Adherence to the Mediterranean diet assessed by a novel dietary biomarker score and mortality in older adults: the InCHIANTI cohort study

Gender and sex differences in adherence to a Mediterranean diet and associated factors during the COVID-19 pandemic: a systematic review

Background

The COVID-19 pandemic has led to significant lifestyle changes, including alterations in dietary habits and increases in sedentary behavior. The Mediterranean diet (MD) has been associated with various health benefits, which are especially important given the health challenges posed by the pandemic. During the pandemic, an overall shift towards consuming more highly processed foods has been observed.

Methods

This systematic review investigated adherence to MD during the COVID-19 pandemic, focusing on gender differences and factors influencing adherence to MD in the general public. The literature search focused on papers published between January 1, 2019, and July 8, 2024, across various databases such as Web of Science (WOS), Scopus, PubMed MEDLINE, and PsycINFO.

Results

Following the PRISMA guidelines, this search identified 14,347 references, of which 5,734 were duplicates. After a thorough multi-level screening process, 29 studies, encompassing 55,242 participants, met the inclusion criteria. While seven studies reported that men adhered to a MD more than women during the COVID-19 pandemic, 12 studies also indicated that women had higher adherence to a MD compared to men. Nine studies, however, found no significant gender differences in MD adherence. Additionally, older age, higher education levels, higher socioeconomic status, and increased physical activity were linked to greater adherence to a MD in the pandemic context.

Conclusion

Gender-specific differences in dietary behavior are influenced by factors such as socioeconomic status, gender roles, and pandemic phases as well as biases in sample composition and methodological weaknesses. Significant gaps in the evidence, particularly concerning sexual and gender minorities, are highlighted.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=421727.

The role of Mediterranean diet in cancer incidence and mortality in the older adults

The magnitude of benefit of Mediterranean diet in cancer prevention and mortality in older adults is still unclear, therefore we conducted a systematic review and meta-analysis. Outcomes considered were cancer incidence and cancer mortality. In studies evaluating cancer incidence as a time-to-event endpoint and adherence as quantiles, HR was 0.885 (95% CI 0.773-1.013, I2 = 44%). Including ORs, exploratory pooled effect size was 0.876 (0.794-0.966, I2 = 34%), consistently with results of studies evaluating ORs for adherence as one-point increase (OR 0.744, 0.570-0.972, I2 = 90%). No clear benefit was observed on cancer mortality, with pooled HR of 0.935 (0.800-1.093, I2 = 0%). Significant differences were observed for ORs according to cancer type but not between medium and high adherence for both outcomes. Certainty of evidence was low. Our findings suggest that MD could play a protective role in cancer incidence in advanced age, but no clear effect on cancer mortality was observed.

Towards nutrition with precision: unlocking biomarkers as dietary assessment tools

Precision nutrition requires precise tools to monitor dietary habits. Yet current dietary assessment instruments are subjective, limiting our understanding of the causal relationships between diet and health. Biomarkers of food intake (BFIs) hold promise to increase the objectivity and accuracy of dietary assessment, enabling adjustment for compliance and misreporting. Here, we update current concepts and provide a comprehensive overview of BFIs measured in urine and blood. We rank BFIs based on a four-level utility scale to guide selection and identify combinations of BFIs that specifically reflect complex food intakes, making them applicable as dietary instruments. We discuss the main challenges in biomarker development and illustrate key solutions for the application of BFIs in human studies, highlighting different strategies for selecting and combining BFIs to support specific study designs. Finally, we present a roadmap for BFI development and implementation to leverage current knowledge and enable precision in nutrition research.

Biomarkers of food intake and their relevance to metabolic syndrome

Metabolic syndrome (MetS) constitutes a prevalent risk factor associated with non communicable diseases such as cardiovascular disease and type 2 diabetes. A major factor impacting the etiology of MetS is diet. Dietary patterns and several individual food constituents have been related to the risk of developing MetS or have been proposed as adjuvant treatment. However, traditional methods of dietary assessment such as 24 h recalls rely greatly on intensive user-interaction and are subject to bias. Hence, more objective methods are required for unbiased dietary assessment and efficient prevention. While it is accepted that some dietary-derived constituents in blood plasma are indicators for certain dietary patterns, these may be too unstable (such as vitamin C as a marker for fruits/vegetables) or too broad (e.g. polyphenols for plant-based diets) or reflect too short-term intake only to allow for strong associations with prolonged intake of individual food groups. In the present manuscript, commonly employed biomarkers of intake including those related to specific food items (e.g. genistein for soybean or astaxanthin and EPA for fish intake) and novel emerging ones (e.g. stable isotopes for meat intake or microRNA for plant foods) are emphasized and their suitability as biomarker for food intake discussed. Promising alternatives to plasma measures (e.g. ethyl glucuronide in hair for ethanol intake) are also emphasized. As many biomarkers (i.e. secondary plant metabolites) are not limited to dietary assessment but are also capable of regulating e.g. anti-inflammatory and antioxidant pathways, special attention will be given to biomarkers presenting a double function to assess both dietary patterns and MetS risk.

Lipid emulsion structure, digestion behavior, physiology, and health: a scoping review and future directions

Research investigating the effects of the food matrix on health is needed to untangle many unresolved questions in nutritional science. Emulsion structure plays a fundamental role in this inquiry; however, the effects of oil-in-water emulsion structure on broad metabolic, physiological, and health-related outcomes have not been comprehensively reviewed. This systematic scoping review targets this gap and examines methodological considerations for the field of relating food structure and health. MEDLINE, Web of Science, and CAB Direct were searched from inception to December 2022, returning 3106 articles, 52 of which were eligible for inclusion. Many investigated emulsion lipid droplet size and/or gastric colloidal stability and their relation to postprandial weight-loss-related outcomes. The present review also identifies numerous novel relationships between emulsion structures and health-related outcomes. "Omics" endpoints present an exciting avenue for more comprehensive analysis in this area, yet interpretation remains difficult. Identifying valid surrogate biomarkers for long-term outcomes and disease risk will be a turning point for food structure research, leading to breakthroughs in the pace and utility of research that generates advancements in health. The review's findings and recommendations aim to support new hypotheses, future trial design, and evidence-based emulsion design for improved health and well-being.

Precision Nutrition and Cardiovascular Disease Risk Reduction: the Promise of High-Density Lipoproteins

PURPOSE OF REVIEW

Emerging evidence supports the promise of precision nutritional approaches for cardiovascular disease (CVD) prevention. Here, we discuss current findings from precision nutrition trials and studies reporting substantial inter-individual variability in responses to diets and dietary components relevant to CVD outcomes. We highlight examples where early precision nutrition research already points to actionable intervention targets tailored to an individual's biology and lifestyle. Finally, we make the case for high-density lipoproteins (HDL) as a compelling next generation target for precision nutrition aimed at CVD prevention. HDL possesses complex structural features including diverse protein components, lipids, size distribution, extensive glycosylation, and interacts with the gut microbiome, all of which influence HDL's anti-inflammatory, antioxidant, and cholesterol efflux properties. Elucidating the nuances of HDL structure and function at an individual level may unlock personalized dietary and lifestyle strategies to optimize HDL-mediated atheroprotection and reduce CVD risk.

RECENT FINDINGS

Recent human studies have demonstrated that HDL particles are key players in the reduction of CVD risk. Our review highlights the role of HDL and the importance of personalized therapeutic approaches to improve their potential for reducing CVD risk. Factors such as diet, genetics, glycosylation, and gut microbiome interactions can modulate HDL structure and function at the individual level. We emphasize that fractionating HDL into size-based subclasses and measuring particle concentration are necessary to understand HDL biology and for developing the next generation of diagnostics and biomarkers. These discoveries underscore the need to move beyond a one-size-fits-all approach to HDL management. Precision nutrition strategies that account for personalized metabolic, genetic, and lifestyle data hold promise for optimizing HDL therapies and function to mitigate CVD risk more potently. While human studies show HDL play a key role in reducing CVD risk, recent findings indicate that factors such as diet, genetics, glycosylation, and gut microbes modulate HDL function at the individual level, underscoring the need for precision nutrition strategies that account for personalized variability to optimize HDL's potential for mitigating CVD risk.

Low adherence to the Mediterranean diet is associated with increased prevalence and number of atherosclerotic plaques in the ILERVAS cohort

BACKGROUND AND AIMS

Current research on the association between dietary patterns and subclinical atherosclerotic disease (SAD) is still limited, and published results are inconsistent and often consist of small population sizes. We aimed to evaluate the association between the Mediterranean diet (MDiet) and SAD in a large cohort of Mediterranean individuals.

METHODS

This was a cross-sectional study that included 8116 subjects from the ILERVAS cohort. The presence of atherosclerotic plaques (AP) was assessed by ultrasound examination. Adherence to the MDiet was assessed using the 14-item Mediterranean Diet Adherence Score (MEDAS). Inclusion criteria were subjects with at least one cardiovascular risk factor. Exclusion criteria were a clinical history of diabetes, chronic kidney disease, or a prior cardiovascular event. Bivariable and multivariable models were performed.

RESULTS

Compared with subjects without SAD, participants with SAD were older and had a higher frequency of smoking habit, hypertension, dyslipidemia, HbA1c and waist circumference. The adjusted multivariable analysis showed that a higher MEDAS was associated with a lower risk of AP (incidence rate ratios [IRR] 0.97, 95% CI [0.96-0.98]; p<0.001). Furthermore, moderate or high adherence to the MDiet was associated with a lower number of AP compared with a low MDiet adherence (IRR 0.90, 95% CI [0.87-0.94]; p<0.001). In both models, female sex was associated with a lower risk of AP.

CONCLUSIONS

Our findings point to a potentially protective role of MDiet for SAD in a Mediterranean population with low-to-moderate cardiovascular risk. Further research is needed to establish a causal relationship between both variables.

Which Factors Influence Healthy Aging? A Lesson from the Longevity Village of Bama in China

A growing aging population is associated with increasing incidences of aging-related diseases and socioeconomic burdens. Hence, research into healthy longevity and aging is urgently needed. Longevity is an important phenomenon in healthy aging. The present review summarizes the characteristics of longevity in the elderly population in Bama, China, where the proportion of centenarians is 5.7-fold greater than the international standard. We examined the impact of genetic and environmental factors on longevity from multiple perspectives. We proposed that the phenomenon of longevity in this region is of high value for future investigations in healthy aging and aging-related disease and may provide guidance for fostering the establishment and maintenance of a healthy aging society.

Mediterranean Diet Adherence Is Associated with Favorable Health-Related Quality of Life, Physical Activity, and Sleep Quality in a Community-Dwelling Greek Older Population

BACKGROUND

The Mediterranean diet (MD) is a beneficial dietary pattern with strong antioxidant and anti-inflammatory properties that can promote mental and physical human health. This study aims to assess the impact of MD adherence on health-related quality of life, physical activity levels, and sleep quality in a representative Greek elderly population.

METHODS

This is a cross-sectional study. A total of 3254 persons ≥65 years from 14 different Greek regions, urban, rural and islands participated in this study, of which 48.4% were female and 51.6% were male. Health-Related Quality of Life (HRQOL) was evaluated utilizing a short form healthy survey, physical activity was determined by the International Physical Activity Questionnaire (IPAQ), sleep quality was assessed utilizing the Pittsburgh Sleep Quality Index (PSQI) and MD adherence was assessed via the Mediterranean Diet Score (MedDietScore).

RESULTS

Moderate adherence to the MD and an increased prevalence of poor quality of life, low physical activity levels and inadequate sleep quality among the elderly population were recorded. High MD adherence was independently associated with better quality of life (OR: 2.31, 95% CI: 2.06-2.68, p = 0.0008), higher physical activity (OR: 1.89, 95% CI: 1.47-2.35, p = 0.0141) and adequate sleep quality (OR: 2.11, 95%: 1.79-2.44, p = 0.0018), female sex (OR: 1.36, 95% CI: 1.02-1.68, p = 0.0032) and living with others (OR: 1.24, 95% CI: 0.81-1.76, p = 0.0375), after adjustment for potential confounding factors. In unadjusted analysis, participants' age (p < 0.0001), anthropometric characteristics (p < 0.005), educational (p = 0.0026) and financial status (p = 0.0005) and smoking habits (p = 0.0031) were also identified as indicators of MD adherence; however, their impact on MD adherence was considerably attenuated after adjusting for confounding factors (p > 0.05).

CONCLUSION

High MD adherence was correlated with favorable quality of life, higher levels of physical activity, and a more adequate sleep quality score. Strategies and public health policies that facilitate MD adherence and physical activity in older adults may improve sleep and quality of life, impacting overall wellbeing in this age group.

Adherence to Mediterranean Diet: A Population-Based Longitudinal Cohort Study

Adherence to the Mediterranean diet (MedDiet) is recommended for cardiovascular disease prevention. However, recent epidemiological studies report a shift toward lower adherence to MedDiet. We have conducted a prospective cohort study to evaluate changes in individual determinants of MedDiet adherence over time. Clinical information and MedDiet adherence score (MEDAS) were collected in 711 subjects (mean age 68 ± 10 years; 42% males), enrolled in the PLIC study (Progression of Intimal Atherosclerotic Lesions in Carotid arteries), during two visits conducted, on average, 4.5 years apart. MEDAS score worsening and improvements (absolute change, ΔMEDAS) and the variation in the proportion of subjects reporting to meet each MEDAS criteria were assessed. Overall, 34% of the subjects improved their MedDiet adherence (ΔMEDAS: +1.87 ± 1.13), by consuming more olive oil, legumes and fish and use of dishes seasoned with sofrito and 48% subjects worsened their MedDiet adherence (ΔMEDAS: -2.02 ± 1.14) by consuming less fruit, legumes, fish and nuts, with higher rates of worsening in women and subjects aged 50-65 years. Subjects who improved the score were more obese, had higher plasma glucose levels, and metabolic syndrome at the basal visit. In summary, we report an overall decrease in MedDiet adherence, evaluated during a timeframe heavily affected by the COVID-19 pandemic, underlining the need for better dietary interventions.

A nutritional biomarker score of the Mediterranean diet and incident type 2 diabetes: Integrated analysis of data from the MedLey randomised controlled trial and the EPIC-InterAct case-cohort study

BACKGROUND

Self-reported adherence to the Mediterranean diet has been modestly inversely associated with incidence of type 2 diabetes (T2D) in cohort studies. There is uncertainty about the validity and magnitude of this association due to subjective reporting of diet. The association has not been evaluated using an objectively measured biomarker of the Mediterranean diet.

METHODS AND FINDINGS

We derived a biomarker score based on 5 circulating carotenoids and 24 fatty acids that discriminated between the Mediterranean or habitual diet arms of a parallel design, 6-month partial-feeding randomised controlled trial (RCT) conducted between 2013 and 2014, the MedLey trial (128 participants out of 166 randomised). We applied this biomarker score in an observational study, the European Prospective Investigation into Cancer and Nutrition (EPIC)-InterAct case-cohort study, to assess the association of the score with T2D incidence over an average of 9.7 years of follow-up since the baseline (1991 to 1998). We included 22,202 participants, of whom 9,453 were T2D cases, with relevant biomarkers from an original case-cohort of 27,779 participants sampled from a cohort of 340,234 people. As a secondary measure of the Mediterranean diet, we used a score estimated from dietary-self report. Within the trial, the biomarker score discriminated well between the 2 arms; the cross-validated C-statistic was 0.88 (95% confidence interval (CI) 0.82 to 0.94). The score was inversely associated with incident T2D in EPIC-InterAct: the hazard ratio (HR) per standard deviation of the score was 0.71 (95% CI: 0.65 to 0.77) following adjustment for sociodemographic, lifestyle and medical factors, and adiposity. In comparison, the HR per standard deviation of the self-reported Mediterranean diet was 0.90 (95% CI: 0.86 to 0.95). Assuming the score was causally associated with T2D, higher adherence to the Mediterranean diet in Western European adults by 10 percentiles of the score was estimated to reduce the incidence of T2D by 11% (95% CI: 7% to 14%). The study limitations included potential measurement error in nutritional biomarkers, unclear specificity of the biomarker score to the Mediterranean diet, and possible residual confounding.

CONCLUSIONS

These findings suggest that objectively assessed adherence to the Mediterranean diet is associated with lower risk of T2D and that even modestly higher adherence may have the potential to reduce the population burden of T2D meaningfully.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000602729 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363860.

Association of healthy sleep pattern with the risk of cardiovascular disease and all-cause mortality among people with diabetes: A prospective cohort study

AIMS

This study aimed to assess the association of healthy sleep pattern with the risk of cardiovascular disease and all-cause mortality among people with diabetes.

METHODS

Our study included 12,770 individuals from the UK Biobank at baseline. Sleep patterns were defined by a combination of five sleep behaviors (chronotype, sleep duration, snoring, insomnia, and excessive daytime sleepiness). The competing risk models were used to estimate the relationship between sleep patterns and CVD (including coronary heart disease [CHD] and stroke) in individuals with diabetes. To examine the association between sleep patterns and all-cause mortality risk, we utilized the flexible parametric Royston-Parmar proportion-hazard models.

RESULTS

We recorded 2627 CVD events, which includes 1999 CHD and 903 S events, and 1576 all-cause mortality events. Compared to those with poor sleep pattern, individuals having healthy sleep pattern have a 24% lower CVD risk (p < 0.001), a 26% lower CHD risk (p = 0.001), a 25% lower stroke risk (p = 0.036), and a 21% lower all-cause mortality risk (p = 0.020).

CONCLUSIONS

Adherence to healthy sleep pattern has been significantly related to cardiovascular disease and all-cause mortality risk reduction among people with diabetes.