Cardiovascular health in Spain based on the Life's Essential 8 and its association with all-cause and cardiovascular mortality: the ENRICA cohort

INTRODUCTION AND OBJECTIVES

The American Heart Association has recently developed the Life's Essential 8 (LE8) score to encourage prevention of cardiovascular disease (CVD). This study assessed the distribution of LE8 in the Spanish adult population and its association with all-cause and CVD death.

METHODS

We used data from 11 616 individuals aged 18 years and older (50.5% women) from the ENRICA study, recruited between 2008 and 2010 and followed up until 2020 to 2022. The LE8 score includes 8 metrics (diet, physical activity, nicotine exposure, sleep health, body mass index, blood lipids and glucose, and blood pressure) and ranges from 0 to 100. The association of LE8 score with mortality was summarized with hazard ratios (HR), obtained from Cox regression.

RESULTS

In total, 13.2% of participants (range, 6.1%-16.9% across regions) had low cardiovascular health (LE8 ≤ 49). During a median follow-up of 12.9 years, 908 total deaths occurred, and, during a median follow-up of 11.8 years, 207 CVD deaths were ascertained. After adjustment for the main potential confounders and compared with being in the least healthy (lowest) quartile of LE8, the HR (95%CI) of all-cause mortality for the second, third and fourth quartiles were 0.68 (0.56-0.83), 0.63 (0.51-0.78), and 0.53 (0.39-0.72), respectively. The corresponding figures for CVD mortality, after accounting for competing mortality risks, were 0.62 (0.39-0.97), 0.55 (0.32-0.93), and 0.38 (0.16-0.89).

CONCLUSIONS

A substantial proportion of the Spanish population showed low cardiovascular health. A higher LE8 score, starting from the second quartile, was associated with lower all-cause and CVD mortality.

Diet Quality and Multimorbidity in Older Adults: A Prospective Cohort Study

BACKGROUND

The role of diet quality in the accumulation of multiple chronic conditions is mostly unknown. This study examined diet quality in association with the number of chronic conditions and the rate of multimorbidity development among community-dwelling older adults.

METHODS

We used data from 2 784 adults aged ≥65 years from the Seniors-ENRICA 2 cohort. Diet quality was assessed at baseline (2015-17) with the Alternate Healthy Eating Index-2010 (AHEI-2010) and the Mediterranean Diet Adherence Screener (MEDAS). Information on medical diagnoses was obtained from electronic clinical records up to 2021.

RESULTS

Higher adherence to the AHEI-2010 was associated with a lower number of total chronic conditions (β [95% CI] quartile 4 vs 1: -0.57 [-0.86 to 0.27], p trend < .001] and cardiometabolic conditions (-0.30 [-0.44 to -0.17], p trend < .001) at baseline, while higher adherence to the MEDAS was associated with a lower number of total chronic conditions (-0.30 [-0.58 to -0.02], p trend = .01) and neuropsychiatric and neurodegenerative conditions (-0.09 [-0.17 to -0.01], p trend = .01). After a median follow-up of 5.2 years (range: 0.1-6.1 years) higher adherence to the AHEI-2010 was associated with a lower increase in chronic conditions (β [95% confidence interval] quartile 4 vs 1: -0.16 [-0.30 to -0.01], p trend = .04) and with lower rate of chronic disease accumulation.

CONCLUSIONS

Higher diet quality, as measured by the AHEI-2010, was associated with a lower number of chronic health conditions and a lower rate of multimorbidity development over time.

Dietary vitamin C intake and changes in frequency, severity, and location of pain in older adults

BACKGROUND

Oral vitamin C supplementation has been associated with lower risk of chronic postsurgical pain. However, the effect of dietary vitamin C on pain in a non-surgical setting is unknown. We aimed to investigate the association between dietary vitamin C intake and changes over time in chronic pain and its characteristics in community-dwelling adults aged 60+ years.

METHODS

We pooled data from participants of the Seniors-ENRICA-1 (n=864) and Seniors-ENRICA-2 (n=862) cohorts who reported pain at baseline or at follow-up. Habitual diet was assessed with a face-to-face diet history and dietary vitamin C intake was estimated using standard food composition tables. Pain changes over time were the difference between scores at baseline and follow-up obtained from a pain scale that considered the frequency, severity, and number of pain locations. Multivariable-adjusted relative risk ratios (RRR) were obtained using multinomial logistic regression.

RESULTS

After a median follow-up of 2.6 years, pain worsened for 696 (40.3%) participants, improved for 734 (42.5%), and did not change for 296 (17.2%). Compared to the lowest tertile of energy-adjusted vitamin C intake, those in the highest tertile had a higher likelihood of overall pain improvement (RRR 1.61 [95% confidence interval 1.07-2.41],p-trend 0.02). Higher vitamin C intake was also associated with lower pain frequency (1.57 [1.00-2.47],p-trend=0.05) and number of pain locations (1.75 [1.13-2.70],p-trend=0.01).

CONCLUSIONS

Higher dietary vitamin C intake was associated with improvement of pain and with lower pain frequency and number of pain locations in older adults. Nutritional interventions to increase dietary vitamin C intake with the aim of improving pain management require clinical testing.

Growth differentiation factor 15 and malnutrition in older adults

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.

Association of a Mediterranean Lifestyle With All-Cause and Cause-Specific Mortality: A Prospective Study from the UK Biobank

OBJECTIVE

To examine the association between the Mediterranean lifestyle and all-cause, cancer, and cardiovascular disease (CVD) mortality in a British population.

PATIENTS AND METHODS

We studied 110,799 individuals 40 to 75 years of age from the UK Biobank cohort, free of CVD or cancer between 2009 and 2012 who were followed-up to 2021. The Mediterranean lifestyle was assessed at baseline through the Mediterranean Lifestyle (MEDLIFE) index, derived from the lifestyle questionnaire and diet assessments and comprising three blocks: (1) "Mediterranean food consumption," (2) "Mediterranean dietary habits," and (3) "physical activity, rest, social habits, and conviviality." Death information was retrieved from death register records. Cox regression models were used to analyze the study associations.

RESULTS

During a median 9.4-year follow-up, 4247 total deaths, 2401 cancer deaths, and 731 CVD deaths were identified. Compared with the first quartile of the MEDLIFE index, increasing quartiles had HRs of 0.89 (95% CI, 0.81 to 0.97), 0.81 (95% CI, 0.74 to 0.89), and 0.71 (95% CI, 0.65 to 0.78) (P-trend<.001 for all-cause mortality). For cancer mortality, the quartiles had HRs of 0.90 (95% CI, 0.80 to 1.01), 0.83 (95% CI, 0.74 to 0.93), and 0.72 (95% CI, 0.64 to 0.82) (P-trend<.001). All MEDLIFE index blocks were independently associated with lower risk of all-cause and cancer death, and block 3 was associated with lower CVD mortality.

CONCLUSION

Higher adherence to the Mediterranean lifestyle was associated with lower all-cause and cancer mortality in British middle-aged and older adults in a dose-response manner. Adopting a Mediterranean lifestyle adapted to the local characteristics of non-Mediterranean populations may be possible and part of a healthy lifestyle.

Exposure to green spaces, cardiovascular risk biomarkers and incident cardiovascular disease in older adults: The Seniors-Enrica II cohort

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.

The Southern European Atlantic diet and all-cause and cause-specific mortality: a European multicohort study

AIMS

The Southern European Atlantic diet (SEAD) is the traditional dietary pattern of northwestern Spain and northern Portugal, but it may resemble that of central, eastern, and western European countries. The SEAD has been found associated with lower risk of myocardial infarction and mortality in older adults, but it is uncertain whether this association also exists in other European populations and if it is similar as that found in its countries of origin.

METHODS AND RESULTS

We conducted a prospective analysis of four cohorts with 35 917 subjects aged 18-96 years: ENRICA (Spain), HAPIEE (Czechia and Poland), and Whitehall II (United Kingdom). The SEAD comprised fresh fish, cod, red meat and pork products, dairy, legumes and vegetables, vegetable soup, potatoes, whole-grain bread, and moderate wine consumption. Associations were adjusted for sociodemographic variables, energy intake, lifestyle, and morbidity. After a median follow-up of 13.6 years (range = 0-15), we recorded 4 973 all-cause, 1 581 cardiovascular, and 1 814 cancer deaths. Higher adherence to the SEAD was associated with lower mortality in the pooled sample. Fully adjusted hazard ratios and 95% confidence interval per 1-standard deviation increment in the SEAD were 0.92 (0.89, 0.95), 0.91 (0.86, 0.96), and 0.94 (0.89, 0.99) for all-cause, cardiovascular, and cancer mortality, respectively. The association of the SEAD with all-cause mortality was not significantly different between countries [Spain = 0.93 (0.88, 0.99), Czechia = 0.94 (0.89,0.99), Poland = 0.89 (0.85, 0.93), United Kingdom = 0.98 (0.89, 1.07); P for interaction = 0.16].

CONCLUSION

The SEAD was associated with lower all-cause, cardiovascular, and cancer mortality in southern, central, eastern, and western European populations. Associations were of similar magnitude as those found for existing healthy dietary patterns.

Mediterranean lifestyle index and 24-h systolic blood pressure and heart rate in community-dwelling older adults

Specific foods, nutrients, dietary patterns, and physical activity are associated with lower blood pressure (BP) and heart rate (HR), but little is known about the joint effect of lifestyle factors captured in a multidimensional score. We assessed the association of a validated Mediterranean-lifestyle (MEDLIFE) index with 24-h-ambulatory BP and HR in everyday life among community-living older adults. Data were taken from 2,184 individuals (51% females, mean age: 71.4 years) from the Seniors-ENRICA-2 cohort. The MEDLIFE index consisted of 29 items arranged in three blocks: 1) Food consumption; 2) Dietary habits; and 3) Physical activity, rest, and conviviality. A higher MEDLIFE score (0-29 points) represented a better Mediterranean lifestyle adherence. 24-h-ambulatory BP and HR were obtained with validated oscillometric devices. Analyses were performed with linear regression adjusted for the main confounders. The MEDLIFE-highest quintile (vs Q1) was associated with lower nighttime systolic BP (SBP) (-3.17 mmHg [95% CI: -5.25, -1.08]; p-trend = 0.011), greater nocturnal-SBP fall (1.67% [0.51, 2.83]; p-trend = 0.052), and lower HR (-2.04 bpm [daytime], -2.33 bpm [nighttime], and -1.93 bpm [24-h]; all p-trend < 0.001). Results were similar for each of the three blocks of MEDLIFE and by hypertension status (yes/no). Among older adults, higher adherence to MEDLIFE was associated with lower nighttime SBP, greater nocturnal-SBP fall, and lower HR in their everyday life. These results suggest a synergistic BP-related protection from the components of the Mediterranean lifestyle. Future studies should determine whether these results replicate in older adults from other Mediterranean and non-Mediterranean countries.

Exposure to residential traffic and trajectories of unhealthy ageing: results from a nationally-representative cohort of older adults

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.

Animal and vegetable protein intake and malnutrition in older adults: a multicohort study

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.

Associations of physical activity type, volume, intensity, and changes over time with all-cause mortality in older adults: The Seniors-ENRICA cohorts

OBJECTIVE

To assess the association of physical activity (PA) type, volume, intensity, and changes over time with all-cause mortality in older adults.

METHODS

We used data from 3518 and 3273 older adults recruited in the Seniors-ENRICA-1 and 2 cohorts. PA was assessed with the EPIC questionnaire. Participants reported how many hours they spent a week in walking, cycling, gardening, do-it-yourself (DIY), sports, and housework. Then, time at each intensity (moderate PA [MPA], vigorous PA [VPA], moderate-to-vigorous PA [MVPA] and total PA) was calculated. Changes in PA were calculated from the date of the baseline interview to Wave 1. All-cause mortality was ascertained up January 31, 2022. Analyses were performed with Cox regression models, adjusting for the main confounders.

RESULTS

Walking, gardening, sports, and housework was associated with lower mortality (ranged 20%-46%). Also, MPA, VPA, MVPA was associated with lower risk of mortality (ranged 28%-53%). Analyses of PA change showed that, compared no PA participation (at baseline nor Wave 1), maintain walking, sports, and housework (ranged 28%-53%) and maintaining MPA, VPA, and MVPA (ranged 32%-36%) levels was linked to decreased mortality risk. Those who increased, maintained, or even decreased total PA had lower mortality (57%, 52%, and 36%, respectively) than those with consistently very low PA.

CONCLUSIONS

The lower mortality was observed in those with a high baseline level of total PA. Maintaining PA levels such as walking, gardening, and housework, or at all analyzed intensities, was related to lower mortality.

Blood Selenium Concentrations Are Inversely Associated with the Risk of Undernutrition in Older Adults

BACKGROUND

Selenium is an essential trace element with an antioxidant and anti-inflammatory capacity that has been associated in experimental studies with beneficial effects on appetite control, the regulation of the gut microbiota, and control of the anabolic-catabolic balance. The main aim of the present study was to evaluate the association between circulating selenium concentrations and the risk of developing undernutrition in older adults.

METHODS

This was a cohort study with 1398 well-nourished community-dwelling individuals aged ≥ 65 years residing in Spain in 2017, who were followed for a mean of 2.3 years. Whole blood selenium was measured at baseline using inductively coupled plasma-mass spectrometry. Undernutrition was assessed at baseline and at follow-up, and defined as having at least one of the three GLIM phenotypic criteria (involuntary weight loss, a low body mass index, and a reduced muscle mass) and at least one of the two etiologic criteria (reduced food consumption or nutrient assimilation and inflammation/disease burden).

RESULTS

During the follow-up, 142 participants (11%) developed moderate undernutrition and 113 (8.8%) severe undernutrition. The standardized relative risks of moderate and severe undernutrition at the 75th percentile of Se levels versus the 25th were 0.90 and 0.70, respectively. In dose-response analyses, the risk of severe undernutrition decreased linearly with increasing selenium concentrations. This association was independent of protein intake or diet quality and was stronger among participants with a diagnosis of a musculoskeletal disorder.

CONCLUSIONS

The results suggest that an adequate dietary selenium status is needed to prevent undernutrition in older adults. Also, this may open the door for clinical trials with selenium supplementation, at doses considered as safe, to prevent undernutrition.

Association between a mediterranean lifestyle and Type 2 diabetes incidence: a prospective UK biobank study

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 < 0.001). All three blocks of MEDLIFE were independently associated with lower risk of diabetes.

CONCLUSIONS

Higher adherence to the MEDLIFE index was associated with lower risk of type 2 diabetes in the UK Biobank. A Mediterranean-type lifestyle, culturally adapted to non-Mediterranean populations, could help prevent diabetes.

The Southern European Atlantic diet and depression risk: a European multicohort study

The Southern European Atlantic diet (SEAD) is the traditional dietary pattern of north-western Spain and northern Portugal, but it may resemble that of other European countries. The SEAD has been found associated with lower risk for myocardial infarction and mortality. Since dietary patterns may also influence mental health, we examined the association between the SEAD and depression risk in southern, central, eastern, and western European populations. We conducted a prospective analysis of five cohorts (13,297 participants aged 45-92 years, free of depression at baseline): Seniors-ENRICA-1 and Seniors-ENRICA-2 (Spain), HAPIEE (Czechia and Poland), and Whitehall-II (United Kingdom). The SEAD comprised cod, other fresh fish, red meat and pork products, dairy, legumes and vegetables, vegetable soup, potatoes, whole-grain bread, and moderate wine consumption. Depression at follow-up was defined according to presence of depressive symptoms (based on available scales), use of prescribed antidepressants, inpatient admissions, or self-reported diagnosis. Associations were adjusted for sociodemographic, lifestyle, and dietary variables. During a median follow-up of 3.9 years (interquartile range 3.4-4.9), there were 1437 new depression cases. Higher adherence to the SEAD was associated with lower depression risk in the pooled sample. Individual food groups showed a similar tendency, albeit non-significant. The fully adjusted odds ratio (95% confidence interval) per 1-standard deviation increment in the SEAD was 0.91 (0.86, 0.96). This association was rather consistent across countries [Spain = 0.86 (0.75, 0.99), Czechia = 0.86 (0.75, 0.99), Poland = 0.97 (0.89, 1.06), United Kingdom = 0.85 (0.75, 0.97); p for interaction = 0.24], and was of similar magnitude as that found for existing healthy dietary patterns. In conclusion, the SEAD was associated with lower depression risk across European populations. This may support the development of mood disorder guidelines for Southern European Atlantic regions based on their traditional diet, and for central, eastern, and western European populations based on the SEAD food groups that are culturally rooted in these places.

Performance and validation of the Healthy Heart Score model for predicting 12-year cardiovascular mortality in a nationwide Mediterranean population

INTRODUCTION AND OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

The role of lifestyle in the association between frailty and all-cause mortality amongst older adults: a mediation analysis in the UK Biobank

OBJECTIVE

frailty is a syndrome characterised by increased vulnerability to stressors, which manifests as higher death risk. Whilst guidelines for frailty management usually entails lifestyle modifications (e.g. physical exercise, diet), the mediating role of lifestyle on the excess mortality associated with frailty is unclear. This study estimates the death risk due to frailty that could be avoided with a healthy lifestyle in older adults.

SUBJECTS AND METHODS

we analysed data from 91,906 British individuals aged ≥60 years recruited between 2006 and 2010. At baseline, frailty was identified according to Fried's phenotype, and a four-item Healthy Lifestyle Index (HLS) was calculated based on physical activity, diet, smoking and alcohol consumption. Mortality was ascertained from baseline through 2021. A mediation analysis under the counterfactual framework was performed adjusting for the main confounders.

RESULTS

during a median follow-up of 12.5 years, 9,383 deaths occurred. Frailty was directly associated with all-cause mortality (hazard ratio: 2.30 [95% confidence interval {CI} 2.07, 2.54]), and inversely associated with the HLS (ß: -0.45 points [-0.49, -0.40]). The hazard ratio [95%CI] for the direct effect of frailty on mortality was 2.12 [1.91, 2.34], whilst for the indirect effect (mediated by HLS) was 1.08 [1.07, 1.10]. The mediated proportion of HLS on mortality was 13.55% [11.26, 16.20], with physical activity having the highest proportion amongst the four HLS items (7.69% [5.00, 10.40]).

CONCLUSIONS

a healthy lifestyle partly mediates the association between frailty and mortality in British older adults. Since this was an exploratory mediation analysis, these results should be specifically tested in future research.

Association of blood manganese concentrations with 24-h based brachial and central blood pressure, and pulse-wave velocity

Potential environmental determinants of BP and hypertension in older adults are far less known than their lifestyle risk factors. Manganese (Mn) is an essential element for life that may induce changes in blood pressure (BP), but the direction of the association is unclear. We aimed to examine the association of blood manganese (bMn) with 24-h-based brachial, central BP (cBP), and pulse-wave velocity (PWV). With this purpose, we analyzed data from 1009 community-living adults aged >65 years without BP medication. bMn was measured using inductively-coupled plasma-mass spectrometry and 24-h BP with validated devices. The association of bMn (median: 6.77 μg/L; IQR: 5.59-8.27) with daytime brachial and central systolic (SBP) and with diastolic BP (DBP) was non-linear, with BP increases up to around the median of Mn and then stabilization or slight rightward decrease. Mean BP differences (95% confidence interval) comparing Mn Q2 to Q5 (vs Q1 quintile) for brachial daytime SBP were 2.56 (0.22; 4.90), 3.59 (1.22; 5.96), 3.14 (0.77; 5.51) and 1.72 (-0.68; 4.11) mmHg, respectively; and 2.22 (0.70, 3.73), 2.55 (1.01, 4.08), 2.45 (0.91; 3.98), and 1.68 (0.13; 3.24), respectively, for DBP. Daytime central-pressures showed a similar dose-response relationship with bMn as daytime brachial-pressures. The association with nighttime BP was linearly positive for brachial BPs, and only increasing for Q5 for cBP. Regarding PWV, a tendency to significant linear increase along bMn levels was observed (p-trend = 0.042). The present findings extend the scarce evidence on the association between Mn and brachial BP to 2 other vascular parameters, suggesting Mn levels as a candidate risk factor for increasing levels of both brachial and cBPs in older adults, yet further research is needed with larger cohort studies in adults at all age ranges.

Device-measured movement behaviors and cardiac biomarkers in older adults without major cardiovascular disease: the Seniors-ENRICA-2 study

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.

The Inflammatory Potential of Diet and Pain Incidence: A Cohort Study in Older Adults

BACKGROUND

Despite its importance, evidence regarding pain prevention is inadequate. Leveraging the growing knowledge on how diet regulates inflammation, we examined the association of 3-year changes in the inflammatory potential of diet with pain incidence over the subsequent 3 years.

METHODS

We used data from 819 individuals aged ≥60 years and free of pain in 2012, drawn from the Spanish Seniors-ENRICA-1 cohort. The inflammatory potential of diet was estimated via a validated diet history and 2 indices: the dietary inflammatory index (DII) and the empirical dietary inflammatory index (EDII). The frequency, severity, and number of locations of incident pain were combined into a scale that classified participants as suffering from no pain, intermediate pain, or highest pain.

RESULTS

Shifting the diet toward a higher inflammatory potential was associated with subsequent increased risk of highest pain (fully-adjusted relative risk ratio [95% confidence interval] per 1-standard deviation increment in the DII and the EDII = 1.45 [1.16,1.80] and 1.21 [0.98,1.49], respectively) and intermediate pain (0.99 [0.75,1.31] and 1.37 [1.05,1.79]). The 3 components of the pain scale followed similar trends, the most consistent one being pain severity (moderate-to-severe pain: DII = 1.39 [1.11,1.74]; EDII = 1.35 [1.08,1.70]). The association of increasing DII with highest incident pain was only apparent among the less physically active participants (2.08 [1.53,2.83] vs 1.02 [0.76,1.37]; p-interaction = .002).

CONCLUSION

An increase in the inflammatory potential of diet was associated with higher pain incidence over the following years, especially among the less physically active participants. Future studies in older adults should assess the efficacy of pain prevention interventions targeting the inflammatory potential of diet.

Association between a Mediterranean lifestyle and growth differentiation factor 15: The seniors ENRICA-2 cohort

BACKGROUND

Growth Differentiation Factor 15 (GDF-15) is a marker of inflammation and oxidative stress that has been associated with multiple age-related chronic diseases. Since lifestyle is key for preventing these adverse health outcomes, we examined the association between a Mediterranean lifestyle and GDF-15 serum concentrations in Spanish older adults.

METHODS

We used cross-sectional data from 2502 older adults participating in the Seniors ENRICA-2 cohort. Adherence to the Mediterranean lifestyle was assessed with the 27-item MEDLIFE index, divided into three blocks: 1) "Mediterranean food consumption, 2) Mediterranean dietary habits, 3) Physical activity, rest, social habits, and conviviality". Analyses of the association between the MEFLIFE index and GDF-15 concentrations were performed using multivariable linear regression models adjusting for the main potential confounders.

RESULTS

The MEDLIFE index was inversely associated with GDF-15. Compared with participants in the lowest quartile of the MEDLIFE score, GDF-15 mean percentage differences (95% CI) were -3.0% (-8.0, 2.3) for the second quartile, -8.7% (-13.0, -4.1) for the third quartile, and -10.1% (-15.0, -4.9) for the fourth quartile (p-trend<0.001). Block 3 of MEDLIFE, and particularly doing sufficient physical activity, adequate sleep duration, and participating in collective sports, was individually linked to lower concentrations of GDF-15. Results remained similar after excluding participants with cardiovascular disease, type 2 diabetes, or obesity.

CONCLUSIONS

A Mediterranean lifestyle was associated with reduced levels of GDF-15, suggesting that a combination of multiple lifestyles may be an integral approach to reduce chronic inflammation and disease burden in older adults.

Nut Consumption and Depression: Cross-Sectional and Longitudinal Analyses in Two Cohorts of Older Adults

OBJECTIVES

To assess the cross-sectional and longitudinal associations between nut consumption and depression in two cohorts of older adults.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

The first cohort (Seniors-ENRICA-I or SE-I) included a representative sample of Spanish noninstitutionalized adults aged ≥65 years interviewed in 2010 and 2013. The second cohort (SE-II) included individuals from the Madrid region, Spain, aged ≥65 years interviewed in 2017 and in 2019. Nut consumption was estimated with a validated computer-based diet history. Depression was defined as self-reported physician-diagnosed depression or the use of antidepressants. Logistic regression models were adjusted for the main confounders. The DerSimonian and Laird random-effect method was used to meta-analyze the results from both studies. A participant-level pooled analysis was conducted to examine the robustness of our analyses.

RESULTS

The SE-I included 2278 individuals (233 prevalent cases) in the cross-sectional analysis and 1534 (108 incident cases) in the longitudinal analysis; the corresponding figures for SE-II were 2726 (407 prevalent cases) and 1566 (74 incident cases). In the meta-analysis of cross-sectional results from the two studies, compared to consuming <1 serving (30 g) of nuts/week, the odds ratio (95% confidence interval) for depression was 0.90 (0.64, 1.16) for consuming 1 to <3 servings/week and 0.92 (0.70, 1.13) for consuming ≥3 servings/week; the corresponding figures for the longitudinal results were 0.90 (0.41, 1.38) and 0.66 (0.35, 0.97).

CONCLUSION

Nut consumption was associated with a lower risk of depression in a pooled longitudinal analysis using data from two cohorts of older adults. Nuts should be recommended as part of a healthy diet in older adults.

Proinflammatory dietary pattern and depression risk in older adults: Prospective analyses from the Seniors-ENRICA studies

BACKGROUND & AIMS

Only a few studies have assessed the association between a proinflammatory diet and the risk of depression in older adults, and they have rendered weak results. The present study analysed the association between the Dietary Inflammatory Index (DII) and incident self-reported diagnosis or symptoms of depression in two cohorts of community-dwelling older adults in Spain.

METHODS

We used data from the Seniors-ENRICA-I (SE-I) and Seniors-ENRICA-II (SE-II) cohorts. In both cohorts, the baseline DII was calculated from habitual food consumption estimated with a validated computer-based diet history. The incidence of both physician self-reported diagnosis of depression and mild-to-major depressive symptoms (≥3 on the 10-item Geriatric Depression Scale) was analysed. Logistic regression models were adjusted for the main potential confounders, such as sociodemographics, lifestyles, and comorbidities. The results of both cohorts were pooled using a random effects model.

RESULTS

Among the 1627 participants in SE-I (mean age 71.5 ± 5.5 y, 53.1% women) and the 1579 in SE-II (mean age 71.4 ± 4.2, 46.7% women), 86 (5.3%) and 140 (8.9%) incident cases of depression were identified after a mean 3.2-y and 2.3-y follow-up, respectively. The fully adjusted odds ratio (95% confidence interval) of incident depression for the highest (the highest proinflammatory diet) versus the lowest quartile of DII was 2.76 (1.25-6.08, p-for-trend = 0.005) in the SE-I, 1.90 (1.04-3.40, p-for-trend = 0.005) in the SE-II and 2.07 (1.01-3.13) in the pooled cohorts. The results were consistent across strata defined by sex, age, physical activity, loneliness/poor social network, and morbidity.

CONCLUSIONS

A proinflammatory dietary pattern is associated with depression risk in older adults. Future research should evaluate whether reducing the inflammatory component of diet leads to reduced depression symptoms in this population.

Secondhand Tobacco Smoke and Functional Impairments in Older Adults Living in the Community

BACKGROUND/AIM

There has been no comprehensive examination of the potential association of SHS with broad functional limitation assessment in older adults, where functional limitations are burdensome and challenging.

METHODS

We examined 2258 community-dwelling non-smoking older adults from the Seniors-Enrica-2-cohort. At baseline (2017) and follow-up (2019) grip strength was measured with a Jamar dynamometer, lower-extremity performance with the Short Physical Performance Battery (SPPB), overall physical function using the physical component summary (PCS) of the Spanish version of the SF-12, frailty with a Deficits Accumulation Index (DAI), and mobility limitations with the Rosow-Breslau scale. Baseline exposure to SHS was assessed by serum cotinine, and past exposure was self-reported. Cross-sectional analyses were performed using linear and logistic regression models, whereas functional performance changes were examined using repeated measures models with robust SE estimates.

RESULTS

Overall, the median (IQR) serum cotinine concentration was 0.079 (0.035-0.175) ng/ml, with 20 participants presenting concentrations ≥3 ng/ml. Compared to the unexposed, fully-adjusted models showed that the highest exposure group (≥0.239 ng/ml) presented lower grip strength (mean difference: -1.05 kg; 95% CI = -1.80, -0.31) and higher DAI scores (1.52; 95% CI = 0.38, 2.66) at baseline. Similarly, in models of self-reported past exposure, never-smokers who had lived with ≥2 smokers or been exposed to higher SHS cumulative doses showed lower baseline SPPB values, higher DAI scores, and higher prevalence of mobility limitations. In prospective analyses, those in the highest quartile of baseline cotinine presented harmful SPPB [-0.24 (-0.46, -0.02)] and DAI [1.28 (0.00, 2.55)] changes, and higher risk of mobility limitations [hazard ratio: 1.64; 95% CI = 1.01, 2.68] than the unexposed.

CONCLUSIONS

SHS exposure over the life-course and during old age may accelerate functional decline.

IMPLICATIONS

This manuscript provides a comprehensive examination of the relationship between secondhand smoke exposure and a broad range of functional limitations in older adults. Results show that: (i) non-smokers who had been exposed to higher cumulative doses of SHS in adulthood show worse physical function than non-exposed. (ii) Exposure to SHS during old age, as measured with cotinine concentrations, is associated with accelerated short-term functional declines. (iii) The effects of SHS are stronger among older adults with chronic morbidities. (iv) Results suggest that more efforts are needed to protect older adults from passive smoking, especially to those with chronic conditions because of their potential greater vulnerability to the effects of SHS.

Plant-Based Diets and All-cause and Cardiovascular Mortality in a Nationwide Cohort in Spain: The ENRICA Study

OBJECTIVE

To investigate the associations of a healthful plant-based diet index (hPDI) and an unhealthful plant-based diet index (uPDI) with all-cause and cardiovascular disease (CVD) mortality in Spanish adults.

PATIENTS AND METHODS

We analyzed data from 11,825 individuals 18 years of age or older, representative of the Spanish population, recruited between 2008 and 2010 and followed-up to 2020. Food consumption was collected at baseline using a validated dietary history, which served to calculate two plant-based diet indices based on 18 major food groups (range, 18-90 points). For (1) hPDI only the consumption of healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils, and tea/coffee) received positive scores; whereas for (2) uPDI, only the consumption of less healthy plant foods (fruit juices, sugar-sweetened beverages, refined grains, potatoes, and sweets/desserts) received positive scores. Multivariable-adjusted Cox models were used to estimate HRs and their 95% CIs.

RESULTS

After a median follow-up of 10.9 and 9.8 years, 699 all-cause and 157 CVD deaths were ascertained, respectively. Each 10-point increase in hPDI was associated with 14% lower risk of all-cause death (HR, 0.86; 95% CI, 0.74 to 0.99), and 37% lower risk of CVD death (HR, 0.63; 95% CI, 0.46 to 0.85). No significant associations were found for uPDI.

CONCLUSION

Higher adherence to an hPDI diet, but not to a uPDI, was associated with lower all-cause and CVD mortality. This suggests that the quality of the plant food consumed is paramount to achieve diet-related benefits in mortality.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02804672.

Fish consumption, omega-3 fatty acid intake, and risk of pain: the Seniors-ENRICA-1 cohort

BACKGROUND & AIMS

Omega-3 fatty acids have anti-inflammatory and analgesic (anti-nociceptive) actions. However, the relation of habitual omega-3 fatty acid intake and fish consumption - its main food source - with pain remains largely unknown. We examined the association of fish consumption and marine omega-3 fatty acid intake with pain incidence and worsening over 5 years among older adults.

METHODS

Data were taken from the Seniors - ENRICA-1 cohort, which included 950 individuals aged ≥60 years in Spain. Habitual fish consumption and marine omega-3 fatty acid intake during the previous year were assessed in 2008-2010 and 2012 with a validated diet history. Pain was assessed in 2012 and 2017 with a scale developed from the Survey on Chronic Pain in Europe, ranging from 0 (no pain) to 6 (highest pain), according to its severity, frequency, and number of locations. Analyses on pain incidence were conducted in the 524 participants free of pain at baseline, while those on pain worsening were performed in the overall cohort, and both were adjusted for sociodemographic variables, lifestyle, morbidity, and diet quality.

RESULTS

Higher oily fish consumption was associated with reduced pain incidence and worsening over 5 years [fully adjusted odds ratios (95% confidence interval) = 0.68 (0.50,0.94) and 0.70 (0.55,0.88) for every 25 g/day increment (1.5 servings/week), respectively]. Total and white fish consumption were not associated with pain. Higher marine omega-3 fatty acid intake was inversely associated with pain worsening [odds ratio (95% confidence interval) per 0.5 g/day increment = 0.83 (0.72,0.96)]. The corresponding associations for eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were 0.53 (0.33,0.87) and 0.73 (0.57,0.94).

CONCLUSIONS

In this cohort of Spanish older adults, increased oily fish consumption was inversely associated with pain incidence and worsening over 5 years, while higher marine omega-3 fatty acid intake (and that of EPA and DHA) was linked to less pain worsening.

The Southern European Atlantic Diet and depression incidence: a multicohort study

Background

The Southern European Atlantic Diet (SEAD) is the traditional diet of Northern Portugal and North-Western Spain, but it may resemble that of other European countries. Higher adherence to SEAD has been associated with lower risk for myocardial infarction and all-cause mortality, but its relationship with mental health is uncertain. We examined the association between SEAD and depression incidence in Southern, Central, and Eastern Europe.

Methods

We used data from participants ≥45 years from the Seniors-ENRICA-2 and HAPIEE cohorts, who were followed for a median time of 3.6 years. SEAD comprised fresh fish, cod, red meat and pork products, dairy, legumes and vegetables, vegetable soup, potatoes, whole-grain bread, and wine. Depressive symptoms were assessed with the GDS 10 and the CES-D 10 (participants with scores ≥4 were considered depression cases). Statistical analyses were performed among the 14675 participants who were depression-free at baseline.

Results

Higher adherence to SEAD was preliminarily associated with lower depression incidence in the pooled sample (fully adjusted odds ratio [95% confidence interval] per 1-SD increment in the SEAD = 0.93 [0.89,0.98]). Results were consistent in Spain (odds ratio [95% confidence interval] 0.86 [0.68,1.08]), Czechia (0.92 [0.82,1.04]), Poland (0.94 [0.88,1.01]), and Russia (0.93 [0.87,1.00]). The association of SEAD with depression in the pooled sample was similar to that found for the Alternate Healthy Eating Index (odds ratio [95% confidence interval] per 1-SD increment = 0.94 [0.89,0.99]) and the Mediterranean Dietary Score (0.94 [0.90,0.98]).

Conclusions

Adherence to SEAD was preliminarily associated with lower depression incidence in Spain, Czechia, Poland, and Russia. These findings may support the development of mental health guidelines for Southern European Atlantic populations based on their traditional diet, and for Central and Eastern European countries based on the food components of SEAD.

Key messages

• Adherence to the Southern European Atlantic Diet (traditional diet of Northern Portugal and North-Western Spain) was associated with lower depression incidence in Spain, Czechia, Poland, and Russia.

• Mental health guidelines for Southern European Atlantic populations may reference their traditional diet, while those for Central and Eastern Europe could benefit from including its food components.

Cooking methods are associated with inflammatory factors, renal function, and other hormones and nutritional biomarkers in older adults

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.

Dietary Vitamin D Intake, Pain Incidence, and Pain Changes in Older Adults: The Seniors-ENRICA-1 Cohort

Background: Vitamin D plays a role in bone health, pain signaling, and inflammation. We examined the largely unknown relation of dietary vitamin D intake with pain incidence and pain changes over time in older adults. Methods: Data were taken from the Seniors-ENRICA-1 cohort, which included 950 individuals aged ≥60 years. Habitual vitamin D intake was assessed in 2012 with a validated diet history, and pain both in 2012 and 2017 with a scale ranging from 0 (no pain) to 6 (highest pain), according to its severity, frequency, and number of locations. Analyses on pain incidence and pain changes were performed in the 524 participants free of pain at baseline and the overall sample, respectively. Results: Higher dietary vitamin D intake was associated with lower 5-year pain incidence; the multivariable-adjusted odds ratio (95% confidence interval) was 0.88 (0.79,0.99) for every 1-µg/day increase in vitamin D intake, and 0.49 (0.28,0.88) for the highest (>3.52 µg/day) vs. lowest (<1.85 µg/day) tertile. Dietary vitamin D intake (highest vs. lowest tertile) was also associated with 5-year favorable pain changes: the multivariable-adjusted odds ratio of pain worsening vs. no change/pain improvement was 0.55 (0.36,0.86), and the β coefficient for changes in the pain scale was −0.56 (−1.03,−0.09). Similar results were found for pain severity, frequency, and number of pain locations. Conclusions: In an older adult population, where compliance with vitamin D intake recommendations was very low, a slightly increased dietary intake was associated with lower pain incidence and favorable pain changes over 5 years.

Objectively measured secondhand tobacco smoke and cognitive impairment in disability-free older adults

Previous studies have suggested that exposure to secondhand smoke (SHS) may be associated with greater risk of cognitive impairment. However, no longitudinal study has examined the association of serum cotinine (as objective measure of SHS exposure) and cognitive function in older adults. We used data from 2087 non-smoking adults aged≥65 years participating in the ENRICA-2 cohort and free from limitations in Instrumental Activities of Daily Living. Cognitive function was assessed through the Mini-Mental State Examination (MMSE), the Digit Span Backwards subtest (DSBT), the Luria's motor series subtest from the Frontal Assessment Battery, the Trail Making Test A (TMT-A), the Free and Cued Selective Reminding Test (FCSRT), and the Categorical Verbal Fluency Test (CFT) of the 7 min test. Cross-sectional analyses were performed using multivariable logistic and ordered logistic models, while analyses on changes in cognition over time used multivariable repeated-measures mixed-effects models. Compared to the unexposed, those in the highest exposure group (≥0.161 ng/ml) were more likely to have cognitive impairment (MMSE<24) (odds ratio [OR]:1.64; 95% confidence interval [CI]:1.04-2.60) and lower DSBT scores (OR:1.25; 95%CI:1.00-1.57), as well as a non-significant higher odds of a lower score in the Luria test (OR:1.23; 95%CI:0.92-1.64) or episodic memory impairment (FCSRT<12, OR:1.38; 95%CI:0.90-2.11). In longitudinal analyses, those with baseline cotinine ≥0.161 ng/ml showed an increased risk of cognitive impairment (MMSE<24,OR:2.23; 95%CI:1.14-4.33; p-trend across cotinine categories = 0.028) and decreased DSBT (OR:1.23; 95%CI:1.01-1.51; p-trend across cotinine categories = 0.046). Findings show an increased risk of global cognitive impairment and declines in working memory performance in older adults exposed to SHS. More efforts are needed to protect older adults from SHS in areas not covered by smoke-free legislation.

Plant-based diets and risk of frailty in community-dwelling older adults: the Seniors-ENRICA-1 cohort

Frailty is a geriatric syndrome that leads to increased risk of hospitalization, disability, and death. The effect of plant-based diets defined by the quality of their plant foods is unclear. Our objective is to study the association between two plant-based diet indices and the occurrence of frailty among community-dwelling older adults in Spain. We analyzed data from 1880 individuals aged ≥ 60 years from the Spanish Seniors ENRICA-1 cohort. We used a validated diet history to build two indices: (a) the healthful Plant-based Diet Index (hPDI) where healthy plant foods received positive scores, whereas less-healthy plant foods and animal foods received reverse scores; and (b) the unhealthful Plant-based Diet Index (uPDI), with positive scores to less-healthy plant foods and reverse scores to animal and healthy plant foods. Incident frailty was defined with the Fried phenotype. Study associations were summarized with odds ratios (OR) and 95% confidence intervals (CI) obtained from multivariable logistic models. After 3.3 years of follow-up, 136 incident frailty cases were ascertained. Comparing the highest vs. the lowest tertile of adherence, the OR [95% CI] for frailty was 0.43 (0.25-0.74; p-trend = .003) for the hPDI, and 2.89 (1.73-4.84; p-trend < .001) for the uPDI. Higher consumption of healthy plant foods was inversely associated with frailty (0.39 [0.23-0.66; p-trend < 0.001]); higher consumption of unhealthy plant foods was associated with higher frailty risk (2.40 [1.23-4.71; p-trend = .01]). In older adults, the hPDI was associated with lower risk of frailty, while the opposite was found for the uPDI.

Adherence to a Mediterranean Lifestyle and Changes in Frequency, Severity, and Localization of Pain in Older Adults

OBJECTIVE

To assess the association between adherence to a Mediterranean lifestyle and changes in pain, and its characteristics over time in older adults.

PATIENTS AND METHODS

We analyzed data from 864 and 862 community-dwelling individuals aged 65+ years from the Study on Cardiovascular Health, Nutrition and Frailty in Older Adults in Spain (Seniors-ENRICA) Seniors-ENRICA-1 (2008-2010 to 2012) and Seniors-ENRICA-2 (2015-2017 to 2019) cohorts, with a median follow-up of 2.8 and 2.4 years, respectively. Adherence to a Mediterranean lifestyle was assessed at baseline with the 27-item Mediterranean lifestyle (MEDLIFE) index. Pain changes over time were calculated with a pain scale that assessed the frequency, severity, and the number of pain locations both at baseline and follow-up. Multivariable-adjusted relative risk ratios (RRRs) were obtained using multinomial logistic regression.

RESULTS

In the pooled cohorts, after a median follow-up of 2.6 years, pain worsened for 697 participants, improved for 734, and did not change for 295. Compared with the lowest category of MEDLIFE adherence, those in the highest category showed an RRR of improvement vs worsening of overall pain of 1.85 (95% CI, 1.28 to 2.67; P-trend<.001). MEDLIFE adherence was also linked to improvement in pain frequency (RRR, 1.98; 95% CI, 1.31 to 3.01; P-trend=.001), pain severity (RRR, 2.00; 95% CI, 1.33 to 3.00; P-trend=.001), and a reduction in the number of pain locations (RRR, 1.68; 95% CI, 1.13 to 2.50; P-trend=.004). Limitations of this study are the use of self-reported lifestyle data.

CONCLUSION

A Mediterranean lifestyle was associated with improvement of pain characteristics in older adults. Experimental studies should assess the efficacy of an integral lifestyle approach for the management of pain in older adults.

Alcohol consumption patterns and growth differentiation factor 15 among life-time drinkers aged 65+ years in Spain: a cross-sectional study

AIMS

To examine the association of alcohol consumption patterns with growth differentiation factor 15 (GDF-15) in older drinkers, separately among individuals with cardiovascular disease (CVD)/diabetes and those without them, as GDF-15 is a strong biomarker of chronic disease burden.

DESIGN

Cross-sectional study.

SETTING

Population-based study in Madrid (Spain).

PARTICIPANTS

A total of 2051 life-time drinkers aged 65+ years included in the Seniors-ENRICA-2 study in 2015-17. Participants' mean age was 71.4 years and 55.4% were men.

MEASUREMENTS

According to their average life-time alcohol intake, participants were classified as occasional (≤ 1.43 g/day), low-risk (men: > 1.43-20 g/day; women: > 1.43-10 g/day), moderate-risk (men: > 20-40 g/day; women: > 10-20 g/day) and high-risk drinkers (men: > 40 g/day; women: > 20 g/day; or binge drinkers). We also ascertained wine preference (> 80% of alcohol derived from wine), drinking with meals and adherence to a Mediterranean drinking pattern (MDP) defined as low-risk drinking, wine preference and one of the following: drinking only with meals; higher adherence to the Mediterranean diet; or any of these.

FINDINGS

In participants without CVD/diabetes, GDF-15 increased by 0.27% [95% confidence interval (CI) = 0.06%, 0.48%] per 1 g/day increment in alcohol among high-risk drinkers, but there was no clear evidence of association in those with lower intakes or in the overall group, or across categories of alcohol consumption status. Conversely, among those with CVD/diabetes, GDF-15 rose by 0.19% (95% CI = 0.05%, 0.33%) per 1 g/day increment in the overall group and GDF-15 was 26.89% (95% CI = 12.93%, 42.58%) higher in high-risk versus low-risk drinkers. Drinking with meals did not appear to be related to GDF-15, but among those without CVD/diabetes, wine preference and adherence to the MDP were associated with lower GDF-15, especially when combined with high adherence to the Mediterranean diet.

CONCLUSIONS

Among older life-time drinkers in Madrid, Spain, high-risk drinking was positively associated with growth differentiation factor 15 (a biomarker of chronic disease burden). There was inconclusive evidence of a beneficial association for low-risk consumption.

Association of prolonged nightly fasting with cardiovascular, renal, inflammation, and nutritional status biomarkers in community-dwelling older adults

BACKGROUND

Prolonged fasting as a dietary strategy has been linked to metabolic benefits; however, data supporting these benefits corresponded to studies in very small samples of young participants in controlled environments, with few cardiovascular risk markers, who were studied for short periods of time.

OBJECTIVES

We sought to assess the association of habitual prolonged nightly fasting with a wide array of cardiovascular, renal, inflammation, and nutritional status biomarkers among community-dwelling older adults.

METHODS

Cross-sectional analysis of data were obtained from 1047 adults aged ≥65 y from the Seniors Study on Nutrition and Cardiovascular Risk in Spain 2 (Seniors-ENRICA-2) cohort. Habitual diet was assessed through a validated diet history. Fasting time was classified into the following categories: <10, 10 to <12, and 2 h/d, the latter being considered prolonged nightly fasting. Adjusted geometric means of biomarker concentrations in blood and serum were estimated using linear regression models, by categories of fasting time. Main confounders included overall diet quality, defined as adherence to a Mediterranean diet score, and BMI (in kg/m2).

RESULTS

Longer fasting time was associated with: lower concentration of HDL cholesterol (difference between the longest and shortest fasting category: -2.94 mg/dL; 95% CI: -4.80, -1.09; P-trend: 0.01); higher potassium concentration (0.11 mEq/L; 95% CI: 0.03, 0.19; P-trend: 0.01); and lower concentration of chloride (-0.50 mEq/L; 95% CI: -0.91, -0.09; P-trend: 0.03). These results were slightly attenuated after additional adjustment for BMI.

CONCLUSIONS

Habitual prolonged nightly fasting did not show beneficial associations with the examined biomarkers. By contrast, some modest detrimental associations were found suggesting that extended periods of time between meals may not be beneficial for older adults.

Cadmium exposure and growth differentiation factor-15 (GDF-15) levels in non-smoking older adults

BACKGROUND

Cadmium (Cd) exposure is a risk factor for cardiovascular disease (CVD); however, understanding the effects of Cd at the cellular level remains incomplete. Since growth differentiation factor-15 (GDF-15) is a cytokine produced in many cell types in response to tissue injury and inflammation that may capture several pathways between Cd and CVD, this study examined the relationship between blood Cd levels and serum GDF-15 concentrations in community-dwelling older adults.

METHODS

Cd and GDF-15 were measured in 1942 non-smoking individuals aged 65+ with no previous history of CVD. The association of Cd with GDF-15 was evaluated in linear regression models that adjusted for sociodemographic, lifestyle and biological risk factors, inflammatory biomarkers (IL-6, C-reactive protein and neutrophil to lymphocyte ratio), and markers of vascular damage (NTproBNP and cTnT-hs).

RESULTS

Geometric mean Cd exposure was 0.11 μg/L (0.09 in never- and 0.15 in former-smokers) and geometric mean GDF-15 was 1186.21 pg/mL (1182.67 in never- and 1191.66 in former-smokers). In multivariable analyses, we found a dose-response association between Cd levels and GDF-15: adjusted mean percentage differences in GDF-15 (95% confidence interval) per 2-fold increase in Cd concentrations in the overall non-smoking population and in never smokers were, respectively, 2.54% (1.01, 4.06) and 2.50% (0.47, 4.54). In spline regression, the dose-response relationship was progressive over the range of Cd concentrations with no significant departures from linearity.

CONCLUSIONS

Cd exposure may be related to enhanced GDF-15 expression. Future studies with repeated GDF-15 measurements should confirm the present findings to better understand the biological mechanisms underlying this association.

Associations of device-measured sleep, sedentariness and physical activity with growth differentiation factor 15 in older adults

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.

Home and ambulatory blood pressure levels below target range and clinical effort to detect this condition: a population-based study in older treated hypertensives

BACKGROUND

With implementation of stricter blood pressure (BP) treatment targets, potential for excessive BP lowering becomes an important issue, especially in older patients.

OBJECTIVES

Assess the magnitude, indicators and detection effort of BP levels below-target-range (BTR-BP) recommended by the European hypertension guidelines in older treated hypertensive patients (130-139/70-79 mmHg).

DESIGN

Cross-sectional, retrospective study (Seniors-ENRICA-2 cohort).

SETTING

General population.

SUBJECTS

1,329 treated hypertensive patients aged ≥65, assessed with three home casual BP measurements and 24-hour ambulatory BP monitoring (ABPM).

METHODS

Based on the European hypertension guidelines and the literature, BTR-BPs were defined as mean BP <130/70, <125/65, <130/70 and <110/55 mmHg, for casual BP, 24-hour BP, daytime BP and nighttime BP, respectively, and hypotension as <110/70, <105/65, <110/70 and <90/55 mmHg, respectively.

RESULTS

Participants' mean age was 72 ± 4.4 (50.3%, women). Based on casual BP, 7.2% of patients were in target range (130-139/70-79 mmHg), 44.3% in BTR-BP (<130/70) and 20.8% hypotensive (<110/70). Some 44.9, 54.9 and 22.0% of patients were in BTR-BP for 24-hour BP, daytime BP and nighttime BP, respectively, and 11.0, 21.1 and 5.6%, respectively, were hypotensive. The number of patients needed for ABPM to detect one case of 24-hour-, daytime-, and nighttime-BTR-BP was 3, 2 and 5, respectively, and 10, 5 and 18, respectively, for detecting one hypotensive case. Cardiovascular disease and female sex were associated with both BTR-BP and hypotension, and the number of antihypertensive drugs was only associated with hypotension.

CONCLUSIONS

BTR-BP levels were common in older treated patients at home and in everyday life, more frequent than many trials report, and daytime ABPM is highly size-efficient for detecting the low ambulatory BP conditions.

A Mediterranean lifestyle and frailty incidence in older adults: the Seniors-ENRICA-1 cohort

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 three 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; e) Unintentional weight loss. Main statistical analyses were performed using logistic regression models, adjusting for the main confounders.

RESULTS

After a 3.3-y 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 = 0.003). 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.

Cross-sectional and prospective associations of sleep, sedentary and active behaviors with mental health in older people: a compositional data analysis from the Seniors-ENRICA-2 study

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 < 0.01). The time spent in MVPA relative to other behaviors was beneficially associated with depression (γ = -0.397, p < 0.001), loneliness (γ = -0.124, p = 0.017) and happiness (γ = 0.243, p < 0.001). Hypothetically, replacing 30-min of Sleep, SB or LPA with MVPA was beneficially cross-sectionally related with depression (effect size [ES] ranged -0.326 to -0.246), loneliness (ES ranged -0.118 to -0.073), and happiness (ES ranged 0.152 to 0.172). In prospective analyses (n = 1679), MVPA relative to other behaviors at baseline, was associated with favorable changes in global mental health (γ = 0.892, p = 0.049). We observed a beneficial prospective effect on global mental health when 30-min of sleep (ES = 0.521), SB (ES = 0.479) or LPA (ES = 0.755) were theoretically replaced for MVPA.

CONCLUSIONS

MVPA was cross-sectionally related with reduced depression symptoms and loneliness and elevated level of happiness, and prospectively related with enhanced global mental health. Compositional isotemporal analyses showed that hypothetically replacing sleep, SB or LPA with MVPA could result in modest but significantly improvements on mental health indicators. Our findings add evidence to the emerging body of research on 24-h time-use and health using CoDA and suggest an integrated role of daily behaviors on mental health in older people.

Causal effects of physical activity and sedentary behaviour on health deficits accumulation in older adults

BACKGROUND

Increasing physical activity (PA) and reducing sedentary behaviour (SB) have been associated with healthy ageing, but their effects when adjusted for reverse causation and selection bias remain unclear.

METHODS

A deficits accumulation (DA) index based on the number and severity of 51 health deficits (0-100%) was calculated at baseline and three biannual follow-up visits, in a representative cohort of 3 228 community-dwelling older adults in Spain. Average differences in DA index by previous recreational PA, household PA, mentally-active SB and passive SB were estimated using marginal structural models with inverse probability of exposure and censoring weights.

RESULTS

Compared with participants with previous recreational PA of 10-19.9 metabolic equivalent hours/week (MET-hours/week), average differences in DA index (95% confidence intervals) were 0.19 (-1.09, 1.48), 0.69 (-0.23, 1.61), -0.66 (-1.34, 0.02), -0.87 (-1.59, -0.13) and -0.55 (-1.37, 0.28) for 0, 0.1-9.9, 20-29.9, 30-39.9 and ≥40 MET-hours/week, respectively (P for trend = 0.006). Household PA showed no effect on subsequent DA after adjusting for reverse causation. Women, but not men, who spent 7-14.9, 15-20.9 and ≥21 h/week on mentally active SB had DA decreases of 0.09 (-1.00, 1.19), 1.08 (-0.28, 2.45) and 2.17 (0.58, 3.75), respectively, compared with 1-6.9 h/week (P for trend = 0.005); whereas women who spent 3-3.9, 4-4.9 and ≥5 h/day on passive SB showed DA increases of 0.41 (-0.52, 1.35), 1.35 (0.13, 2.57) and 2.13 (0.78, 3.47), respectively, compared with 2-2.9 h/day (P for trend = 0.001).

CONCLUSIONS

The proposed methodology allows estimation of the causal effects of PA and SB on ageing, by simulating a random assignment in which all subjects have the same probability of exposure.

Adherence to the Mediterranean Diet and Physical Resilience in Older Adults: The Seniors-ENRICA Cohort

BACKGROUND

No prior studies have studied the association between diet and physical resilience, thus our aim was to assess the association between the adherence to the Mediterranean diet and other healthy dietary patterns and physical resilience, assessed empirically as a trajectory through exposure to chronic and acute stressors, in older adults participating in the Seniors-ENRICA (The Study on Nutrition and Cardiovascular Risk in Spain) cohort.

METHODS

Data were assessed from 1301 individuals aged 60 and older, participating in the ENRICA prospective cohort study and recruited in 2008-2010 and followed up to 2012 (trial registration: NCT02804672). A Mediterranean Diet Adherence Screener score and the Alternate Healthy Eating Index 2010 were derived at baseline from a validated diet history. Health status was assessed at baseline and at the end of follow-up with a 52-item health Deficit Accumulation Index (DAI) including 4 domains (physical and cognitive function, mental health, self-rated health/vitality, and morbidity); higher DAI values indicate worse health. Physical resilience was defined as accumulating fewer health deficits than the expected age-related increase in DAI over follow-up, despite exposure to chronic and acute stressors.

RESULTS

Over a 3.2-year follow-up, 610 individuals showed physical resilience. In multivariate analyses, the odds ratio (95% confidence interval) of physical resilience for the highest versus lowest tertile (lowest adherence) of the Mediterranean Diet Adherence Screener score was 1.47 (1.10-1.98). The association held for those maintaining or improving the DAI over follow-up (over-resilience): 1.58 (1.10-2.26). Results were consistent in those with unintentional weight loss (2.21 [1.10-4.88]) or hospitalization (2.32 [1.18, 4.57]) as acute stressors.

CONCLUSION

In older adults, a higher adherence to the Mediterranean diet is associated with a greater likelihood of physical resilience.

Changes in Health Behaviors, Mental and Physical Health among Older Adults under Severe Lockdown Restrictions during the COVID-19 Pandemic in Spain

We used data from 3041 participants in four cohorts of community-dwelling individuals aged ≥65 years in Spain collected through a pre-pandemic face-to-face interview and a telephone interview conducted between weeks 7 to 15 after the beginning of the COVID-19 lockdown. On average, the confinement was not associated with a deterioration in lifestyle risk factors (smoking, alcohol intake, diet, or weight), except for a decreased physical activity and increased sedentary time, which reversed with the end of confinement. However, chronic pain worsened, and moderate declines in mental health, that did not seem to reverse after restrictions were lifted, were observed. Males, older adults with greater social isolation or greater feelings of loneliness, those with poorer housing conditions, as well as those with a higher prevalence of chronic morbidities were at increased risk of developing unhealthier lifestyles or mental health declines with confinement. On the other hand, previously having a greater adherence to the Mediterranean diet and doing more physical activity protected older adults from developing unhealthier lifestyles with confinement. If another lockdown were imposed during this or future pandemics, public health programs should specially address the needs of older individuals with male sex, greater social isolation, sub-optimal housing conditions, and chronic morbidities because of their greater vulnerability to the enacted movement restrictions.

Healthy dietary patterns are associated with lower concentrations of growth differentiation factor 15 in older adults

BACKGROUND

Growth differentiation factor 15 (GDF-15) is a biomarker for aging and chronic disease burden that may capture the anti-inflammatory and antioxidant effects attributed to healthy diets.

OBJECTIVE

The aim was to examine whether several healthy dietary patterns and a lower inflammatory potential of diet are associated with lower concentrations of GDF-15 in older adults.

METHODS

We used cross-sectional data from 2501 older adults participating in the Seniors-ENRICA-2 study. Four diet indices were derived from habitual food consumption estimated with a validated diet history: Mediterranean Diet Adherence Screener (MEDAS), Alternate Healthy Eating Index-2010 (AHEI-2010), Dietary Approaches to Stop Hypertension (DASH), and Dietary Inflammatory Index (DII). Associations of these indices with GDF-15 concentrations were analyzed using linear regression models and adjusted for risk factors and biomarkers associated with chronic disease.

RESULTS

There was a clear dose-response association between all dietary patterns and serum GDF-15 concentrations; the GDF-15 mean reductions (95% CI) per 1-SD increment in the diet indices were 1.6% (0.1%, 3.1%) for the MEDAS, 2.1% (0.5%, 3.7%) for the AHEI-2010, and 1.6% (0.1%, 3.2%) for the DASH, whereas a mean GDF-15 increase of 1.7% (0.2%, 3.4%) was observed per 1-SD increment in the DII. In analyses excluding fruit and vegetable components from the diet indices, the association for the MEDAS and the AHEI-2010 remained but was attenuated for the DASH. Analyses excluding participants with cardiovascular disease or diabetes rendered very similar results.

CONCLUSIONS

A higher adherence to several healthy dietary patterns and a lower inflammatory potential of diet were related to lower concentrations of GDF-15 in older adults, suggesting that improving diet quality may reduce inflammation and possibly promote healthy aging.

Metabolic syndrome and Growth Differentiation Factor 15 in older adults

Growth Differentiation Factor 15 (GDF-15) is a cytokine produced in response to tissue injury and inflammatory states that may capture distinct pathways between the risk factors aggregated within metabolic syndrome (MS) and the development of diabetes and cardiovascular disease. This work aims to study the association of MS and its components with GDF-15 among older adults, examining the roles of body fat distribution, glucose metabolism, and inflammation. Data were taken from the Seniors-ENRICA-2 study in Spain, which included 1938 non-institutionalized individuals aged ≥65 years free of diabetes and cardiovascular disease. MS was defined as the presence of ≥3 of the following components: high waist circumference, elevated fasting blood glucose levels, raised blood pressure, increased triglyceride levels, and low serum high-density lipoprotein (HDL) cholesterol. Statistical analyses were performed with linear regression models and adjusted for potential sociodemographic and lifestyle confounders. MS was associated with higher GDF-15 levels (fully adjusted mean increase [95% confidence interval] = 9.34% [5.16,13.7]). The MS components showing the strongest associations were high waist circumference (6.74% [2.97,10.6]), elevated glucose levels (4.91% [0.77,9.23]), and low HDL-cholesterol (8.13% [3.51,13.0]). High waist-to-hip ratio (7.07% [2.63,11.7]), urine albumin (12.1% [2.57,22.5]), and C-reactive protein (10.4% [3.89,17.3]) were also associated with increased GDF-15. In conclusion, MS was associated with higher GDF-15 levels in older adults. Abdominal obesity, hyperglycemia -possibly linked to microvascular disease, as inferred from elevated urine albumin-, low HDL-cholesterol, and inflammation were the main drivers of this association.

Blood cadmium and physical function limitations in older adults

BACKGROUND

Cadmium (Cd) is a toxic metal found in tobacco, air and food. Recent cross-sectional studies have suggested that Cd negatively impacts physical performance, but the prospective association is uncertain.

METHODS

We used data from 2548 older adults from the Seniors-ENRICA II cohort in Madrid, Spain. Whole blood Cd levels were measured at baseline using inductively coupled plasma-mass spectrometry. At baseline (2017) and follow-up (2019), overall physical function was evaluated using the physical component summary (PCS) of the SF 12-Item Health questionnaire, lower-extremity performance with the Short Physical Performance Battery (SPPB), muscle weakness with a hand dynamometer, and frailty with a Deficit Accumulation index. Mobility limitations and disability in instrumental activities of daily living (IADL) were ascertained with standardized questionnaires. Analyses were adjusted for relevant confounders, including tobacco smoke, number of cigarettes smoked per day and time since cessation in former smokers.

RESULTS

In cross-sectional analyses, odds ratios (95% confidence interval) per two-fold increase in blood Cd were 1.16 (1.03; 1.31) for low PCS scores, 1.08 (0.97; 1.20) for impaired lower-extremity performance, 1.10 (0.98; 1.23) for low grip strength, 1.11 (1.02; 1.20) for mobility limitations, 1.16 (1.02; 1.31) for frailty, and 1.26 (1.08; 1.47) for IADL disability. In longitudinal analyses, corresponding hazard ratios were 1.25 (1.03; 1.51) for low PCS scores, 1.14 (1.03; 1.27) for impaired lower-extremity performance, 1.02 (0.92; 1.13) for low grip strength, 1.03 (0.91; 1.16) for mobility limitations, and 1.16 (1.00; 1.35) for frailty. All the associations where consistent when current smokers were excluded from the analyses.

CONCLUSIONS

Our results support the role of Cd as a risk factor for physical function impairments in older adults.

Mediterranean diet and changes in frequency, severity and localization of pain in older adults: The Seniors-ENRICA cohorts

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 two 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.

Pain Characteristics, Cardiovascular Risk Factors, and Cardiovascular Disease

BACKGROUND

There is unclear evidence that chronic pain may increase the risk of cardiovascular disease (CVD) incidence and mortality. This work evaluated the association between chronic pain, incidence of CVD and changes in CVD risk factors.

METHODS

Cohort of 1091 community-dwelling individuals ≥60years, free from CVD at baseline, followed up for 6 years. Data on psychosocial factors and CVD risk factors was obtained through validated questionnaires and laboratory measurements. A pain scale ranging from 0 (no pain) to 6 (worst pain) was created according to pain frequency, location and intensity.

RESULTS

The cumulative incidence of CVD was 4.2% at 3 years, and 7.7% at 5-years of follow-up. Compared to individuals without pain in the first 3 years (2012-2015), those with maintained scores ≥2 showed a mean reduction of 3.57 (-5.77,-1.37) METs-h/week in recreational physical activity; a 0.38-point (0.04,0.73) increase in psychological distress; and a 1.79 (1.03,3.11) higher odds of poor sleep. These associations held in the second follow-up period, when individuals with maintained pain also worsened their diet quality. A 1-point increase in the pain scale in 2012 was associated with a 1.21 (1.03,1.42) and 1.18 (0.97,1.44) increased CVD incidence in 2015 and 2017, respectively; none of the studied factors mediated this relationship.

CONCLUSIONS

Older adults with chronic pain show important reductions in recreational physical activity and deterioration in mental health, sleep and diet quality, which may well aggravate pain. Future studies should evaluate whether these factors mediate the increased risk of CVD observed in older adults with chronic pain.

The Southern European Atlantic Diet and all-cause mortality in older adults

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 < 0.001). Most food components of the SEAD showed some tendency to lower all-cause mortality, especially moderate wine consumption (hazard ratio [95% confidence interval] 0.71 [0.59, 0.86]). The results were robust in several sensitivity analyses. The protective association between SEAD and all-cause death was of similar magnitude to that found for the Mediterranean Diet Adherence Screener (hazard ratio [95% confidence interval] per 1-SD increment 0.89 [0.80, 0.98]) and the Alternate Healthy Eating Index (0.83 [0.76, 0.92]).

CONCLUSIONS

Adherence to the SEAD is associated with a lower risk of all-cause death among older adults in Spain.

Association of Physical Activity, Sedentary Behavior, and Sleep With Unhealthy Aging: Consistent Results for Device-Measured and Self-reported Behaviors Using Isotemporal Substitution Models

BACKGROUND

We examined the association of time allocation among physical activity (PA), sedentary behavior (SB), and sleep with unhealthy aging (UA), using both accelerometry and self-reports.

METHOD

We used cross-sectional data from 2312 individuals aged 65 years and older. Physical activity, SB, and sleep were ascertained by both wrist accelerometers and validated questionnaires, and UA was measured with a 52-item health-deficit accumulation index. Analyses used isotemporal substitution linear regression models.

RESULTS

Less deficit accumulation was observed when the distribution of activities was 30 min/d less of SB and 30 min/d more of PA for both accelerometer (fully adjusted β [95% CI]: -0.75 [-0.90, -0.61]) and self-reports (-0.55 [-0.65, -0.45]), as well as less long sleep and more PA (accelerometer: -1.44 [-1.86, -1.01]; self-reports: -2.35 [-3.35, -1.36]) or more SB (accelerometer: -0.45 [-0.86, -0.05]; self-reports: -1.28 [-2.29, -0.28]), less normal sleep and more moderate-to-vigorous PA (accelerometer: -1.70 [-2.28, -1.13]; self-reports: -0.65 [-0.99, -0.31]), and less accelerometer light PA and more moderate-to-vigorous PA (-1.62 [-2.17, -1.07]). However, more deficit accumulation was observed when less sleep was accompanied by either more SB or more light PA in short sleepers. Self-reports captured differential associations by activity: walking appeared to be as beneficial as more vigorous activities, such as cycling or sports, and reading was associated with less UA than more mentally passive SBs, such as watching TV.

CONCLUSIONS

More PA was associated with less UA when accompanied by less SB time or sleep in long/normal sleepers, but not in short sleepers, where the opposite was found. Accelerometry and self-reports provided consistent associations.