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The Healthy Heart Score (HHS) is a lifestyle-based equation for predicting cardiovascular disease (CVD) risk and may serve as a tool in primordial prevention. However, its performance outside North American populations is unknown. This study assessed the performance of the HHS for estimating CVD mortality in the adult population of Spain.We analyzed data from the ENRICA cohort, comprising 10 228 participants free of chronic disease and representative of the Spanish population aged ≥ 18-years, who were recruited from 2008 to 2010 and were followed up to 2020. The HHS includes body mass index, alcohol, physical activity, smoking, and a 5-component dietary score. The HHS was calculated at baseline using the sex-specific beta coefficients from the original development cohorts. Model discrimination was assessed using the Harrell c-statistic and Gonen-Heller c-statistic for survival data, and calibration was evaluated through calibration plots.After a median follow-up of 11.8 years, 110 CVD deaths were ascertained. The discrimination of the HHS was similar for women (Harrell c, 0.91; 95%CI, 0.87-0.95; Gonen-Heller-c, 0.85; 95%CI, 0.83-0.88) and men (Harrell c, 0.91; 95%CI, 0.88-0.94; Gonen-Heller c: 0.85; 95%CI, 0.83-0.88). After recalibration by the sex-specific baseline survival function, the calibration became optimal for: a) all deciles of predicted CVD risk except the highest decile, where HHS underestimated the risk, and b) all age groups except 70 years and older, where there was an underestimation.In this Spanish cohort, the HHS showed good discrimination and calibration for predicting CVD death. The performance of HHS in other European populations and its implementation in the clinical setting warrants further investigation.

A Mediterranean lifestyle may prevent and mitigate cardiometabolic disorders. We explored whether adherence to a Mediterranean lifestyle was prospectively associated with risk of metabolic syndrome (MetS) among coronary heart disease (CHD) patients.The CORDIOPREV study was an interventional diet study to compare a Mediterranean diet with a low-fat diet, in 1002 CHD patients. The Mediterranean lifestyle (MEDLIFE) index was used to assess adherence to a Mediterranean lifestyle at baseline, and after five years, in 851 participants from the CORDIOPREV study. Subjects were classified as having high (13 points), moderate (12-13 points), and low (12 points) adherence to the Mediterranean lifestyle. Multivariable logistic regression models were used to determine the association between MEDLIFE adherence and the risk of MetS development or reversal.During the five-year follow-up, CORDIOPREV participants with high adherence to MEDLIFE had a lower risk of MetS development (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.19-0.75, p0.01) and a higher likelihood of reversing pre-existing MetS (OR 2.08 CI 95% 1.11-3.91, p = 0.02) compared with participants in the low MEDLIFE adherence group. Each additional one-point increment in the MEDLIFE index was associated with a 24% lower risk of MetS development (OR 0.76, 95% CI 0.64-0.90, p0.01) and a 21% higher likelihood of reversing pre-existing MetS (OR 1.21 CI 95% 1.04-1.41, p = 0.01).Our results showed that greater adherence to a Mediterranean lifestyle reduced the risk of subsequent MetS development and increased the likelihood of reversing pre-existing MetS among patients with CHD at baseline. This article is protected by copyright. All rights reserved.

Background Red meat is a nutrient‐dense source of protein fundamental for older adults; however, red meat is also high in detrimental components, including saturated fat. It is unclear whether habitual red meat consumption is associated with risk of frailty. This study aimed to examine the prospective association between the consumption of total, unprocessed, and processed red meat and the risk of frailty in older adults. Methods We analysed data from 85 871 women aged ≥60 participating in the Nurses' Health Study. Consumption of total, unprocessed, and processed red meat was obtained from repeated food frequency questionnaires administered between 1980 and 2010. Frailty was defined as having at least three of the following five criteria from the FRAIL scale: fatigue, low strength, reduced aerobic capacity, having ≥5 chronic illnesses, and unintentional weight loss ≥5%. The occurrence of frailty was assessed every four years from 1992 to 2014. Results During 22 years of follow‐up (median follow‐up 14 years), we identified 13 279 incident cases of frailty. Women with a higher intake of red meat showed an increased risk of frailty after adjustment for lifestyle factors, medication use, and dietary factors. The relative risk (95% confidence interval) for one serving/day increment in consumption was 1.13 (1.08, 1.18) for total red meat, 1.08 (1.02, 1.15) for unprocessed red meat, and 1.26 (1.15, 1.39) for processed red meat. When each component of the frailty syndrome was individually examined, each of them was positively associated with total red meat consumption, except for the weight loss criterion. Replacing one serving/day of unprocessed red meat with other protein sources was associated with significantly lower risk of frailty; the risk reduction estimates were 22% for fish and 14% for nuts, while for replacement of processed red meat, the percentages were 33% for fish, 26% for nuts, 13% for legumes, and 16% for low‐fat dairy. Conclusions Habitual consumption of unprocessed and processed red meat was associated with a higher risk of frailty. Replacement of red meat by other protein sources might reduce the risk of frailty. These findings are in line with dietary guidelines promoting diets that emphasize plant‐based sources of protein.

Background Recent evidence has indicated a greater number of protective factors is associated with a greater decreased risk for depression and depressive symptoms compared with individual factors alone. Moreover, adherence to healthy modifiable lifestyle behaviors may lower the risk of depression regardless of underlying genetic risk. Objective We longitudinally evaluated the association of the Mediterranean lifestyle (MEDLIFE) with the risk of depression. Methods We prospectively analyzed data from 15,279 participants (6,089 men and 9,190 women, mean age 37 years) in the "Seguimiento Universidad de Navarra" (SUN) cohort. The MEDLIFE index is composed of 28 items on food consumption, dietary habits, physical activity, rest, social habits, and conviviality, each of which were assigned 0 or 1 point. Final scores ranged from 0-28 points and were categorized into quartiles of MEDLIFE adherence. Cox proportional regression models determined the association of total MEDLIFE adherence, each item, and block with incident depression. Results After a mean follow-up of 11.7 years, 912 (6%) incident cases of depression were reported. The mean final score for MEDLIFE adherence was 11.9 points (standard deviation (SD): 2.7). The multivariable model showed that compared to the first quartile, the second and third quartiles of MEDLIFE adherence were significantly associated with a decreased relative risk for incident depression (hazard ratio (HR) = 0.82; 95% confidence intervals (CI): 0.69-0.96 and HR = 0.74; 95%CI: 0.61-0.89, respectively). The fourth quartile did not show a statistically significant association with incident depression (HR = 0.89; 95%CI: 0.73-1.09). Conclusion MEDLIFE adherence may decrease the risk of depression in a Spanish cohort of university graduates. Given no clear association was observed among the highest MEDLIFE adherence, future studies are warranted to better understand the nature of this association. Evidence on MEDLIFE, beyond the Mediterranean diet, may contribute towards more effective prevention strategies for depression.

Background: There is strong evidence that the Mediterranean diet protects from cardiovascular disease (CVD); however, beyond diet, the Mediterranean lifestyle may have synergistic effects through the combination of other health behaviors, such as adequate rest or sociability. While most evidence on this lifestyle pattern comes from Mediterranean countries, little is known about the health effects of a Mediterranean lifestyle in non-Mediterranean populations. Our aim was to examine the association between a Mediterranean lifestyle index (MEDLIFE) and all-cause, (CVD), and cancer mortality in a British population. Methods: We used data from 110,799 individuals free of CVD or cancer, aged 40-69 years, from the UK Biobank cohort, who were followed from 2006-2010 to 2020. The Mediterranean lifestyle was assessed through the validated 26-item MEDLIFE index derived from the lifestyle questionnaire and from 2 or more Oxford WebQ Online 24-hour diet recalls. MEDLIFE comprised three blocks: a) Block 1 (13 items): Mediterranean food consumption, b) Block 2 (7 items): Mediterranean dietary habits, c) Block 3 (6 items): Physical activity, rest, social habits, and conviviality. Mortality was obtained from the death register records. Multivariable-adjusted Cox proportional-hazards regression models were used to analyse associations between MEDLIFE and all-cause, CVD, and cancer mortality. Results: After a mean 9.4-year follow-up, 4,247 deaths were identified. Higher adherence to the MEDLIFE index was associated with lower all-cause and cancer mortality in a dose-response manner. Compared to the first quartile of adherence to the MEDLIFE, the increasingly higher quartiles had a HR (95% CI) of 0.89 (0.81 -0.97), 0.81 (0.74-0.89) and 0.71 (0.65-0.78), p-trend p -trend Conclusions: A Mediterranean lifestyle was associated to reduced all-cause and cancer-mortality in British middle-aged and older adults; this suggests that adopting a Mediterranean lifestyle adapted to the local characteristics of non-Mediterranean populations is possible and can be part of a healthy lifestyle.

Background: United States (US) career firefighters represent a working population at high risk for cardiovascular disease that may benefit from a Mediterranean diet (MedDiet) nutrition intervention (MDNI). The Feeding America’s Bravest trial was the first workplace randomized controlled trial with nutrition education, behavior change, and incentives strategies promoting adherence to the MedDiet within US firehouses and homes. We assessed the hypothesis that a 12-month MDNI with a novel worksite behavior change approach would increase adherence to the MedDiet. Methods: 486 US career firefighters within the Indianapolis and Fishers Fire Departments were enrolled and cluster randomized by fire station to either a MDNI or control group and completed 6-month (n=336) and 12-month follow-up (n=260). Stepwise-selection regression analyses and nested least-squares linear regression models determined the contribution of each item to the between person variability of a modified Mediterranean Diet Score (mMDS). To assess the intervention effect, an intention-to-treat analysis used multilevel mixed-effects linear regression models for repeated measures to evaluate between-group and within-group mean differences in mMDS from baseline to 6-months and baseline to 12-months adjusting for age, sex, physical activity, race, and waist circumference with clusters as the random effects parameter. Results: Among 484 US career firefighters (95% male with mean age of 47 years (SD=7.5; range: 26-68) observed mean scores (SD) in the MDNI group were 23.41 (6.34) at baseline, 25.26 (5.73) at 6-months, and 24.79 (6.15) at 12-months, and in the control group; 22.87 (6.78), 26.20 (6.15), and 26.68 (6.42), respectively. Between person variability of mMDS scores was largely due to the cooking oil used at home, fried foods, beverages at home, vegetables, and quantity of alcohol. Adjusted mean changes in mMDS showed statistically significant improvements among the MDNI group at 6-months by 1.28 points (pts.) (95%CI: -0.24 to 2.81) and 1.93 pts. (95%CI: 0.39 to 3.46) at 12 months compared to the control group. Multiple imputation methods supported these findings showing 6-month improvements of 1.23 pts. (95%CI: 0.22 to 2.25) and 1.63 pts. (95%CI: 0.58 to 2.67) at 12-months in the MDNI group compared to the control group. Conclusions: In conclusion, firefighters’ increased mMDS scores evidenced the effect of a multicomponent MDNI in a non-Mediterranean working population at high cardiovascular risk. Although more research is warranted, these findings support MedDiet promotion among the US fire service and other similar workforces. Furthermore, the intervention strategies used in this trial; cooking demonstrations, positive reinforcement, family involvement, and discounted access to staple MedDiet foods, may serve as effective nutrition worksite approaches for reducing the burden of chronic disease.

Introduction: Cardiovascular disease (CVD) remains the leading cause of death for women in the US, yet many young women are unaware of their lifetime risk of CVD. We employed user-centered design principles to adapt a validated CVD risk prediction tool for young women. Hypothesis: We hypothesized that young women would rate the tool (HerHeart) as user-friendly, be likely to recommend it to their friends, experience a change in their perceived risk of CVD, and report intent to change their health habits after engaging with it. Methods: We recruited 13 young women ages 13-21 from two clinical practices in Atlanta, GA to engage with the HerHeart CVD risk prediction tool. Participants rated the tool’s usability via the Website Analysis and Measurement Inventory (WAMMI), which is scored from 0 to 100. Participants rated their perceived 10-year and lifetime risk of CVD on a visual analog scale from 0 (Never going to happen) to 10 (Definitely will happen) before and after completing the tool. Participants reported their likelihood of recommending the tool to their friends and changing their health habits from 0 (Not likely at all) to 10 (Extremely likely). Results: Participants rated the tool’s usability highly on the WAMMI (M = 78.62 +/- 9.70). Participants’ perceived 10-year risk of a heart attack increased from a mean of 0.85 +/- 0.99 to 1.83 +/- 1.90, and perceived lifetime risk increased from a mean of 2.38 +/- 2.72 to 2.75 +/- 2.63, on the 10-point scale after engaging with the tool. Participants were more than likely to recommend HerHeart to their friends (M = 8.00 +/- 2.22) and to report intent to change their health habits (M = 8.82 +/- 1.47) after completing the tool. Participant data captured in the HerHeart tool are shown in the Table. Conclusions: The HerHeart tool is acceptable to young women and demonstrates potential for changing their risk perception and improving their health habits to reduce their risk of CVD. Recruitment is ongoing and will include input from clinicians on the feasibility of incorporating the tool in clinical practice.

PURPOSE OF REVIEW Workplaces provide a unique opportunity to deliver health promotion interventions to their workers. This review summarizes evidence from the most recent studies (September 2019 to April 2021) of workplace healthy lifestyle interventions and identifies gaps in the literature and key aspects for successful future workplace lifestyle interventions. RECENT FINDINGS Recent intervention studies have focused on four health domains: (1) multicomponent wellness programs, (2) healthy diet interventions, (3) physical activity interventions, and (4) mental health/sleep interventions. Within each group of studies, there was significant heterogeneity in study length, intervention components, and worker populations. Nonetheless, most studies across all categories showed positive associations between healthy lifestyle interventions and improved worker health. SUMMARY Although recent literature has shown an overall positive trend between healthy lifestyle interventions implemented at the workplace and improvements in markers of health and wellbeing, further research should include longer follow-up periods, more objective measures of wellbeing, evaluation of worker performance, and analogous interventions between studies to identify the most effective interventions to improve worker health and wellness.

Background Frailty is a geriatric syndrome that entails high risk of hospitalization, disability, and death. While adherence to Mediterranean diet has been associated with lower risk of frailty, the joint effect of diet and lifestyle is uncertain. This study examined the association between a Mediterranean lifestyle (diet, customs, and traditions) and frailty incidence in older adults. Methods We analyzed data from 1 880 individuals aged ≥ 60 from the prospective Seniors-ENRICA-1 cohort. Adherence to the Mediterranean lifestyle was assessed at baseline with the 27-item MEDLIFE index (higher scores representing better adherence), divided into 3 blocks: (1) “Mediterranean food consumption,” (2) “Mediterranean dietary habits” (practices around meals),” and (3) “Physical activity, rest, social habits and conviviality.” Frailty was ascertained as the presence of ≥ 3 of the 5 Fried criteria: (a) Exhaustion; (b) Muscle weakness; (c) Low physical activity; (d) Slow walking speed; and (e) Unintentional weight loss. Main statistical analyses were performed using logistic regression models, adjusting for the main confounders. Results After a 3.3-year follow-up, 136 incident frailty cases were ascertained. Compared with participants in the lowest tertile of the MEDLIFE score, the OR (95% CI) for frailty was 0.88 (0.58–1.34) for the second tertile, and 0.38 (0.21–0.69) for the third tertile (p-trend = .003). Blocks 1 and 3 of the MEDLIFE score were independently associated with lower frailty risk. Most items within these blocks showed a tendency to reduced frailty. Conclusions Higher adherence to a Mediterranean lifestyle was associated with lower risk of frailty.

Background and aims A healthy lifestyle is essential to prevent cardiovascular disease (CVD). However, beyond dietary habits, there is a scarcity of studies comprehensively assessing the typical traditional Mediterranean lifestyle with a multi-dimensional index. We assessed the association between the Mediterranean lifestyle (measured with the MEDLIFE index including diet, physical activity, and other lifestyle factors) and the incidence of CVD. Methods and results The “Seguimiento Universidad de Navarra” (SUN) project is a prospective, dynamic and multipurpose cohort of Spanish university graduates. We calculated a MEDLIFE score, composed of 28 items on food consumption, dietary habits, physical activity, rest, social habits, and conviviality, for 18,631 participants by assigning 1 point for each typical Mediterranean lifestyle factor achieved, for a theoretically possible final score ranging from 0 to 28 points. During an average follow-up of 11.5 years, 172 CVD cases (myocardial infarction, stroke or cardiovascular death) were observed. An inverse association between the MEDLIFE score and the risk of primary cardiovascular events was observed, with multivariable-adjusted hazard ratio (HR) = 0.50; (95% confidence interval, 0.31–0.81) for the highest MEDLIFE scores (14–23 points) compared to the lowest scores (0–9 points), p (trend) = 0.004. Conclusion A higher level of adherence to the Mediterranean lifestyle was significantly associated with a lower risk of CVD in a Spanish cohort. Public health strategies should promote the Mediterranean lifestyle to preserve cardiovascular health.

BACKGROUND Cardiovascular disease (CVD) is the number one cause of death in women in the United States. Awareness of CVD and its risk factors are critical to reversing this trend. OBJECTIVE This project aimed to assess CVD awareness among adolescent and young adult women and develop a lifestyle-based cardiovascular risk assessment tool for use with this population. METHODS This study used a 3-phase iterative design process with young women from primary care and reproductive care clinics in Atlanta, Georgia. In Phase 1, we administered a modified version of the American Heart Association Women’s Health Survey to young women ages 15-24 (n=67) to assess their general CVD awareness. In Phase 2, we interviewed young women ages 13-21 (n=10) and healthcare practitioners (n=10) to solicit suggestions for adapting an existing adult cardiovascular risk assessment tool for this age group. In Phase 3, we employed an iterative user-centered design process to collect feedback from approximately 105 young women as we adapted the adult tool. RESULTS Only 10.5% (n=7) of young women surveyed correctly identified CVD as the leading cause of death among women in the US. Few respondents reported having discussed their personal risk (6%, n=4) or family history of CVD (11.9%, n=8) with a healthcare provider. Young women demonstrated increased CVD awareness and knowledge after completing the adult risk assessment tool and suggested making the tool more teen-friendly by incorporating relevant foods and activity options. The result of the iterative design process was a youth friendly prototype of a CVD risk assessment tool. CONCLUSIONS Adolescent and young adult women demonstrate low awareness of CVD. This study illustrates the potential value of a CVD risk assessment tool adapted for use with young women and showcases the importance of user-centered design when creating digital health interventions.

Background Although some components of the Mediterranean diet have shown benefits in pain risk through its anti-inflammatory/antioxidant properties, no population-based studies have investigated the effect of adherence to this diet on changes in pain over time. Methods We used data from 864 and 862 older adults recruited in the Seniors-ENRICA-1 and Seniors-ENRICA-2 cohorts and followed-up for 2.8 and 2.4 years, respectively. Adherence to the Mediterranean diet was assessed with the MEDAS score at baseline. Frequency, severity, and locations of pain obtained at baseline and follow-up were used to compute a pain scale. Analyses were performed using multinomial logistic regression models, and adjusted for the main confounders. Results Participants had a mean (SD) age of 71.5 (5.1) years, 36.8% were men, and 78.3% had chronic conditions. In the pooled cohorts, compared with participants in the lowest quartile of the MEDAS score (lowest adherence to the Mediterranean diet), those in the highest quartile showed a higher frequency of pain improvement versus worsening (relative risk ratio [95% confidence interval]: 1.43 [1.03, 1.99]). This association was also evidenced in 2 components of the pain scale: improvement in pain severity (1.43 [1.01, 2.04]) and reduction in pain locations (1.54 [1.08, 2.20]), but a tendency to pain frequency improvement (1.34 [0.92, 1.93]) was also observed. The main contributors to these associations were high consumption of fruit and vegetables, and low consumption of sugar-sweetened beverages. Conclusions A higher adherence to the Mediterranean diet was related to a subsequent improvement in pain characteristics in older adults, suggesting that improving diet quality may help reduce the high health impact of pain.

Background: Epidemiological studies have yielded conflicting results regarding climate and incident SARS-CoV-2 infection, and seasonality of infection rates is debated. Moreover, few studies have focused on COVD-19 deaths. We studied the association of average ambient temperature with subsequent COVID-19 mortality in the OECD countries and the individual United States (US), while accounting for other important meteorological and non-meteorological co-variates. Methods: Information on average temperature and other weather conditions for 25 days prior and 25 days after the first reported COVID-19 death was collected in the OECD countries and US states. Cumulative COVID-19 mortality was assessed for each region at 25, 30, 35, and 40 days after the first reported death. Analyses were performed with negative binomial regression and adjusted for other weather conditions, particulate matter, soc iodemographic factors, smoking, obesity, ICU beds, and social distancing. Findings: A 1oC increase in ambient temperature was associated with 6% lower COVID-19 mortality at 30 days following the first reported death (multivariate-adjusted mortality rate ratio: 0.94, 95% CI: 0.90, 0.99, p=0.016). The results were robust for COVID-19 mortality at 25, 35 and 40 days after the first death, as well as other sensitivity analyses. Interpretation: The results provide consistent evidence across various models of an inverse association between higher average temperatures and subsequent COVID-19 mortality rates after accounting for other meteorological variables and predictors of SARS-CoV-2 infection or death. This suggests potentially decreased viral transmission in warmer regions and during the summer season. Funding Statement: None declared. Declaration of Interests: The authors declare no competing interests.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations, Background: Evidence is limited about the joint health effects of the Mediterranean lifestyle on cardiometabolic health and mortality. The aim of this study was to evaluate the association of the Mediterranean lifestyle with the frequency of the metabolic syndrome (MS) and the risk of all‑cause and cardiovascular mortality in Spain. Methods: Data were taken from ENRICA study, a prospective cohort of 11,090 individuals aged 18 + years, representative of the population of Spain, who were free of cardiovascular disease (CVD) and diabetes at 2008–2010 and were followed‑up to 2017. The Mediterranean lifestyle was assessed at baseline with the 27‑item MEDLIFE index (with higher score representing better adherence). Results: Compared to participants in the lowest quartile of MEDLIFE, those in the highest quartile had a multivariable‑adjusted odds ratio 0.73 (95% confidence interval (CI) 0.5, 0.93) for MS, 0.63. (0.51, 0.80) for abdominal obesity, and 0.76 (0.63, 0.90) for low HDL‑cholesterol. Similarly, a higher MELDIFE score was associated with lower HOMA‑IR and highly‑sensitivity C‑reactive protein (P‑trend < 0.001). During a mean follow‑up of 8.7 years, 330 total deaths (74 CVD deaths) were ascertained. When comparing those in highest vs. lowest quartile of MEDLIFE, the multivariable‑adjusted hazard ratio (95% CI) was 0.58 (0.37, 0.90) for total mortality and 0.33 (0.11, 1.02) for cardiovascular mortality. Conclusions: The Mediterranean lifestyle was associated with lower frequency of MS and reduced all‑cause mortality in Spain. Future studies should determine if this also applies to other Mediterranean countries, and also improve cardiovascular health outside the Mediterranean basin, This work was supported by FIS grants 16/609, 16/1512, 18/287, 19/319 and PI20/00896 (Instituto de Salud Carlos III, State Secretary of R+D+I and FEDER/FSE), the Salamander Project (JPI-A Healthy Diet for a Healthy Life, State Secretary of R+D+I PCIN-2016-145), and the Cátedra de Epidemiología y Control del Riesgo Cardiovascular at UAM (#820024). Mercedes Sotos Prieto holds a Ramón y Cajal contract (RYC-2018-025069-I) from the Ministry of Science, Innovation and Universities and FEDER/FSE. The funding agencies had no role in study design, data collection and analysis, interpretation of results, manuscript preparation or in the decision to submit this manuscript for publication

It is unknown if time-restricted feeding confers a protective effect on the physical function of older adults. The aim of this study was to assess prolonged nightly fasting in association with performance-based lower-extremity function (LEF) in a large population of community-dwelling older adults. A cross-sectional study was carried out among 1226 individuals ≥64 years from the Seniors-ENRICA-II (Study on Nutrition and Cardiovascular Risk in Spain) cohort. Habitual diet was assessed through a validated diet history. Fasting time was classified into the following categories: ≤9, 10–11 and ≥12 h/d (prolonged nightly fasting). Performance-based LEF was assessed with the Short Physical Performance Battery (SPPB). After adjusting for potential confounders, a longer fasting period was associated with a higher likelihood of impaired LEF (OR for the second and third categories v. ≤ 9 h/d fasting: 2·27 (95 % CI 1·56, 3·33) and 2·70 (95 % CI 1·80, 4·04), respectively; Ptrend < 0·001). Fasting time showed a significant association with the SPPB subtests balance impairment (OR for highest v. shortest fasting time: 2.48; 95 % CI 1·51, 4·08; Ptrend = 0·001) and difficulty to rise from a chair (OR 1·47; 95 % CI 1·05, 2·06; Ptrend = 0·01). The risk associated with ≥12 h fasting among those with the lowest levels of physical activity was three times higher than among those with ≤9 h fasting with the same low level of physical activity. Prolonged nightly fasting was associated with a higher likelihood of impaired LEF, balance impairment, and difficulty to rise from a chair in older adults, especially among those with low levels of physical activity.

Cardiovascular disease is the leading cause of on-duty mortality among firefighters, with obesity as an important risk factor. However, little is known regarding the dietary patterns which are characteristic in this population and how these patterns relate to cardiometabolic outcomes. The aim of this study was to identify the dietary patterns of US firefighters and examine their association with cardiometabolic outcomes. The participants (n = 413) were from the Indianapolis Fire Department, and were recruited for a Federal Emergency Management Agency (FEMA)-sponsored Mediterranean diet intervention study. All of the participants underwent physical and medical examinations, routine laboratory tests, resting electrocardiograms, and maximal treadmill exercise testing. A comprehensive food frequency questionnaire was administered, and dietary patterns were derived using principal component analysis. The mean body mass index (BMI) was 30.0 ± 4.5 kg/m2 and the percentage of body fat was 28.1 ± 6.6%. Using principal component analysis, two dietary patterns were identified, namely a Mediterranean diet and a Standard American diet. Following the adjustment for gender, BMI, maximal oxygen consumption (VO2 max), max metabolic equivalents (METS), age, and body fat percent, the Mediterranean diet was positively associated with high-density lipoprotein (HDL) cholesterol (β = 1.20, p = 0.036) in linear regression models. The Standard American diet was associated with an increase in low-density lipoprotein (LDL) cholesterol (β = −3.76, p = 0.022). In conclusion, the Mediterranean diet was associated with more favorable cardiometabolic profiles, whereas the Standard American diet had an inverse association. These findings could help in providing adequate nutrition recommendations for US firefighters to improve their health.

Importance: 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. Objective: To assess the association between plant-based diet quality and risk of frailty. Design, setting, and participants: Prospective cohort with 82,234 women aged ≥60y from the Nurses’ Health Study, who were followed from 1990 through 2014. The dates of analysis were April 14 to -June 23, 2021. Exposures: Dietary data were collected every 4-y using a validated semi-quantitative food frequency questionnaire. The plant-based diet quality was assessed with 2 indices (range 18 - 90 points).: a) Healthful Plant-Based Diet Index (hPDI), where healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils, tea/coffee) received positive scores, while less healthy plant foods (fruit juices, sweetened beverages, refined grains, potatoes, 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. Main outcomes: Frailty incidence was assessed every 4 years, being defined as having ≥3 of the following 5 criteria from the FRAIL scale: fatigue, low strength, reduced aerobic capacity, having ≥5 illnesses, and weight loss ≥5%. Methods: 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 (HR for the highest vs. lowest quintile: 0.69, 95% CI: 0.65-0.73; p-trend Conclusions and relevance: A healthful plant-based diet was associated with lower risk of frailty whereas an unhealthful plant-based diet was associated with higher risk.

Objective To evaluate the opinions of primary health-care providers and patients regarding the use of the Healthy Heart Score 20-year cardiovascular disease risk assessment tool in the clinical setting. Methods Semi-structured in person or phone interviews among 20 patients with no self-reported cardiovascular disease diagnoses and 20 health-care providers in Central (Columbus) and Southeastern (Athens) regions of Ohio. The researchers independently coded transcribed interviews, discussed codes to resolve discrepancies, and agreed on common themes. Results Participants suggested ways to best utilize and improve the tool, including adding graphics for visual reference of serving size. Patients showed interest in cardiovascular disease primordial prevention and expressed willingness to take the assessment prior to seeing a health-care provider. Health-care providers said that they would recommend the assessment to their patients and would be willing to use the tool in their practice. Health-care providers stated few barriers to using the tool, yet discussed numerous challenges to successful primordial prevention. Conclusions Our findings support the utilization of the Healthy Heart Score as a cardiovascular disease primordial prevention tool in the clinical setting. Additional research implementing the tool into the clinical setting will provide deeper insight into how the tool can impact behavior change and cardiovascular disease prevention.

Background Evidence on the comprehensive role of lifestyle in frailty risk is scarce. To assess the association between a lifestyle-based Healthy Heart Score (HHS), which estimates the 20-year risk of cardiovascular disease (CVD), and risk of frailty among older women. Methods Prospective cohort study in 121,700 nurses from the USA participating at the Nurses’ Health Study. This study included 68,416 women aged ≥60 year with a follow-up from 1990 to 2014. The HHS was computed using the gender-specific beta-coefficients of the nine lifestyle factors, including current smoking, high body mass index, low physical activity, lack of moderate alcohol intake and unhealthy diet. Frailty incidence was assessed every 4 years from 1992 to 2014 as having ≥3 of the following five criteria from the FRAIL scale: fatigue, low strength, reduced aerobic capacity, having ≥5 illnesses and weight loss ≥5%. Results During 22 years of follow-up, 11,041 total incident cases of frailty were ascertained. Compared to women in the lowest quintile of the HHS (lowest estimated CVD risk), the multivariable-adjusted hazard ratio of frailty across quintiles was: Q2:1.67 (95% confidence interval 1.53, 1.82); Q3: 2.34 (2.15, 2.53); Q4: 3.54 (3.28, 3.83) and Q5: 5.92 (5.48, 6.38); P-trend > 0.001. Results were consistent for each frailty criterion, among participants with 0 frailty criteria at baseline, when using only baseline exposure or in 6-year-, 10-year- and 14-year-exposure lagged analyses, and after excluding participants with diabetes and CVD at baseline. Conclusions The HHS, based on a set of modifiable-lifestyle factors, is strongly associated with risk of frailty in older women.

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.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.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.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.

IntroductionCardiovascular disease is the leading cause of on-duty fatalities among U.S. firefighters. Research has demonstrated that many modifiable risk factors are contributors to the high prevalence of cardiometabolic risk factors. The current study aimed to assess whether sleep is associated with cardiometabolic risk factors among Indianapolis firefighters. The findings could support improving sleep hygiene in this population.Material and MethodsThis cross-sectional study was conducted from the baseline data of eligible firefighters enrolled in “Feeding America’s Bravest”, a Mediterranean diet lifestyle intervention within the Indiana Fire Departments. Participants’ sleep quality was categorized as “good” (≤ 8 points) or “bad” (>8 points) by a sleep quality questionnaire based on some questions from Pittsburgh Sleep Quality Index. In addition, firefighters’ sleep duration was stratified based on the number of hours slept per night (≤6 as “short sleep” or >6 hours as normal). Linear and logistic regression models were used to examine the association of sleep with cardiometabolic risk factors.ResultsA total of 258 firefighters were included. Bad sleepers had higher weight, greater waist circumference, higher body mass index (BMI), and increased body fat (all pConclusionsOur study supports that both sleep quality and quantity are associated with cardiometabolic risk among firefighters.

Refining existing dietary assessment methods to reduce measurement error and facilitate the routine evaluation of dietary quality is essential to inform health policy. Notable advancements in technology in the past decade have enhanced the precision and transformation of dietary assessment methods with applications toward both population health and precision nutrition. Within population health, innovative applications of big data including use of automatically collected food purchasing data, quantitative measurement of food environments, and novel, yet simplified dietary quality metrics provide important complementary data to traditional self-report methods. Precision nutrition is similarly advancing with greater use of validated biomarkers for assessing dietary patterns and understanding individual variability in metabolism. Concurrently enhancing our understanding of diet–disease relations at the population health and precision nutrition levels provides tremendous potential to generate evidence needed to advance public health nutrition policy. This commentary highlights the importance of these advances toward progressing the field of dietary assessment and discusses the application of food purchasing data, data analytics, alternative dietary quality metrics, and -omics technology in population and clinical medicine.

The traditional Mediterranean diet is considered the world's most evidence-based eating pattern for promoting health and longevity. However, institutional food environments and their busy consumers often sacrifice health benefits for the convenience of faster and cheaper foods that generally are of lower quality and are more processed, and thus, contribute to the current epidemics of obesity and diabetes. Expert consensus has even identified the Mediterranean diet as the easiest to follow among healthy eating patterns. Nonetheless, fewer American families cook at home and many food services have been slow to implement healthier food options compatible with the Mediterranean diet. In September 2019, we convened a group of thought leaders at an exploratory seminar entitled: "Mediterranean Diet: Promotion and Dissemination of Healthy Eating", hosted by the Radcliffe Institute for Advanced Studies at Harvard University. The multidisciplinary faculty discussed best practices for translating traditional Mediterranean lifestyle principles to modern society.