition from non‐frail‐to‐frail (25.91% vs. 4.47%, P ≤ 0.001) and for remaining stable as non‐frail (91.25% vs. 70.98%, P ≤ 0.001). Sarcopenia was associated with an increased risk of progression from robustness‐to‐prefrailty [odds ratio (OR) 2.34 (95% confidence interval, CI) (1.51, 3.63); P ≤ 0.001], from prefrailty‐to‐frailty [OR(95% CI) 2.50 (1.08, 5.79); P = 0.033] (FP), and from non‐frail‐to‐frail [OR(95% CI) 4.73 (2.94, 7.62); P‐value ≤ 0.001]. Sarcopenia does not seem to modify the risk of death associated with a poor frailty status (hazard ratios (HR, 95%) P > 0.05). Conclusions Transitions within frailty status, but not the risk of death associated to frailty, are modulated by the presence of sarcopenia.

Abstract Evidence of the role of cooking methods on inflammation and metabolic health is scarce due to the paucity of large-size studies. Our aim was to evaluate the association of cooking methods with inflammatory markers, renal function, and other hormones and nutritional biomarkers in a general population of older adults. In a cross sectional analysis with 2467 individuals aged ≥ 65, dietary and cooking information was collected using a validated face-to-face dietary history. Eight cooking methods were considered: raw, boiling, roasting, pan-frying, frying, toasting, sautéing, and stewing. Biomarkers were analyzed in a central laboratory following standard procedures. Marginal effects from generalized linear models were calculated and percentage differences (PD) of the multivariable-adjusted means of biomarkers between extreme sex-specific quintiles (Q) of cooking methods consumption were computed ([Q5 − Q1/Q1] × 100). Participants’ mean age was 71.6 years (53% women). Significant PD for the highest vs lowest quintile of raw food consumption was − 54.7% for high sensitivity-C reactive protein (hs-CRP), − 11.9% for neutrophils, − 11.9% for Growth Differentiation Factor-15, − 25.0% for Interleukin-6 (IL-6), − 12.3% for urinary albumin, and − 10.3% for uric acid. PD for boiling were − 17.8% for hs-CRP, − 12.4% for urinary albumin, and − 11.3% for thyroid-stimulating hormone. Concerning pan-frying, the PD was − 23.2% for hs-CRP, − 11.5% for IL-6, − 16.3% for urinary albumin and 10.9% for serum vitamin D. For frying, the PD was a 25.7% for hs-CRP, and − 12.6% for vitamin D. For toasting, corresponding figures were − 21.4% for hs-CRP, − 11.1% for IL-6 and 10.6% for vitamin D. For stewing, the PD was 13.3% for hs-CRP. Raw, boiling, pan-frying, and toasting were associated with healthy profiles as for inflammatory markers, renal function, thyroid hormones, and serum vitamin D. On the contrary, frying and, to a less extent, stewing showed unhealthier profiles. Cooking methods not including added fats where healthier than those with added fats heated at high temperatures or during longer periods of time.

Abstract Background Depression and anxiety are the leading mental health problems worldwide; depression is ranked as the leading cause of global disability with anxiety disorders ranked sixth. Preventive strategies based on the identification of modifiable factors merit exploration. The aim of the present study was to investigate the associations of handgrip strength (HGS) with incident depression and anxiety and to explore how these associations differ by socio‐demographic, lifestyle, and health‐related factors. Methods The analytic sample comprised 162 167 participants (55% women), aged 38–70 years, from the UK Biobank prospective cohort study. HGS was assessed at baseline using dynamometry. Depression and anxiety were extracted from primary care and hospital admission records. Cox proportional models were applied, with a 2 year landmark analysis, to investigate the associations between HGS and incident depression and anxiety. Results Of the 162 167 participants included, 5462 (3.4%) developed depression and 6614 (4.1%) anxiety, over a median follow‐up period of 10.0 years (inter‐quartile range: 9.3–10.8) for depression and 9.9 (inter‐quartile range: 9.0–10.8) for anxiety. In the fully adjusted model, a 5 kg lower HGS was associated with a 7% (HR: 1.07 [95% CI: 1.05, 1.10]; P

Frailty is a geriatric syndrome whose frequency is increasing in parallel with population aging and is of great interest due to its dire consequences: increased disability, hospitalizations, falls and fractures, institutionalization, and mortality. Frailty is multifactorial but nutritional factors, which are modifiable, play a crucial role in its pathogenesis. Epidemiologic evidence supports that high-quality dietary patterns can prevent, delay or even reverse the occurrence of frailty. In order to add new knowledge bridging the gap as the main purpose of the present article we performed a comprehensive review of the rationale behind the association of MedDiet with frailty and a systematic review and meta-analysis updating the latest ones published in 2018 specifically examining the relationship of Mediterranean diet (MedDiet) and incident frailty. Adding the updated information, our results confirmed a robust association of a higher adherence to MedDiet with reduced incident frailty. Key components of the MedDiet, i.e., abundant consumption of vegetables and fruit as well as the use of olive oil as the main source of fat, all of which have been associated with a lower incidence of frailty, may help explain the observed benefit. Future well-designed and sufficiently large intervention studies are needed to confirm the encouraging findings of the current observational evidence. Meanwhile, based on the existing evidence, the promotion of MedDiet, a high-quality dietary pattern, adapted to the conditions and traditions of each region, and considering lifelong and person-tailored strategies, is an open opportunity to reduced incident frailty. This could also help counteract the worrying trend towards the spread of unhealthy eating and lifestyle models such as those of Western diets that greatly contribute to the genesis of chronic non-communicable diseases and disability.

Abstract Background There is evidence that an overall healthy diet is associated with lower risk of frailty. However, the effect of diet composition, specifically the role of protein intake on frailty, is mostly unclear. The aim of this study was to evaluate the intake of protein, including total, plant, animal, and dairy protein, in relation to frailty incidence in a large cohort of older women. Methods We analysed data from 85 871 women aged ≥60 participating in the Nurses' Health Study. Intake of protein was measured nine times during follow‐up from 1980 until 2010. Frailty was defined as having at least three of the following five criteria from the Fatigue, Resistance, Ambulation, Illnesses and Loss of Weight (FRAIL) scale: fatigue, low strength, reduced aerobic capacity, having ≥5 illnesses, and weight loss of ≥5%. The occurrence of frailty was assessed every 4 years from 1992 up to 2014. Results During follow‐up, we identified 13 279 incident cases of frailty. Women with a higher intake of plant protein had a lower risk of developing frailty after adjustment for all relevant confounders [relative risks across quintiles of consumption: 1.00, 0.94, 0.89, 0.86, and 0.86; P‐trend

Abstract Background Growth differentiation factor 15 (GDF‐15) is a biomarker for chronic disease burden that might explain the health effects of sedentary behaviours (SBs) and physical activity (PA). We examined associations of device‐measured sleep, SB and PA, and time reallocations among them, with GDF‐15 in older adults. Methods We used data from 2245 older adults participating in the Seniors‐ENRICA‐2 study. Wrist‐worn accelerometers were employed to ascertain total time in sleep, SB, light PA (LPA) and moderate‐to vigorous PA (MVPA). Associations between these activities and serum GDF‐15 levels were analysed using linear regression, including isotemporal substitution models for time reallocations among activities, and adjusted for potential confounders. Analyses were conducted separately in two groups (less active and more active individuals) according to the median total PA time. Results In the less active participants, 30 min/day more of MVPA were related to lower levels of GDF‐15 when replacing sleep (fully adjusted mean percentage differences [95% confidence interval] in GDF‐15 of −9.2% [−13.2, −5.0]), SB (−9.8% [−13.6, −5.8]) and LPA (−5.8% [−11.1, −0.3]), whereas 30 min/day more of LPA were related to lower GDF‐15 when replacing both sleep (−3.6% [−6.1, −1.0]) and SB (−4.2% [−6.7, −1.7]). In the more active participants, 30 min/day more of MVPA were also associated with lower GDF‐15 when replacing sleep (−2.9% [−5.3, −0.3]), SB (−2.4% [−4.6, −0.2]) and LPA (−3.5% [−6.6, −0.3]), but no associations were found for more time in LPA. Spending more time in SB was associated with higher GDF‐15 levels only among those less active (1.9% [0.9, 2.9] per 30 min/day increment). Sleep time did not appear to be associated with GDF‐15. Conclusions The MVPA was inversely associated with GDF‐15, with stronger associations at lower PA volumes. Also, more LPA and less SB time were linked to lower GDF‐15 in the less active individuals. This suggests that simply moving more and sitting less may reduce chronic disease burden in older adults.

Resumen: Objetivo: Explorar la asociación entre la limitación auditiva y la fragilidad social en una muestra de personas mayores de España. Método: Estudio transversal con una muestra de 445 personas (190 hombres y 255 mujeres) de 65 y más años de edad no institucionalizadas, reclutadas de centros de atención primaria en España. La limitación auditiva se determinó de forma autoinformada utilizando tres preguntas. Se consideró que existía fragilidad social cuando la persona presentó dos o más de las siguientes condiciones: vivir solo/a, ausencia de persona que brinde ayuda, contacto infrecuente con la familia, contacto infrecuente con amistades, falta de confidente y falta de ayuda para las actividades cotidianas en los últimos 3 meses. Para estudiar la asociación entre la limitación auditiva y la fragilidad social se realizaron modelos de regresión logística ajustados por posibles factores de confusión, incluyendo la presencia de fragilidad física. Resultados: La edad media de los/las participantes fue de 76,2 años (77,5 años para las mujeres). El 54,4% presentaban limitación auditiva y el 23,2% fueron considerados/as frágiles sociales. La limitación auditiva se asoció con la fragilidad social (odds ratio ajustada [ORa] = 1,78; intervalo de confianza del 95% [IC95%]: 1,04-3,06). No obstante, la asociación fue dependiente del sexo (p de interacción = 0,041) y en los análisis estratificados la asociación solo se halló en las mujeres (ORa = 3,21; IC95%: 1,44-7,17). Conclusiones: La limitación auditiva se asoció con fragilidad social en las mujeres, pero no en los hombres. Se precisan estudios longitudinales que confirmen esta asociación y ayuden a entender el efecto diferencial del sexo. Abstract: Objective: To explore the association between hearing loss and social frailty in a sample of Spanish older adults recruited from primary health care network. Method: Cross-sectional study on a sample of 445 non-institutionalized adults aged 65 or more years (190 men and 255 women), recruited from primary care centers in Spain. Three self-reported hearing impairment questions were used to assess hearing loss. Social frailty was deemed to exist when the person presented two or more of the following conditions: living alone, absence of a person to provide help, infrequent contact with family, infrequent contact with friends, lack of confident and lack of help for daily activities in the last 3 months. To study the association between hearing loss and social frailty we used logistic regression models adjusted for potential confounders, including physical frailty. Results: The mean age of participants was 76.2 years (77.5 years for women). More than half of the participants (54.4%) reported hearing loss and the frequency of social frailty was 23.2%. Hearing loss was associated with social frailty (adjusted odds ratio [aOR] = 1.78; 95% confidence interval [95%CI]: 1.04-3.06). However, the association was sex-dependent (p for interaction = 0.041). In stratified analysis, the association was only found in women (aOR = 3.21; 95%CI: 1.44-7.17). Conclusions: Hearing loss was associated with social frailty in women, but not in men. Longitudinal studies are needed to confirm this association and to understand the differential effect of gender.

Abstract Background Most studies on the effects of sleep, sedentary behavior (SB), and physical activity (PA) on mental health did not account for the intrinsically compositional nature of the time spent in several behaviors. Thus, we examined the cross-sectional and prospective associations of device-measured compositional time in sleep, SB, light PA (LPA) and moderate-to-vigorous PA (MVPA) with depression symptoms, loneliness, happiness, and global mental health in older people (≥ 65 years). Methods Data were taken from the Seniors-ENRICA-2 study, with assessments in 2015–2017 (wave 0) and 2018–2019 (wave 1). Time spent in sleep, SB, LPA and MVPA was assessed by wrist-worn accelerometers. Depression symptoms, loneliness, happiness, and global mental health were self-reported using validated questionnaires. Analyses were performed using a compositional data analysis (CoDA) paradigm and adjusted for potential confounders. Results In cross-sectional analyses at wave 0 (n = 2489), time-use composition as a whole was associated with depression and happiness (all p

Resumen: Objetivo: Describir de forma sistemática las políticas nutricionales escolares de las 17 comunidades autónomas de España. Método: Mediante una búsqueda en bases de datos bibliográficas, páginas web y otros sistemas de información oficiales se localizaron 183 documentos de interés. La información se extrajo de manera sistemática con el cuestionario SNIPE (School Nutrition Index of Programme Effectiveness), adaptado a España, y se validó por personal de referencia de las consejerías de sanidad y educación de las comunidades participantes. Resultados: El principal objetivo de las políticas es prevenir la obesidad y mejorar la nutrición de los escolares. Las 17 comunidades autónomas abordan el servicio de comedor escolar, 11 los servicios de cafetería y las máquinas expendedoras, y 9 el servicio de desayuno. Todas las comunidades usan el Documento de Consenso sobre la Alimentación en los Centros Educativos como referencia para la composición del menú y la calidad nutricional de los productos ofertados en la escuela; sin embargo, solo 4 han regulado estos aspectos por decreto. La frecuencia de evaluación de los objetivos de las políticas varió entre el 58,8% de las comunidades para el suministro alimentario y el 5,9% para la rotación y la calidad de los menús. Conclusión: Aunque todas las comunidades autónomas disponen de estándares para el menú escolar, la cobertura del resto de la oferta alimentaria es variable, la evaluación de objetivos escasa y solo 4 comunidades disponen de normativa de obligado cumplimiento. Los estándares nutricionales deben revisarse según el conocimiento científico actual y aprobarse reglamentariamente, en cumplimiento de la legislación vigente (Ley 17/2011). Abstract: Objective: To systematically describe the school nutritional policies of the 17 autonomous communities of Spain. Method: Through a search of bibliographic databases, web pages and other official information systems, 183 documents of interest were identified. Information was systematically collected with the SNIPE (school nutrition index of programme effectiveness) questionnaire, adapted to Spain, and validated by reference staff of the regional government's health and education ministries. Results: The main objective of the policies is to prevent obesity and improve the nutrition of schoolchildren. The 17 autonomous communities cover the school canteen service, 11 cafeteria and vending machines, and 9 the breakfast service. All communities use the Consensus Document on School Food as a reference for the content of the menu and the nutritional quality of the products offered at the school; however, only 4 of them have regulated these aspects. The evaluation of policy objectives ranges from 58.8% of the autonomous communities for food supply to 5.9% for rotation and menu quality. Conclusion: Although all the autonomous communities have standards for the school menu, the standards for the rest of the food supply vary across them; also, evaluation of objectives is scarce and only 4 communities have approved mandatory regulations. Nutritional standards should be reviewed according to current scientific knowledge and enacted by law, in compliance with the current legislation (Act 17/2011).

Abstract Background The Southern European Atlantic Diet (SEAD) is the traditional diet of Northern Portugal and North-Western Spain. Higher adherence to the SEAD has been associated with lower levels of some cardiovascular risk factors and reduced risk for myocardial infarction, but whether this translates into lower all-cause mortality is uncertain. We hence examined the association between adherence to the SEAD and all-cause mortality in older adults. Methods Data were taken from the Seniors-ENRICA-1 cohort, which included 3165 individuals representative of the non-institutionalized population aged ≥ 60 years in Spain. Food consumption was assessed with a validated diet history, and adherence to the SEAD was measured with an index comprising 9 food components: fresh fish, cod, red meat and pork products, dairy products, legumes and vegetables, vegetable soup, potatoes, whole-grain bread, and wine. Vital status was ascertained with the National Death Index of Spain. Statistical analyses were performed with Cox regression models and adjusted for the main confounders. Results During a median follow-up of 10.9 years, 646 deaths occurred. Higher adherence to the SEAD was associated with lower all-cause mortality (fully adjusted hazard ratio [95% confidence interval] per 1-SD increment in the SEAD score 0.86 [0.79, 0.94]; p-trend

Abstract Elevated concentrations of acylcarnitines have been associated with higher risk of obesity, type 2 diabetes and cardiovascular disease. The aim of the present study was to assess the association between L-carnitine and acylcarnitine profiles, and 2-year risk of incident lower-extremity functional impairment (LEFI). This case–control study is nested in the Seniors-ENRICA cohort of community-dwelling older adults, which included 43 incident cases of LEFI and 86 age- and sex- matched controls. LEFI was assessed with the Short Physical Performance Battery. Plasma L-carnitine and 28 acylcarnitine species were measured. After adjusting for potential confounders, medium-chain acylcarnitines levels were associated with 2-year incidence of LEFI [odds ratio per 1-SD increase: 1.69; 95% confidence interval: 1.08, 2.64; p = 0.02]. Similar results were observed for long-chain acylcarnitines [odds ratio per 1-SD increase: 1.70; 95% confidence interval: 1.03, 2.80; p = 0.04]. Stratified analyses showed a stronger association between medium- and long-chain acylcarnitines and incidence of LEFI among those with body mass index and energy intake below the median value. In conclusion, higher plasma concentrations of medium- and long-chain acylcarnitines were associated with higher risk of LEFI. Given the role of these molecules on mitochondrial transport of fatty acids, our results suggest that bioenergetics dysbalance contributes to LEFI.

Abstract Plasma fibrinogen predicts cardiovascular and nonvascular mortality. However, there is limited population-based evidence on the association between fibrinogen levels and dietary intakes of micronutrients possibly associated with inflammation status. Data were taken from the ENRICA study, conducted with 10,808 individuals representative of the population of Spain aged ≥ 18 years. Nutrient intake (vitamin A, carotenoids, vitamin B6, vitamin C, vitamin D, vitamin E, magnesium, selenium, zinc and iron) was estimated with a validated diet history, and plasma fibrinogen was measured under appropriate quality checks. Statistical analyses were performed with linear regression and adjusted for main confounders. The geometric means of fibrinogen (g/L) across increasing quintiles of nutrient intake were 3.22, 3.22, 3.22, 3.16, and 3.19 (p-trend = 0.030) for vitamin E; 3.23, 3.22, 3.20, 3.19, and 3.19 (p-trend = 0.047) for magnesium; and 3.24, 3.22, 3.19, 3.21, and 3.19 (p-trend = 0.050) for iron. These inverse associations were more marked in participants with abdominal obesity and aged ≥ 60 years, but lost statistical significance after adjustment for other nutrients. Although dietary intakes of vitamin E, magnesium and iron were inversely associated with fibrinogen levels, clinical implications of these findings are uncertain since these results were of very small magnitude and mostly explained by intake levels of other nutrients.

OBJECTIVES This study investigated the associations of chronic diseases with changes in lifestyle and health behaviours in older people following the coronavirus disease 2019 (COVID-19) lockdown in Spain and compared the differences in changes over time. METHODS 1,092 participants (80.3±5.6 years; 66.5% female) from 2 Spanish cohorts were included. Telephone-based questionnaires were conducted to evaluate lifestyle and health risk behaviours at the end of lockdown and 7 months post-lockdown. Participants were classified as having physician-diagnosed chronic diseases based on self-reported data. Cox proportional models adjusted for major confounders were used. RESULTS Compared to those without the corresponding chronic diseases, older people with hypertension were less likely to report increased alcohol consumption (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.55 to 0.99). Pulmonary diseases were associated with lower risks of increased sedentary time (HR, 0.58; 95% CI, 0.39 to 0.86) and worsened sleep quality (HR, 0.56; 95% CI, 0.36 to 0.87), while cardiovascular diseases were associated with a lower risk of decreased sedentary time (HR, 0.58; 95% CI, 0.38 to 0.88). Depression was linked to a higher likelihood of improved diet quality (HR, 1.53; 95% CI, 1.00 to 2.36). Cancer pacients were less likely to have worsened sleep quality (HR, 0.44; 95% CI, 0.22 to 0.89) but more likely to have reduced their frequency of social contact (HR, 2.05; 95% CI, 1.05 to 3.99). CONCLUSIONS Older people with chronic diseases showed beneficial changes in lifestyle and health risk behaviours after the COVID-19 lockdown. In particular, older people with hypertension, pulmonary disease, and cancer tended to make beneficial lifestyle and health behaviour changes. However, older people with cardiovascular disease and depression engaged in more health risk behaviours.

Resumen: Introducción: En España, un tercio de los menores y dos tercios de los adultos padecen exceso de peso, una condición que genera un sobrecoste médico directo de 2000 millones de euros. El entorno alimentario obesogénico causa obesidad al promover el consumo de bebidas azucaradas y de alimentos ultraprocesados. Por ello, proponemos cinco políticas prioritarias con el PODER de revertir la epidemia de obesidad y de enfermedades no transmisibles asociadas a ella, mediante la creación de entornos alimentarios saludables. El PODER de las políticas alimentarias: P (Publicidad): regulación de la publicidad de alimentos y bebidas no saludables dirigida a menores por todos los medios y prohibición de patrocinios de congresos o eventos deportivos y avales de asociaciones científicas o profesionales de la salud. O (Oferta): promoción de una oferta 100% saludable en máquinas expendedoras de centros educativos, sanitarios y deportivos.D (Demanda): implantación de un impuesto, al menos del 20%, a las bebidas azucaradas, acompañado de subvenciones o bajadas de impuestos a alimentos saludables y disponibilidad de agua potable a coste cero en todos los centros y espacios públicos. E (Etiquetado): aplicación efectiva del Nutri-Score mediante el uso de incentivos, regulación y mecanismos de contratación pública. R (Reformulación): reformular los acuerdos de reformulación con la industria con objetivos más ambiciosos y de obligado cumplimiento. Reflexión final: Las cinco intervenciones propuestas, aplicadas con éxito en otros países, contribuirán a concienciar a la población y tendrán un impacto positivo en la salud y en la economía, por una reducción de los costes sanitarios de la obesidad y un aumento de la productividad laboral. Estas medidas deberían formar parte de una gran transformación del sistema alimentario, con políticas agroalimentarias que fomenten una producción sostenible de alimentos saludables. Abstract: Introduction: In Spain, one third of all children and two-thirds of adults suffer from excess weight, a condition that generates a direct excess medical cost of 2000 million Euros. Obesogenic food environments cause obesity by promoting the consumption of sugar-sweetened beverages and ultra-processed foods. Accordingly, we propose five priority policies capable of reversing the epidemic of obesity and related non-communicable diseases through the creation of healthy food environments. The power (PODER in Spanish) of food policies: Advertising (Publicidad): regulation of unhealthy food and drink advertisements carried by all media and targeted at children, and prohibition of sponsorships of congresses, conferences or sports events and endorsements by scientific associations or health professionals. Supply (Oferta): promotion of a 100% healthy supply of goods on sale in vending machines sited at educational, health and sports centres. Demand (Demanda): levying a tax of at least 20% on sugar-sweetened beverages, accompanied by subsidies or reduced taxes on healthy foods and availability of drinking water free of charge at all public venues and areas. Labelling (Etiquetado): effective application of the Nutri-Score through the use of incentives, regulation and public-tender mechanisms. Reformulation (Reformulación): revising and redrawing reformulation agreements with the industry, setting more ambitious goals and mandatory compliance. A final thought: These five proposed interventions, all of which have been successfully applied in other countries, will serve to raise population awareness and have a positive impact on health and the economy, through reducing the health care costs of obesity and enhancing work productivity. These measures should form part of a wide-ranging transformation of the food system, with agri-food policies that foster the sustainable production of healthy foods. Palabras clave: Política alimentaria, Impuestos, Publicidad alimentaria, Etiquetado alimentario, Obesidad, Enfermedades no transmisibles, Keywords: Food policy, Taxes, Food advertising, Food labelling, Obesity, Non-transmissible diseases

Abstract Background Optimal type 1 diabetes mellitus (T1D) care requires lifelong appropriate insulin treatment, which can be provided either by multiple daily injections (MDI) of insulin or by continuous subcutaneous insulin infusion (CSII). An increasing number of trials and previous systematic reviews and meta-analyses (SRMA) have compared both CSII and MDI but have provided limited information on equity and fairness regarding access to, and the effect of, those insulin devices. This study protocol proposes a clear and transparent methodology for conducting a SRMA of the literature (1) to assess the effect of CSII versus MDI on glycemic and patient-reported outcomes (PROs) among young patients with T1D and (2) to identify health inequalities in the use of CSII. Methods This protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P), the PRISMA-E (PRISMA-Equity 2012 Guidelines), and the Cochrane Collaboration Handbook. We will include randomized clinical trials and non-randomized studies published between January 2000 and June 2019 to assess the effectiveness of CSII versus MDI on glycemic and PROs in young patients with T1D. To assess health inequality among those who received CSII, we will use the PROGRESS framework. To gather relevant studies, a search will be conducted in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews, and the Health Technology Assessment (HTA) database. We will select studies that compared glycemic outcomes (the glycosylated hemoglobin values, severe hypoglycemia episodes, diabetic ketoacidosis events, and/or time spent in range or in hyper-hypoglycemia), and health-related quality of life, as a PRO, between therapies. Screening and selection of studies will be conducted independently by two researchers. Subgroup analyses will be performed according to age group, length of follow-up, and the use of adjunctive technological therapies that might influence glycemic outcomes. Discussion Studies of the average effects of CSII versus MDI may have not assessed their impact on health equity, as some intended populations have been excluded. Therefore, this study will address health equity issues when assessing effects of CSII. The results will be published in a peer-review journal. Ethics approval will not be needed. Systematic review registration PROSPERO CRD42018116474

Abstract Background To estimate the relationship of the degree of urbanization to cardiovascular mortality and to risk behaviours before, during and after the 2008 economic crisis in Spain. Methods In three areas of residence – large urban areas, small urban areas and rural areas – we calculated the rate of premature mortality (0–74 years) from cardiovascular diseases before the crisis (2005–2007), during the crisis (2008–2010 and 2011–2013) and after the crisis (2014–2016), and the prevalence of risk behaviours in 2006, 2011 and 2016. In each period we estimated the mortality rate ratio (MRR) and the prevalence ratio, taking large urban areas as the reference. Results In men, no significant differences were observed in mortality between the two urban areas, while the MRR in rural areas went from 0.92 [95% confidence interval, 0.90–0.94) in 2005–2007 to 0.94 (0.92–0.96) in 2014–2016. In women, no significant differences were observed in mortality between the rural and large urban areas, whereas the MRR in small urban areas decreased from 1.11 (1.08–1.14) in 2005–2007 to 1.06 (1.02–1.09) in 2014–2016. The rural areas had the lowest prevalence of smoking, obesity and physical inactivity in men, and of obesity in women. No significant differences were observed in smoking or physical inactivity by area of residence in women. Conclusion The pattern of cardiovascular mortality by degree of urbanization was similar before and after the crisis, although in women the excess mortality in small urban areas with respect to large urban areas was smaller after the crisis. The different pattern of risk behaviours in men and women, according to area of residence, could explain these findings.

Resumen: Objetivo: Cuantificar el impacto de reducir el consumo de carnes rojas y procesadas sobre la mortalidad cardiovascular y la mortalidad total de la población adulta española, basado en 5 revisiones publicadas. Participantes y mediciones principales: Se define la exposición como el consumo de ≥ 3 raciones/semana de carnes rojas o procesadas, y se consideran cuatro escenarios de población expuesta (30-60%). Con datos del Instituto Nacional de Estadística, se calcula la mortalidad ponderada en población española de 40-80 años y, utilizando los riesgos relativos (RR) y los intervalos de confianza (IC) al 95% publicados en 5 revisiones (RR = 0,88; IC 95%: 0,84-0,93 para mortalidad por todas las causas y RR = 0,92; IC 95%: 0,90-0,93 para la mortalidad cardiovascular), se calculó la tasa de mortalidad en expuestos y no expuestos. Multiplicando esas tasas por el número de expuestos, se obtuvo el número de muertes atribuibles. Resultados: Asumiendo un 60% de población española de 40-80 años expuesta, el número de muertes anuales de causa cardiovascular que se podrían evitar consumiendo

BackgroundConsumption of sugar-sweetened beverages (SSBs) has been consistently associated with a higher risk of obesity, type 2 diabetes, cardiovascular disease, and premature mortality, whereas evidence for artificially sweetened beverages (ASBs) and fruit juices on health is less solid. The aim of this study was to evaluate the consumption of SSBs, ASBs, and fruit juices in association with frailty risk among older women.Methods and findingsWe analyzed data from 71,935 women aged ≥60 (average baseline age was 63) participating in the Nurses' Health Study (NHS), an ongoing cohort study initiated in 1976 among female registered nurses in the United States. Consumption of beverages was derived from 6 repeated food frequency questionnaires (FFQs) administered between 1990 and 2010. Frailty was defined as having at least 3 of the following 5 criteria from the FRAIL scale: fatigue, poor strength, reduced aerobic capacity, having ≥5 chronic illnesses, and weight loss ≥5%. The occurrence of frailty was assessed every 4 years from 1992 to 2014. During 22 years of follow-up, we identified 11,559 incident cases of frailty. Consumption of SSBs was associated with higher risk of frailty after adjustment for diet quality, body mass index (BMI), smoking status, and medication use, specifically, the relative risks (RRs) and 95% confidence interval (95% CI) for ≥2 serving/day versus no SSB consumption was 1.32 (1.10, 1.57); p-value ConclusionsIn this study, we observed that consumption of SSBs and ASBs was associated with a higher risk of frailty. However, orange juice intake showed an inverse association with frailty. These results need to be confirmed in further studies using other frailty definitions.

Summary: Background: The rapid growth of the size of the older population is having a substantial effect on health and social care services in many societies across the world. Maintaining health and functioning in older age is a key public health issue but few studies have examined factors associated with inequalities in trajectories of health and functioning across countries. The aim of this study was to investigate trajectories of healthy ageing in older men and women (aged ≥45 years) and the effect of education and wealth on these trajectories. Methods: This population-based study is based on eight longitudinal cohorts from Australia, the USA, Japan, South Korea, Mexico, and Europe harmonised by the EU Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) consortium. We selected these studies from the repository of 17 ageing studies in the ATHLOS consortium because they reported at least three waves of collected data. We used multilevel modelling to investigate the effect of education and wealth on trajectories of healthy ageing scores, which incorporated 41 items of physical and cognitive functioning with a range between 0 (poor) and 100 (good), after adjustment for age, sex, and cohort study. Findings: We used data from 141 214 participants, with a mean age of 62·9 years (SD 10·1) and an age range of 45–106 years, of whom 76 484 (54·2%) were women. The earliest year of baseline data was 1992 and the most recent last follow-up year was 2015. Education and wealth affected baseline scores of healthy ageing but had little effect on the rate of decrease in healthy ageing score thereafter. Compared with those with primary education or less, participants with tertiary education had higher baseline scores (adjusted difference in score of 10·54 points, 95% CI 10·31–10·77). The adjusted difference in healthy ageing score between lowest and highest quintiles of wealth was 8·98 points (95% CI 8·74–9·22). Among the eight cohorts, the strongest inequality gradient for both education and wealth was found in the Health Retirement Study from the USA. Interpretation: The apparent difference in baseline healthy ageing scores between those with high versus low education levels and wealth suggests that cumulative disadvantage due to low education and wealth might have largely deteriorated health conditions in early life stages, leading to persistent differences throughout older age, but no further increase in ageing disparity after age 70 years. Future research should adopt a lifecourse approach to investigate mechanisms of health inequalities across education and wealth in different societies. Funding: European Union Horizon 2020 Research and Innovation Programme.

IntroductionFirst study of social inequalities in tobacco-attributable mortality (TAM) in Spain considering the joint influence of sex, age, and education (intersectional perspective).MethodsData on all deaths due to cancer, cardiometabolic and respiratory diseases among people aged ≥35 years in 2016 were obtained from the Spanish Statistical Office. TAM was calculated based on sex-, age- and education-specific smoking prevalence, and on sex-, age- and disease-specific relative risks of death for former and current smokers vs lifetime non-smokers. As inequality measures, the relative index of inequality (RII) and the slope index of inequality (SII) were calculated using Poisson regression. The RII is interpreted as the relative risk of mortality between the lowest and the highest educational level, and the SII as the absolute difference in mortality.ResultsThe crude TAM rate was 55 and 334 per 100,000 in women and men, respectively. Half of these deaths occurred among people with the lowest educational level (27% of the population). The RII for total mortality was 0.39 (95%CI: 0.35-0.42) in women and 1.61 (95%CI: 1.55-1.67) in men. The SII was -41 and 111 deaths per 100,000, respectively. Less-educated women aged ConclusionsTAM is inversely associated with educational level in men and younger women, and directly associated with education in older women. This could be explained by different smoking patterns. Appropriate tobacco control policies should aim to reduce social inequalities in TAM.

Resumen: Introducción: La enfermedad renal crónica (ERC) constituye un problema de salud pública a nivel mundial. Los objetivos de este estudio fueron estimar la prevalencia de ERC en España y evaluar el impacto de la acumulación de factores de riesgo cardiovascular (FRCV) en la prevalencia. Material y métodos: Análisis del Estudio de Nutrición y Riesgo Cardiovascular en España (ENRICA), estudio epidemiológico de ámbito nacional, de base poblacional, con una muestra de 11.505 sujetos representativos de la población adulta española. La información se recogió mediante cuestionarios estandarizados, exploración física y colección de muestras de sangre y orina que se analizaron en un laboratorio centralizado. La ERC se definió según las guías KDIGO en curso. Se analizó la relación de la ERC con 10 FRCV (edad, hipertensión arterial, obesidad, obesidad abdominal, tabaquismo, colesterol LDL elevado, colesterol HDL disminuido, hipertrigliceridemia, diabetes y sedentarismo. Resultados: La prevalencia de ERC fue del 15,1% (IC 95%: 14,3-16,0). La ERC fue más frecuente en varones (23,1% vs. 7,3% en mujeres), según aumentaba la edad (4,8% en sujetos de 18-44 años, 17,4% en sujetos de 45-64 años, y 37,3% en sujetos ≥ 65 años), y en sujetos con enfermedad cardiovascular (39,8% vs. 14,6% en sujetos sin enfermedad cardiovascular); todas las comparaciones con p

Background: Chronic kidney disease (CKD) is a public health problem worldwide. We aimed to estimate the CKD prevalence in Spain and to examine the impact of the accumulation of cardiovascular risk factors (CVRF). Material and methods: We performed a nationwide, population-based survey evaluating 11,505 individuals representative of the Spanish adult population. Information was collected through standardized questionnaires, physical examination, and analysis of blood and urine samples in a central laboratory. CKD was graded according to current KDIGO definitions. The relationship between CKD and 10 CVRF was assessed (age, hypertension, general obesity, abdominal obesity, smoking, high LDL-cholesterol, low HDL-cholesterol, hypertriglyceridemia, diabetes and sedentary lifestyle). Results: Prevalence of CKD was 15.1% (95% CI: 14.3–16.0%). CKD was more common in men (23.1% vs. 7.3% in women), increased with age (4.8% in 18–44 age group, 17.4% in 45–64 age group, and 37.3% in ≥65), and was more common in those with than those without cardiovascular disease (39.8% vs. 14.6%); all P

Objective: To describe the nutritional content of products offered in food and drink vending machines at secondary schools in the Madrid Autonomous Community (Spain), and to evaluate these items’ adherence to the nutritional recommendations of the National Health System Consensus Document on School Food. Methods: Cross-sectional study of a sample of 330 secondary schools in Madrid across the period 2014-2015. Secondary school vending machines were identified by telephone interview. The products offered in a representative sample of six machines were identified by inspection in situ, and their nutritional composition was obtained from the labelling. Results: A total of 94.5% of the 55 products on offer failed to comply with at least one nutritional criterion of the Consensus Document on School Food. The recommendation relating to sugar content registered the highest level of non-compliance, with 52.7% of products, followed by the recommendations relating to energy (47.3%) and fats (45.5%). The mean number of unmet criteria was 2.2, with this figure being higher in foods than in drinks (2.8 versus 1; p

Abstract Background Meat is an important source of high-quality protein and vitamin B but also has a relatively high content of saturated and trans fatty acids. Although protein and vitamin B intake seems to protect people from functional limitations, little is known about the effect of habitual meat consumption on physical function. The objective of this study was to examine the prospective association between the intake of meat (processed meat, red meat, and poultry) and physical function impairment in older adults. Methods Data were collected for 2982 participants in the Seniors-ENRICA cohort, who were aged ≥60 years and free of physical function impairment. In 2008–2010, their habitual diet was assessed through a validated computer-assisted face-to-face diet history. Study participants were followed up through 2015 to assess self-reported incident impairment in agility, mobility, and performance-based lower-extremity function. Results Over a median follow-up of 5.2 years, we identified 625 participants with impaired agility, 455 with impaired mobility, and 446 with impaired lower-extremity function. After adjustment for potential confounders, processed meat intake was associated with a higher risk of impaired agility (hazard ratio [HR] for highest vs. lowest tertile: 1.33; 95% confidence interval [CI]: 1.08–1.64; p trend = 0.01) and of impaired lower-extremity function (HR for highest vs. lowest tertile: 1.31; 95% CI: 1.02–1.68; p trend = 0.04). No significant associations were found for red meat and poultry. Replacing one serving per day of processed meat with one serving per day of red meat, poultry, or with other important protein sources (fish, legumes, dairy, and nuts) was associated with lower risk of impaired agility and lower-extremity function. Conclusions A higher consumption of processed meat was associated with a higher risk of impairment in agility and lower-extremity function. Replacing processed meat by other protein sources may slow the decline in physical functioning in older adults.

Abstract Background Sedentariness is an important risk factor for poor health. The main objective of this work was to examine the prospective association between television viewing time and indicators of physical function, mobility, agility, and frailty. Methods Data came from two independent cohorts of community-dwelling older adults: the Seniors-ENRICA (n = 2392, 3.5 year follow-up), and the ELSA (n = 3989, 3.9 year follow-up). At baseline, television viewing and other sedentary behaviors were ascertained using interviewer-administered questionnaires. In the Seniors-ENRICA cohort overall physical function at baseline and follow-up was assessed using the physical component summary (PCS) of the SF-12 Health Survey. Measures for incident mobility and agility limitations in both cohorts were based on standardized questions, and incident frailty was measured with the Fried criteria. Analyses were adjusted for the main confounders, including physical activity at baseline. Results across cohorts were pooled using a random effects model. Results Lower (worse) scores in the PCS were observed among those in the highest (vs. the lowest) tertile of television viewing time (b-coefficient:-1.66; 95% confidence interval:-2.81,-0.52; p-trend = 0.01). Moreover, the pooled odds ratios (95% CIs) for mobility limitations for the second and third (vs. the lowest) tertile of television viewing were 1.00 (0.84, 1.20) and 1.17 (1.00, 1.38); p-trend = 0.12, respectively. The corresponding results for agility limitations were 1.18 (0.97, 1.44) and 1.25 (1.03, 1.51); p-trend = 0.02. Results for incident frailty were 1.10 (0.80, 1.51) and 1.47 (1.09, 1.97); p-trend = 0.03. No association between other types of sedentary behavior (time seated at the computer, while commuting, lying in the sun, listening to music/reading, internet use) and risk of functional limitations was found. Conclusions Among older adults, longer television viewing time is prospectively associated with limitations in physical function independently of physical activity.

Introducción: las raciones de consumo son cantidades estándares de alimentos o bebidas sugeridas para asesorar sobre la cantidad de alimento a consumir para preservar un estado de salud adecuado. El objetivo principal de este trabajo es establecer los tamaños de ración de consumo de frutas y hortalizas (FH) para uso en guías alimentarias. Material y métodos: Se adaptó la metodología de la United States Department of Agriculture (USDA) para el establecimiento de los tamaños de ración de consumo para guías, y la del sistema de Intercambios. Se recopilaron datos de porción reportados en encuestas y calibres comunes en el mercado, se ajustó a cantidades de alimento fácilmente reconocibles y con equivalencia de nutrientes clave y se evaluó el grado de cumplimiento de los objetivos de salud pública para el consumo de FH. Resultados: Los tamaños de porción típicamente reportados en encuestas españolas son escasos y poco homogéneos, y no se encontraron datos publicados en revistas científicas sobre los calibres. Las guías alimentarias españolas, a pesar de mostrar un rango de tamaño de ración para FH no aseguran que sean intercambiables ni especifican el método para llegar a las mismas. La ración de hortalizas obtenida ha sido de 139,44 g (DS:±21,98; CV:0,16), de 137,68 g (DS:±49,61; CV:0,36) para frutas y 28,00g (DS:±7,53; CV:0,27) para frutas desecadas. Conclusiones: Con las raciones establecidas, el mensaje “consume al menos 5 raciones entre FH al día” permitiría alcanzar los objetivo de Salud Pública para FH establecidos en 600 g (peso neto)/persona/día. Se recomienda a la Agencia Española de Consumo, Seguridad Alimentaria y Nutrición (AECOSAN) que use esta misma metodología para el establecimiento de raciones en el resto de grupos de alimentos que configuran la Guía Dietética Basada en Alimentos para la población española.

Background: Inflammatory bowel disease (IBD) is associated with a considerable burden to the patient and society. However, current data on IBD incidence and burden are limited because of the paucity of nationwide epidemiological studies, heterogeneous designs, and a low number of participating centers and sample size. The EpidemIBD study is a large-scale investigation to provide an accurate assessment of the incidence of IBD in Spain, as well as treatment patterns and outcomes. Methods: This multicenter, population-based incidence cohort study included patients aged >18 years with IBD (Crohn’s disease, ulcerative colitis, or unclassified IBD) diagnosed during 2017 in 108 hospitals in Spain, covering 50% of the Spanish population. Each participating patient will attend 10 clinic visits during 5 years of follow up. Demographic data, IBD characteristics and family history, complications, treatments, surgeries, and hospital admissions will be recorded. Results: The EpidemIBD study is the first large-scale nationwide study to investigate the incidence of IBD in Spain. Enrollment is now completed and 3627 patients are currently being followed up. Conclusions: The study has been designed to overcome many of the limitations of previous European studies into IBD incidence by prospectively recruiting a large number of patients from all regions of Spain. In addition to epidemiological information about the burden of IBD, the 5-year follow-up period will also provide information on treatment patterns, and the natural history and financial burden of IBD.

Fundamento: Las políticas restrictivas del acceso a bebidas azucaradas y alimentos no saludables en el entorno escolar se asocian con patrones de consumo más saludables. En 2010 se aprobó en España el Documento de Consenso sobre la Alimentación en los Centros Educativos con criterios nutricionales para mejorar el perfil nutricional de los alimentos y bebidas ofertados. El objetivo de este estudio fue describir la frecuencia de máquinas expendedoras de bebidas y alimentos y perfil nutricional de sus productos en los Institutos de Enseñanza Secundaria (IES) de Madrid. Métodos: Estudio transversal sobre una muestra aleatoria de 330 IES de la Comunidad de Madrid durante el curso 2014-2015. A través de internet y por entrevista telefónica se registraron las características de los centros y la existencia o no de máquinas expendedoras en ellos. Los productos ofertados en una muestra representativa de 6 máquinas expendedoras se obtuvieron mediante inspección in situ y su composición nutricional se tomó del etiquetado. Por último, el perfil nutricional de los productos se analizó con el modelo del Reino Unido, que clasifica los productos en saludables y menos saludables. Resultados: La prevalencia de máquinas expendedoras fue del 17,3%. El 80,5% de sus productos fueron menos saludables, altamente energéticos, ricos en grasa o azúcar y pobres en micronutrientes. El 10,5% resultaron ser productos saludables. Conclusión: Las máquinas expendedoras son frecuentes en los IES de Madrid y la mayoría de sus productos tienen un mal perfil nutricional.

Objective: The aim of this study was to examine the independent and combined associations of physical activity (PA) and sitting time (ST) with long-term mortality attributed to inflammatory causes other than cardiovascular disease (CVD) and cancer in a national cohort of older adults in Spain.Design: Prospective study.Setting and Participants: A cohort of 3,677 individuals (1,626 men) aged ≥60 years was followed-up during 14.3 years.Measures: At baseline, individuals reported PA and ST. The study outcome was death from inflammatory diseases when CVD or cancer mortality was excluded. This outcome was classified into infectious and non-infectious conditions. Analyses were performed with Cox regression and adjusted for PA, ST, and other main confounders (age, sex, educational level, smoking, alcohol consumption, body mass index, and chronic conditions).Results: During follow-up, 286 deaths from inflammatory diseases (77 from infectious diseases) were identified. Compared to individuals who defined themselves as inactive/less active, mortality from inflammatory diseases was lower in those who were moderately active (hazard ratio [HR] = 0.67, 95% confidence interval [CI] = 0.50–0.90) or very active (HR = 0.48, 95%CI = 0.33–0.68), independently of ST. Also, being seated ≥7 h/d vs.

The present study examined the relationship between indicators of social capital and health-related behaviors. A cross-sectional study was conducted on a sample of 1,062 participants representative of the population aged 40 years or older from a city in Southern Brazil. The following indicators of social capital were examined: number of friends, number of people they could borrow money from when in need; extent of trust in community members; number of times members of the community help each other; community safety; and extent of membership in community activities. Also, an overall score of social capital including all indicators was calculated. A poor social capital was associated with insufficient leisure-time physical activity (OR = 1.70; 95%CI: 1.07-2.70), low consumption of fruits and vegetables (OR = 1.53; 95%CI: 1.05-2.24), and smoking (OR = 1.97; 95%CI: 1.21-3.21). No clear association was found between capital social and binge drinking. A score of social capital showed an inverse relationship with the number of prevalent risk behaviors (p < 0.001). These results reinforce that policies to promote health should consider social capital.

[This corrects the article DOI: 10.1371/journal.pone.0170513.].

Watching TV has been consistently associated with higher risk of adverse health outcomes, but the effect of other sedentary behaviors (SB) is uncertain. Potential explanations are that watching TV is not a marker of a broader sedentary pattern and that each SB reflects different sociodemographic and health characteristics. Data were taken form a survey on 10,199 individuals, representative of the Spanish population aged ≥18 years. SB and other health behaviors were ascertained using validated questionnaires. Watching TV was the predominant SB (45.4% of the total sitting time), followed by sitting at the computer (22.7%). TV watching time showed no correlation with total time on other SB (r: -0.02, p = 0.07). By contrast, time spent at the computer was directly correlated with time spent on commuting (r: 0.07, p

Combined exposure to several healthy behaviors (HB) is associated with reduced mortality in older adults but its impact on health-related quality of life (HRQL) is uncertain. This is a cohort study of 2,388 individuals aged ≥60 recruited in 2000-2001, whose data were updated in 2003 and 2009. At baseline, participants reported both traditional HB (non-smoking, being very or moderately active, healthy diet) and non-traditional HB (sleeping 7-8 h/d, being seated

Fundamentos: La transición “epidemiológica” de la población inmigrante en el mundo, y en particular en España, es insuficientemente comprendida, tanto porque la morbimortalidad es multicausal como por las limitaciones de información sobre los estilos de vida de los inmigrantes. Por ello, el objetivo de este trabajo fue conocer los factores de riesgo conductuales y biológicos de la enfermedad cardiometabólica en la población inmigrante en España. Métodos: Revisión de conjunto de la literatura publicada durante el periodo 1998-2012. Se seleccionaron artículos en español o inglés, con participantes de Latinoamérica, África, Asia y Europa del Este o que cumplieran la definición de inmigrante de la Organización Internacional de Migraciones. La búsqueda bibliográfica se realizó en Medline y MEDES. Resultados: Se identificaron 117 artículos de los que seleccionaron16. 13 de ellos se publicaron desde 2009. 15 fueron estudios transversales y uno un ensayo no randomizado. 5 se realizaron en población general, 7 con muestras de pacientes y 4 en ámbitos mixtos (comunitario y clínico). En 9 estudios el tamaño muestral fue menor de 500 personas y 15usaron muestras locales o regionales. 13 artículos estudiaron la alimentación y el estado nutricional de los inmigrantes pero hubo mucha heterogeneidad de objetivos y resultados. Algunos estudios mostraban que lafrecuencia de obesidad es mayor en población inmigrante que en la originaria de España, que la duración de la residencia en España no se asociaba con la obesidad y que los inmigrantes consumían menos tabaco y alcohol y realizaban menos actividad física que las personas nacidas enEspaña. Conclusiones: La producción científica sobre estilos de vida y factores de riesgo cardiometabólico en inmigrantes en España es reciente y escasa, por lo que no permite conocer suficientemente el perfil de riesgo de esta población.

Objective: This work examines the trend in obesity and abdominal obesity in the Spanish population aged 60 years and over during the first decade of the 21st century. Methods: We analyze data from a representative study of the Spanish population aged 60 years and older conducted in 2000-2001 and from the Study on Nutrition and Cardiovascular Risk in Spain (ENRICA) conducted in 2008-2010. Results: In men, the distribution of BMI did not vary in the period 2000-2010. In contrast, in women there was a reduction in both mean BMI - from 29.3 to 28.8 kg/m2 - and the prevalence of obesity - from 40.8 to 36.3%. This decline was greatest in women aged 60-69 years. In men, no significant changes were observed in mean waist circumference (WC) or in the prevalence of abdominal obesity. In contrast, WC decreased by 3.6 cm and abdominal obesity prevalence by 12.7% in women. The decline was greatest in women aged 60-69 years, in whom mean WC decreased by 5.1 cm and abdominal obesity prevalence by 18.6%. Conclusion: These findings show that the frequency of obesity has begun to decline in Spanish women aged 60 and over. The causes of this decline are unclear.

Background: Some studies have analysed the relation between well-being and mortality but a none of them have attempted to disentangle the differential influence that positive affect, negative affect, and evaluative well-being might have on mortality using a longitudinal design in the general population and measuring independently and accurately each component of well-being. The aim of the present study is to assess the association of these well-being components with mortality after adjusting for health and other lifestyle factors and to analyze whether this association is different in people with and without depression.Methods: A nationally representative sample of 4753 people from Spain was followed up after three years. Analyses were performed with Cox regression models among the total sample and separately in people with and without depression. Results: In the analyses adjusted for age, sex and years of education, all three well-being variables showed a statistically significant association with mortality. However, after adjustment for health status and other confounders including the well-being components, only positive affect remained as marginally associated with a decreased risk of mortality in the overall sample [OR = 0.87; 95% CI = 0.73-1.03], in particular among individuals without depression [OR = 0.82; 95% CI = 0.68-0.99]. Conclusion: Positive affect is inversely associated with mortality in individuals without depression. Future research should focus on assessing interventions associated with a higher level of positive affect.

IntroductionIn older adults, the Mediterranean diet is associated with lower risk of chronic diseases, but its association with health-related quality of life (HRQL) is still uncertain. This study assessed the association between the Mediterranean diet and HRQL in 2 prospective cohorts of individuals aged ≥60 years in Spain.MethodsThe UAM-cohort (n = 2376) was selected in 2000/2001 and followed-up through 2003. At baseline, diet was collected with a food frequency questionnaire, which was used to develop an 8-item index of Mediterranean diet (UAM-MDP). The Seniors-ENRICA cohort (n = 1911) was recruited in 2008/2010 and followed-up through 2012. At baseline, a diet history was used to obtain food consumption. Mediterranean diet adherence was measured with the PREDIMED score and the Trichopoulou's Mediterranean Diet Score (MSD). HRQL was assessed, at baseline and at the end of follow-up, with the physical and mental component summaries (PCS and MCS) of the SF-36 questionnaire in the UAM-cohort, and the SF-12v.2 questionnaire in the Seniors-ENRICA cohort. Analyses were conducted with linear regression, and adjusted for the main confounders including baseline HRQL.ResultsIn the UAM-cohort, no significant associations between the UAM-MDP and the PCS or the MCS were found. In the Seniors-ENRICA cohort, a higher PREDIMED score was associated with a slightly better PCS; when compared with the lowest tertile of PREDIMED score, the beta coefficient (95% confidence interval) for PCS was 0.55 (-0.48 to 1.59) in the second tertile, and 1.34 (0.21 to 2.47) in the highest tertile. However, the PREDIMED score was non-significantly associated with a better MCS score. The MSD did not show an association with either the PCS or the MCS.ConclusionsNo clinically relevant association was found between the Mediterranean diet and HRQL in older adults in Spain.

[This corrects the article DOI: 10.1371/journal.pone.0151596.].

OBJECTIVE:The objective of this study was to evaluate the accuracy of the recommended glycemic measures for diagnosing diabetic retinopathy. METHODS:We systematically searched MEDLINE, EMBASE, the Cochrane Library, and the Web of Science databases from inception to July 2015 for observational studies comparing the diagnostic accuracy of glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), and 2-hour plasma glucose (2h-PG). Random effects models for the diagnostic odds ratio (dOR) value computed by Moses' constant for a linear model and 95% CIs were used to calculate the accuracy of the test. Hierarchical summary receiver operating characteristic curves (HSROC) were used to summarize the overall test performance. RESULTS:Eleven published studies were included in the meta-analysis. The pooled dOR values for the diagnosis of retinopathy were 16.32 (95% CI 13.86-19.22) for HbA1c and 4.87 (95% CI 4.39-5.40) for FPG. The area under the HSROC was 0.837 (95% CI 0.781-0.892) for HbA1c and 0.735 (95% CI 0.657-0.813) for FPG. The 95% confidence region for the point that summarizes the overall test performance of the included studies occurs where the cut-offs ranged from 6.1% (43.2 mmol/mol) to 7.8% (61.7 mmol/mol) for HbA1c and from 7.8 to 9.3 mmol/L for FPG. In the four studies that provided information regarding 2h-PG, the pooled accuracy estimates for HbA1c were similar to those of 2h-PG; the overall performance for HbA1c was superior to that for FPG. CONCLUSIONS:The three recommended tests for the diagnosis of type 2 diabetes in nonpregnant adults showed sufficient accuracy for their use in clinical settings, although the overall accuracy for the diagnosis of retinopathy was similar for HbA1c and 2h-PG, which were both more accurate than for FPG. Due to the variability and inconveniences of the glucose level-based methods, HbA1c appears to be the most appropriate method for the diagnosis diabetic retinopathy.