ObjectiveTo evaluate the effect of Non-alcoholic fatty liver disease (NAFLD) status in the impact of lifestyle over Health-related quality of life (HRQoL) in patients with metabolic syndrome (MetS). MethodsBaseline and 1 year follow up data from the PREDIMED-plus cohort (men and women, 55-75 years old with overweight/obesity and MetS) were studied. Adherence to an energy-restricted Mediterranean Diet (er-MeDiet) and Physical Activity (PA) were assessed with a validated screeners. Hepatic steatosis index (HSI) was implemented to evaluate NAFLD while the SF-36 questionnaire provided HRQoL evaluation. Statistical analyses were performed to evaluate the influence of baseline NAFLD on HRQoL as affected by lifestyle during 1 year of follow up. ResultsData from 5205 patients with mean age of 65 years and a 48% of female participants. Adjusted linear multivariate mixed regression models showed that patients with lower probability of NAFLD (HSI < 36 points) were more responsive to er-MeDiet (beta 0.64 vs beta 0.05 per er-MeDiet adherence point, p< 0.01) and PA (beta 0.05 vs beta 0.01 per MET-h/week, p = 0.001) than those with high probability for NAFLD in terms Physical SF-36 summary in the 1 year follow up. 10 points of er-MeDiet adherence and 50 MET-h/week were thresholds for a beneficial effect of lifestyle on HRQoL physical domain in patients with lower probability of NAFLD. ConclusionThe evaluation of NAFLD by the HSI index in patients with MetS might identify subjects with different prospective sensitivity to lifestyle changes in terms of physical HRQoL (http://www.isrctn.com/ISRCTN89898870).

Background & aims: Front-of-pack nutrition labelling is a key public health policy that can be adopted as part of a comprehensive set of measures to promote healthy diets. The Nutri-Score, a five-colour summary label based on a modified version of the British Food Standards Agency Nutrient Profiling System (FSAm-NPS), is being considered for implementation in several European countries including Spain. This study aimed to prospectively assess the association between the FSAm-NPS and mortality rate in a Spanish cohort of university graduates. Methods: Analyses included 20 503 participants (mean [SD] age: 38 [12] years) from the SUN cohort. Dietary intake was assessed at baseline and after 10-years of follow-up with a validated semi-quantitative food-frequency questionnaire. The FSAm-NPS was calculated for each food/beverage based on their amount of energy, saturated fat, sugar, sodium, fibre, protein, fruits, vegetables, legumes, nuts, rapeseed, walnut and olive oils per 100 g of product. The FSAm-NPS Dietary Index (DI) was computed as an energy-weighted mean of the FSAm-NPS scores of all foods and beverages consumed by each participant. Multivariable-adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality according to baseline and updated FSAm-NPS DI scores. Results: Over a median follow-up of 10.9 years, 407 participants died. A higher baseline FSAm-NPS DI score, reflecting consumption of foods with lower nutritional quality and hence less favourable Nutri-Score rating, was directly associated with all-cause mortality (HR Q4 versus Q1 = 1.82; 95% CI: 1.34 to 2.47; p-trend<0.001) and cancer mortality (HR: 2.44; 95% CI: 1.54 to 3.85; p-trend<0.001). No association was found for cardiovascular mortality. Conclusions: The consumption of food products with a higher FSAm-NPS score (lower nutritional quality) was associated with a higher rate of all-cause and cancer mortality in a large prospective cohort of Spanish, middle-aged university graduates. These findings further support the implementation of Nutri-Score in Euro-Mediterranean countries.

Objective: The aim of this study was to assess body shape trajectories in childhood and midlife in relation to subsequent risk of breast cancer (BC) in a Mediterranean cohort. Design: The 'Seguimiento Universidad de Navarra' (SUN) Project is a dynamic prospective cohort study of university graduates initiated in 1999. With a group-based modelling approach, we assessed body shape trajectories from age 5 to 40 years. Multivariable Cox regression models were used to estimate the hazard ratio (HR) for BC after the age of 40 years according to the body shape trajectory. Setting: City of Pamplona, in the North of Spain. Participants: 6498 women with a mean age of 40 years (sd 9). Results: We identified four distinct body shape trajectories ('childhood lean-midlife increase' (19 center dot 9 %), 'childhood medium-midlife stable' (53 %), 'childhood heavy-midlife stable' (21 %) and 'childhood heavy-midlife increase' (6 center dot 1 %)). Among 54 978 women-years of follow-up, we confirmed eighty-two incident cases of BC. Women in the 'childhood lean-midlife increase' group showed a higher risk of BC (HR = 1 center dot 84, 95 % CI 1 center dot 11, 3 center dot 04) compared with women in the 'childhood medium-midlife stable' category. This association was stronger for postmenopausal BC (HR = 2 center dot 42, 95 % CI 1 center dot 07, 5 center dot 48). Conclusions: Our results suggest a role for lifetime adiposity in breast carcinogenesis.

Background: Depression is a major public health concern worldwide and its association with metabolic syndrome (MetS) remains unclear. Thus, we prospectively examined the association between depression and the risk of MetS, according to different diagnosis criteria. Methods: This study included 9,237 participants of a Spanish dynamic prospective cohort of adult university graduates [mean (SD) age: 36.7 year (10.7)], initially free of any specific criterion of MetS, who were followed up for a median of 8.3 years. The exposure variables were medical diagnosis of depression at baseline or in the first 2-year follow-up questionnaire. The outcome variable was the incidence of MetS, assessed according to each of three different criteria proposed by: International Diabetes Federation (IDF); National Cholesterol Education Program's Adult Treatment Panel III (NCEP-ATP III); IDF/NCEP-ATP III (updated harmonizing definition). Multivariable-adjusted Relative Risks (RR) of new-onset MetS and their 95% Confidence Intervals (95% CI) were estimated, using Poisson regression models. Results: The cumulative incidences of MetS were 475 cases (IDF definition), 288 cases (NCEP-ATP III definition) and 492 cases (update harmonized definition). No association was observed between baseline depression and incidence of MetS, but the presence of depression after 2-years of follow-up was significantly associated with a higher risk of new-onset MetS, according to NCEP-ATP III definition (multivariable-adjusted RR, 2.46; 95% CI, 1.06-5.67). Limitations: Diagnosis of depression and MetS were self-reported. Conclusions: In this large prospective cohort of Spanish middle-aged adult university graduates, a direct association between depression and the risk of MetS according to NCEP-ATP III definition was found.

Purpose Epidemiological evidence concerning the relationship between calcium and vitamin D intake and breast cancer (BC) is inconclusive. Moreover, the association according to menopausal status remains unclear. We aimed to assess whether total intakes from dietary and supplemental sources of calcium and vitamin D were associated with the incidence of BC in a Mediterranean cohort. Methods We prospectively evaluated the association between intakes of calcium and vitamin D and BC risk among 10,812 women in the Seguimiento Universidad de Navarra (SUN) Project, a Spanish cohort of university graduates. Results During a mean follow-up of 10.7 years, 101 incident BC cases were confirmed. Evidence of a non-linear association between total calcium intake and BC risk was found (Pnon-linearity = 0.011) with risk reductions associated with higher intake up to approximately 1400 mg/day. Moderate intake [Tertile 2 (T2)] of total calcium was associated with lower overall BC risk [HR for T2 vs. Tertile 1 (T1): 0.55; 95% CI 0.33-0.91] and also among postmenopausal women (HRT2 vs. T1 = 0.38; 95% CI 0.16-0.92). Intake of vitamin D was not associated with BC risk. Conclusions Our findings suggest an L-shaped association between total calcium intake and BC incidence. Moderate calcium intake may be associated with lower BC risk among overall and postmenopausal women, but not among premenopausal women. No evidence for any association between vitamin D intake and BC was found. Adherence to current guidelines recommendations for calcium intake may help to reduce BC risk.

Introduction Type 2 diabetes has been linked to greater cognitive decline, but other glycemic parameters such as prediabetes, diabetes control and treatment, and HOMA-IR and HbA(1c) diabetes-related biomarkers have shown inconsistent results. Furthermore, there is limited research assessing these relationships in short-term studies. Thus, we aimed to examine 2-year associations between baseline diabetes/glycemic status and changes in cognitive function in older participants at high risk of cardiovascular disease.</p> Methods We conducted a 2-year prospective cohort study (n=6,874) within the framework of the PREDIMED-Plus study. The participants (with overweight/obesity and metabolic syndrome; mean age 64.9 years; 48.5% women) completed a battery of 8 cognitive tests, and a global cognitive function Z-score (GCF) was estimated. At baseline, participants were categorized by diabetes status (no-diabetes, prediabetes, and <5 or >= 5-year diabetes duration), and also by diabetes control. Furthermore, insulin resistance (HOMA-IR) and glycated hemoglobin (HbA(1c)) levels were measured, and antidiabetic medications were recorded. Linear and logistic regression models, adjusted by potential confounders, were fitted to assess associations between glycemic status and changes in cognitive function.</p> Results Prediabetes status was unrelated to cognitive decline. However, compared to participants without diabetes, those with >= 5-year diabetes duration had greater reductions in GCF (beta=-0.11 (95%CI -0.16;-0.06)], as well as in processing speed and executive function measurements. Inverse associations were observed between baseline HOMA-IR and changes in GCF [beta=-0.0094 (95%CI -0.0164;-0.0023)], but also between HbA(1c) levels and changes in GCF [beta=-0.0085 (95%CI -0.0115, -0.0055)], the Mini-Mental State Examination, and other executive function tests. Poor diabetes control was inversely associated with phonologic fluency. The use of insulin treatment was inversely related to cognitive function as measured by the GCF [beta=-0.31 (95%CI -0.44, -0.18)], and other cognitive tests.</p> Conclusions Insulin resistance, diabetes status, longer diabetes duration, poor glycemic control, and insulin treatment were associated with worsening cognitive function changes in the short term in a population at high cardiovascular risk.</p>

Hypertension is the strongest independent modifiable risk factor for cardiovascular disease. We aimed to investigate the association of magnesium intake with incident hypertension in a Mediterranean population, and the potential modification of this association by body mass index (BMI). We assessed 14,057 participants of the SUN (Seguimiento Universidad de Navarra) prospective cohort (67.0% women) initially free of hypertension. At baseline, a validated 136-item food frequency questionnaire was administered. We used Cox models adjusted for multiple socio-demographic, anthropometric, and lifestyle factors, and prevalent conditions present at baseline. Among a mean 9.6 years of follow-up we observed 1406 incident cases of medically diagnosed hypertension. An inverse association in multivariable-adjusted models was observed for progressively higher magnesium intake up to 500 mg/d vs. intake < 200 mg/d, which was greater among those with a BMI > 27 kg/m(2). Lean participants with magnesium intake < 200 mg/d vs. >200 mg/d also had a higher risk of incident hypertension. Adherence to the Mediterranean diet did not modify these associations. In conclusion, dietary magnesium intake < 200 mg/d was independently associated with a higher risk of developing hypertension in a Mediterranean cohort, stronger for overweight/obese participants. Our results emphasize the importance of encouraging the consumption of magnesium-rich foods (vegetables, nuts, whole cereals, legumes) in order to prevent hypertension.

Background and aims: Modifiable lifestyle factors, such as physical activity (PA) and Mediterranean diet (MD), decrease metabolic syndrome (MetS). The aim was to assess 1-year changes of leisure-time physical activity (LTPA), sedentary behavior, and diet quality according to MetS severity in older population at high cardiovascular risk. Methods and results: Prospective analysis of 55-75-year-old 4359 overweight/obese participants with MetS (PREDIMED-Plus trial) categorized in tertiles according to 1-year changes of a validated MetS severity score (MetSSS). Anthropometrics, visceral adiposity index, triglycerides and glucose index, dietary nutrient intake, biochemical marker levels, dietary inflammatory index, and depression symptoms were measured. Diet quality was assessed by 17-item MD questionnaire. PAs were self-reported using the Minnesota-REGICOR Short Physical Activity Questionnaire and 30-s chair stand test. Sedentary behaviors were measured using the Spanish version of the Nurses' Health Study questionnaire. After 1-year follow-up, decreasing MetSSS was associated with an anti-inflammatory dietary pattern, high intake of vegetables, fruits, legumes, nuts, whole grain cereals, white fish, and bluefish and low intake of refined cereals, red and processed meat, cookies/sweets, and snacks/ready-to-eat-meals. It resulted in high intake of polyunsaturated fatty acids, omega-3 fatty acids, protein, fiber, vitamins B1, B6, B9, C, D, potassium, magnesium, and phosphorus and low glycemic index and saturated fatty acid, trans fatty acid, and carbohydrates intake. Regarding PA and sedentary behavior, decreasing MetSSS was associated with increased moderate-to-vigorous LTPA, chair stand test, and decreased sedentary and TV-viewing time. Conclusion: Decreasing MetSSS was associated with an anti-inflammatory dietary pattern, high LTPA, high MD adherence, low sedentary time, and low depression risk. 2021 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University.

Background: Siesta has been associated with increased incidence of cardiovascular disease but the mechanism remains unclear. New studies into the relationship between siesta and metabolic syndrome have identified siesta length as a crucial differential, suggesting that siesta less than 40 min is associated with decreased risk of metabolic syndrome, while longer siesta is associated with increased risk. We aimed to investigate the effect of siesta duration on development of metabolic syndrome in a Mediterranean population using a prospective cohort study design. Methods: Our sample consisted of 9161 participants of the SUN cohort without components of metabolic syndrome at baseline. Siesta exposure was assessed at baseline and the development of metabolic syndrome components was assessed after an average 6.8 years of follow-up. We estimated odds ratios and fitted logistic regression models to adjust for potential cofounders including night-time sleep duration and quality, as well as other diet, health, and lifestyle factors. Results: We observed a positive association between average daily siesta > 30 min and development of metabolic syndrome (aOR = 1.39 CI: 1.03-1.88). We found no significant difference in risk of developing metabolic syndrome between the group averaging & LE;30 min of daily siesta and the group not taking siesta (aOR = 1.07 CI: 0.83-1.37). Further analysis suggested that average daily siesta < 15 min may reduce risk of metabolic syndrome. Conclusions: Our study supports the J-curve model of the association between siesta and risk of metabolic syndrome, but suggests the protective effect is limited to a shorter range of siesta length than previously proposed.

Background and aim: The aim of this study was to assess the association between body shape trajectories and all-cause mortality in a Mediterranean cohort. Methods and results: Using a group-based modeling approach to fit body shape trajectories from the age of 5-40 years, among 11,423 participants from the Spanish SUN cohort, we assessed the subsequent risk of all-cause mortality. To create the trajectories, we used a censored normal model as a polynomial function of age. Cox regression models adjusted for sex, age, years of university education, marital status, smoking status, package-years of smoking, and recruitment period were used to estimate the hazard ratios (HR) for mortality according to each assigned trajectory. Overall, five distinct trajectories were identified: "lean-moderate increase," "medium-moderate increase," "medium-stable," "heavy-medium," and "heavy-moderate increase." During 106,657 person-years of follow-up, we observed 240 deaths. Compared with those who maintained a medium body shape in early and middle life ("medium-stable" trajectory), those who were heavy and had a moderate increase (" heavy-moderate increase" trajectory) showed higher mortality risk [HR = 1.91 (95% confidence interval: 1.14-3.21)]. In contrast, participants who were heavy in early life, and then decreased their body shape during early adulthood, and maintained a medium body shape throughout middle adulthood ("heavy-medium"), tend to exhibit lower mortality risk [HR = 0.60 (0.34-1.05)], similarly to those who were lean at childhood and had a moderate increase during adulthood ("lean-moderate increase") [HR = 0.82 (0.58-1.15)]. Conclusion: A moderate increase in body shape among subjects who were already heavy at early life was associated with higher risk of mortality in a Mediterranean cohort of university graduates. (C) 2020 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.

Background and objectives: Cured ham is one of the most characteristic foods in the Spanish diet. Because it is a red processed meat and due to its nutritional composition, including high sodium content, a potential association between cured ham consumption and a higher risk of hypertension could be expected. However, epidemiological studies evaluating this association are scarce. We prospectively assessed the association between cured ham consumption and the incidence of hypertension. Methods: The "Seguimiento Universidad de Navarra" (SUN) study is a cohort of Spanish middle-aged adult university graduates (average age: 38 (SD: 12) years, 60% women). We included 13,900 participants of the SUN cohort free of hypertension at baseline. One serving of cured ham is 50g. They were classified into 4 categories of cured ham consumption: <1; 1; 2-4 and ¿5servs/week. Multivariable-adjusted Cox regression models were fitted to assess the association between cured ham consumption and subsequent hypertension risk using the category of lowest consumption as the reference. Results: After a median follow-up of 10.9 years, 1465 incident self-reported cases of hypertension were identified. After adjusting for potential confounders, including dietary confounders, a high consumption of cured ham (¿5servs/week vs. <1serv/week) was not significantly associated with hypertension risk in this prospective cohort (HR=0.88, 95% CI: 0.70-1.10, p linear trend=0.40). Conclusions: Our results showed that cured ham consumption was not associated with a significantly higher or lower risk of hypertension in a prospective cohort of Spanish middle-aged adult university graduates. Further longitudinal and experimental studies are needed to disentangle the association between cured ham consumption and the risk of hypertension.

Healthy lifestyle factors, such as physical activity (PA) and Mediterranean diet (MD), decrease the likelihood of developing metabolic syndrome (MetS). The aim of this study was to report main lifestyle components and related factors according to the MetS severity. Cross-sectional analysis was done of baseline lifestyle factors from 5739 participants with overweight/obesity and MetS features (aged 55-75 years) included in the PREDIMED-PLUS primary cardiovascular prevention randomized trial. Participants were categorized in tertiles according to a validated MetS severity score (MetSSS). Anthropometrics, visceral adiposity index, dietary nutrient intake, biochemical marker levels, as well as a Dietary Inflammatory Index and depression symptoms (Beck Depression Inventory-II) were measured. Diet quality was assessed using a 17-item energy-restricted MD questionnaire. Duration and intensity of PA was self-reported using the Minnesota-REGICOR Short Physical Activity Questionnaire. Sedentary behaviours were measured using the Spanish version of the Nurses' Health Study questionnaire. The 30 s chair stand test was also assessed. Participants with highest MetSSS showed higher values of cardiovascular risk factors (except for total cholesterol and LDL cholesterol), depression risk, sedentary and TV viewing time, and lower moderate and vigorous leisure-time physical activity (LTPA). Highest MetSSS participants tended to a pro-inflammatory dietary pattern and tended to lower MD adherence. In addition, they showed lower carbohydrate and nut intake and higher intake of protein, saturated and trans fatty acids, cholesterol, iodine, sodium, red and processed meat products, other oils different from olive oil and spirit alcoholic drinks. The highest MetS severity score was associated with lower moderate and vigorous LTPA and higher sedentary time and depression risk, as they tended to a pro-inflammatory dietary pattern and lower MD adherence.

Background and aims: We prospectively assessed the association between a healthy lifestyle score (HLS) and the risk of type 2 diabetes mellitus (T2DM) in a Mediterranean cohort. Methods and results: We followed up 11,005 participants initially free of diabetes diagnosis in the "Seguimiento Universidad de Navarra" (SUN) cohort. We evaluated the influence of lifestyle related factors based on a score previously related to a lower risk of cardiovascular disease. Only one incident case of T2DM was found among those with a baseline BMI 22 kg/m(2). Therefore, we excluded the BMI item and restricted the analysis to participants with a baseline BMI 22 kg/m(2). We measured the baseline adherence of a HLS that included: never smoking, physical activity, Mediterranean diet adherence, moderate alcohol consumption, avoidance of binge drinking, low television exposure, taking a short nap, spending time with friends and working hours. Incident cases of T2DM were self-reported by participants and confirmed by a physician. Cox proportional-hazards regression models were fitted to assess the association between HLS and the incidence of T2DM. After a median follow-up of 12 years, 145 incident cases of T2DM were observed. Among participants with a BMI >22 kg/m(2), the highest category of HLS adherence (7-9 points) showed a significant 46% relatively decreased hazard of T2DM compared with the lowest category (0-4 points) (multivariable adjusted HR: 0.54; 95% CI: 0.30-0.99). Conclusions: Higher adherence to a HLS, including some factors not typically studied, may reduce T2DM risk. Preventive efforts should preferentially focus on weight control. However, this score may promote a comprehensive approach to diabetes prevention beyond weight reduction. (C) 2020 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.

Background: High nut consumption has been previously associated with decreased prevalence of metabolic syndrome (MetS) regardless of race and dietary patterns. Objectives: The aim of this study was to assess whether changes in nut consumption over a 1-y follow-up are associated with changes in features of MetS in a middle-aged and older Spanish population at high cardiovascular disease risk. Methods: This prospective 1-y follow-up cohort study, conducted in the framework of the PREvencion con DIeta MEDiterranea (PREDIMED)-Plus randomized trial, included 5800 men and women (55-75 y old) with overweight/obesity [BMI (in kg/m(2)) >= 27 and <40] and MetS. Nut consumption (almonds, pistachios, walnuts, and other nuts) was assessed using data from a validated FFQ. The primary outcome was the change from baseline to 1 y in features of MetS [waist circumference (WC), glycemia, HDL cholesterol, triglyceride (TG), and systolic and diastolic blood pressure] and excess weight (bodyweight and BMI) according to tertiles of change in nut consumption. Secondary outcomes included changes in dietary and lifestyle characteristics. A generalized linear model was used to compare 1-y changes in features of MetS, weight, dietary intakes, and lifestyle characteristics across tertiles of change in nut consumption. Results: As nut consumption increased, between each tertile there was a significant decrease in WC, TG, systolic blood pressure, weight, and BMI (P < 0.05), and a significant increase in HDL cholesterol (only in women, P = 0.044). The interaction effect between time and group was significant for total energy intake (P < 0.001), adherence to the Mediterranean diet (MedDiet) (P < 0.001), and nut consumption (P < 0.001). Across tertiles of increasing nut consumption there was a significant increase in extra virgin olive oil intake and adherence to the MedDiet; change in energy intake, on the other hand, was inversely related to consumption of nuts. Conclusions: Features of MetS and excess weight were inversely associated with nut consumption after a 1-y follow-up in the PREDIMED-Plus study cohort.

Health related quality of life (HRQoL) is a subjective appreciation of how personal characteristics and health influence well-being. This cross-sectional analysis aimed to quantitatively measure the influence of dietary, lifestyle, and demographic factors on HRQoL. A sub-sample of the Seguimiento Universidad de Navarra (SUN) Project, a Mediterranean cohort, was analyzed (n = 15,674). Through self-administered questionnaires the relationship between HRQoL and dietary patterns (Mediterranean-diet (MedDiet) and provegetarian food pattern (FP) assessment), lifestyles (sleeping hours, physical activity) and demographic characteristics were measured. Multivariate linear regression and flexible regression models were used to estimate the pondered effect of personal factors on Short Form-36 (SF-36) scores. Coefficients for MedDiet and provegetarian scores (beta-coefficient for global SF-36 score: 0.32 (0.22, 0.42); 0.09 (0.06, 0.12) respectively for every unit increase), physical activity (beta: 0.03 (0.02, 0.03) for every metabolic equivalent of task indexes (MET)-h/week) had a positive association to HRQoL. The female sex (beta: -3.28 (-3.68, -2.89)), and pre-existing diseases (diabetes, beta: -2.27 (-3.48, -1.06), hypertension beta: -1.79 (-2.36, -1.22), hypercholesterolemia beta: -1.04 (-1.48, -0.59)) account for lower SF-36 scores. Adherence to MedDiet or provegetarian FP, physical activity and sleep are associated with higher HRQoL, whereas the female sex, "other" (versus married status) and the presence of chronic diseases were associated with lower SF-36 scores in this sample.

Background We aimed to investigate the association of metabolic syndrome (MetS) and its single components with cardiovascular risk and estimated their impact on the prematurity of occurrence of cardiovascular events using rate advancement periods (RAPs). Methods We performed prospective analyses among 3976 participants (age range: 35-84, 55% female) in the Vascular Risk in Navarre (RIVANA) Study, a Mediterranean population-based cohort. MetS was defined based on the modified criteria of the American Heart Association/National Heart, Lung, and Blood Institute and the International Diabetes Federation. The primary endpoint was major cardiovascular event (a composite of myocardial infarction, stroke, or mortality from cardiovascular causes). Secondary endpoints were incidence of non-fatal myocardial infarction and non-fatal stroke, cardiovascular mortality, and all-cause mortality. Cox proportional hazards models, adjusted for potential confounders, were fitted to evaluate the association between MetS and its single components at baseline with primary and secondary endpoints. Results During a median follow-up of 12.8 years (interquartile range, 12.5-13.1), we identified 228 primary endpoint events. MetS was associated with higher risk of incidence of major cardiovascular event, cardiovascular and all-cause mortality, but was neither associated with higher risk of myocardial infarction nor stroke. Compared with participants without MetS, the multivariable hazard ratio (95% confidence interval [CI]) among participants with MetS was 1.32 (1.01-1.74) with RAP (95% CI) of 3.23 years (0.03, 6.42) for major cardiovascular event, 1.64 (1.03-2.60) with RAP of 3.73 years (0.02, 7.45) for cardiovascular mortality, and 1.45 (1.17-1.80) with RAP of 3.24 years (1.21, 5.27) for all-cause mortality. The magnitude of the associations of the single components of MetS was similar than the predicted by MetS. Additionally, for each additional trait of MetS, incidence of major cardiovascular event relatively increased by 22% (1.22, 95% CI 1.09-1.36) with RAP of 2.31 years (0.88, 3.74). Conclusions MetS was independently associated with CVD risk, cardiovascular and all-cause mortality. Components of the MetS were associated with similar magnitude of increased CVD, which suggests that MetS was not in excess of the level explained by the presence of its single components. Further research should explore the association of different combinations of the components of MetS with CVD.

Dietary guidelines play a key role in setting standards for nutrition policies and promoting healthy eating. Like other public health guidelines, they are often influenced by political and economic factors that could place other concerns ahead of the population's health. In order to determine their effectiveness on obesity prevention, we prospectively examined the association between adherence to the latest available national dietary guidelines and the incidence of overweight/obesity in a Spanish cohort study. A sample of 11,554 participants of the "Seguimiento Universidad de Navarra" (SUN) cohort, initially free of overweight or obesity, was included in the study. The Spanish Society of Community Nutrition (SENC) food pyramid (FP) score was computed based on the ratio of consumed to recommended daily servings of grains, fruits, vegetables, dairy, protein-rich foods, olive oil, red and processed meat, sweets, salty snacks and spreadable fats, fermented alcoholic beverages and water. The same approach was followed to calculate the SENC hydration pyramid (HP) score, considering the intake of water and different kind of beverages. Adherence was calculated at baseline and after 10 years of follow-up. Cox proportional hazards models were used to assess the incidence of overweight/obesity (BMI >= 25 kg/m(2)). During a median follow-up of 10.3 years, 2320 incident cases were identified. The highest level of adherence to the SENC FP score was modestly associated with a reduced risk of overweight/obesity (multi variable-adjusted HR for the fifth quintile vs. the first quintile = 0.78; 95% CI: 0.67-0.91; p-trend: 0.007). No consistent trends were found for the SENC HP. In a large prospective cohort of Spanish university graduates, we found an inverse linear association between adherence to the SENC FP and overweight/obesity risk, whereas this was not the case for the HP.

Backgrounds and aim: The association between trajectories of body-shape from early childhood to early adulthood (first 40 years of life) and subsequent depression risk has not been explored before. We assessed this association in a prospective cohort of university graduates. Methods: We used a group-based modeling approach to assess the body shape trajectories from age 5 to 40 years, among 3888 women and 4124 men of the "Seguimiento Universidad de Navarra" (SUN) cohort study. All participants were free of depression at the beginning of the follow-up, and the occurrence of a new medical diagnosis of depression was evaluated every two years. Results: Four distinct trajectories for women and men were found ("lean-moderate increase", "medium-stable", "heavy-medium" and "heavy-marked increase" for women and "lean-marked increase", "medium-marked increase", "medium-stable" and "heavy-stable" for men). Among 78,475 person-years of follow-up a total of 351 incident cases of depression were identified. Among women, compared to those who maintained a medium body shape during life span ("medium-stable" trajectory), women who were heavy at childhood and had a marked increase in their body shape during early adult life ("heavy-marked increase" trajectory) showed significantly higher risk of a new-onset depression [HR= 1.92 (1.18-3.13)]. No association was observed in men between body-shape trajectories and subsequent risk of depression. Conclusions: Our results suggest that in a Mediterranean cohort, women who were heavy at early childhood and showed marked increases in body shape during early adulthood were at higher risk of developing depression later in life.

AIMS: Our aim was to assess the association between trajectories of body-shape across the first 40 years of life and subsequent development of hypertension in a Mediterranean cohort. METHODS AND RESULTS: We used a group-based modeling approach to assess body shape trajectories from age 5 to 40 years, among 7514 participants included in the SUN study (1999-2016), and assessed the subsequent incidence of hypertension. To create the trajectories, we used a censored normal model as a polynomial function of age. Cox models were used to estimates hazard ratios (HR) for hypertension according to body shape trajectories. Identified trajectories were "childhood lean -mid-life increase", "childhood medium-mid-life stable", " childhood heavy -mid-life decrease", and "childhood heavy -mid-life increase" for women; and "childhood lean-mid-life increase", "childhood medium-mid-life stable", "childhood medium -mid-life increase" and "childhood heavy-mid-life stable" for men. After a follow-up of 63,068 person-years, 865 incident cases of hypertension were found. Among women, compared to those in the "childhood medium-mid-life stable" trajectory, those, in the "childhood heavy -mid-life increase" trajectory showed higher risk to develop hypertension [HR = 1.72 (1.17-2.53)]. In men, compared with those in the "childhood medium-mid-life stable" trajectory, those in the "childhood lean and childhood medium -mid-life increase" and the "childhood heavy- mid-life stable" trajectories showed higher subsequent incidence of hypertension [HR = 1.43 (1.11-1.85), HR = 1.52 (1.17-1.97) and HR = 1.56 (1.14-2.14), respectively] after adjusting for potential confounders (including age, lifestyles, dietary intake, personality traits, physical activity and sedentary behaviors). CONCLUSIONS: Our results suggest that mid-life increases in body shape or maintaining a heavy body shape during early and middle life in men and childhood heavy-mid-life increase in women is associated with a higher subsequent risk of developing hypertension in this Mediterranean population.

Introduction and objective: Our aim was to examine the secular trends in obesity prevalence among Spanish adults with diabetes. Material and methods: Data were collected from 8 waves (from 1987 to 2012) of the National Health Surveys (NHS). NHS are cross-sectional studies conducted in representative samples of the Spanish adult population. Data of 7378 adults (>= 16 years) who reported having been diagnosed of diabetes were analyzed. Previously validated self-reported weight and height were used to estimate body mass index (BMI). Obesity was defined as a BMI of 30 kg/m(2) or greater. Age-adjusted obesity prevalence for each wave was calculated by the direct standardization method. Results: From 1987 to 2012 age-adjusted prevalence of obesity among persons with diabetes increased from 18.2% (95% confidence interval [CI]: 14.2-22.2%) to 39.8% (95% CI: 36.8-42.8%). Age-adjusted prevalence of obesity in males with diabetes increased from 13.2% (95% CI: 7.3-19.1%) to 38.0% (95% CI: 33.8-42.1%) and in females from 23.0% (95% CI: 17.6-28.4%) to 42.3% (95% CI: 38.0-46.6%). Conclusions: Between 1987 and 2012 the prevalence of obesity markedly increased in Spain among adults with diabetes. (C) 2018 Elsevier Espana, S.L.U. All rights reserved.

A few studies have assessed the association between omega-3 polyunsaturated fatty acids (n-3 PUFA) and cognitive impairment (CI) in very old adults. The aim of this study was to evaluate the effect of a multinutrient supplementation rich in n-3 PUFA on the cognitive function in an institutionalized >= 75-year-old population without CI or with mild cognitive impairment (MCI). A multicenter placebo-controlled double-blind randomized trial was conducted between 2012 and 2013. Cognitive function was assessed at baseline and after one year using 4 neuropsychological tests. Nutritional status was assessed using Mini Nutritional Assessment (MNA). Interaction between Mini-Mental State Examination (MMSE) score and nutritional status were analyzed using linear regression models. A total of 99 participants were randomized to receive placebo or pills rich in n-3 PUFA. After 1-year follow-up, both groups decreased their MMSE score (-1.18, SD:0.53 and-0.82, SD:0.63, p = 0.67 for the control and the intervention group respectively). The memory subscale of the MMSE showed an improvement (+0.26, SD:0.18) in the intervention group against a worsening in the control group (-0.11, SD: 0.14; p = 0.09 for differences between groups). Patients at intervention group with normal nutritional status (MNA >= 24) showed an improvement in the MMSE (+1.03, p = 0.025 for differences between 1-y and baseline measurements) against a worsening in the group with malnutrition (MNA<24) (-0.4, p = 0.886 for differences between 1-y and baseline; p of interaction p = 0.05). Supplementation with n-3 PUFA did not show an improvement in the global cognitive function in institutionalized elderly people without CI or with MCI. They only suggest an apparent improvement in memory loss if previously they were well nourished.

The aim of this study was to investigate determinants of self-rated health (SRH) perception in Spanish adults. This cross-sectional study including data from 11,342 participants from the Spanish PLENUFAR VI study. SRH status was grouped in two categories ('good'/'poor') and the associations of socio-demographic characteristics, lifestyles, diet adequacy and chronic disease with SRH were assessed. After adjusting for relevant confounders, the risk ratios (RR) and (95% confidence intervals) for poor SRH were 1.05 (1.03-1.07) for each hour of increment of sitting, 1.56 (1.30-1.88) for short (>= 5 h vs. 7-8 h) sleep duration, 0.63 (0.55-0.72) for vigorous (vs. light) physical activity, 0.61 (0.50-0.74) for adequate (vs. non-adequate) diet. Activities like jogging [RR for each unit of increment in the METs-h/day = 0.87 (0.82-0.92)], gymnastics [0.87 (0.81-0.93)], biking [0.91 (0.85-0.98)], and track and field [0.94 (0.89-0.98)], were associated with better health perception. Normally weight participants with any chronic disease had lower probability to report poor SRH than overweight/obese participants with any chronic disease. Frequent consumption of bread (>2 servings/day) was associated with a lower adjusted mean of health perception scale, while higher consumption of vegetables and fruit or fish were associated with higher values, concerning good SRH. We can conclude that normal-weight participants even suffering a chronic disease had lower probability to report poor health perception than participants with overweight/obesity and a chronic disease especially for hypertension and diabetes. Activities like jogging, gymnastics, biking, and track and field, and a higher consumption of fruits, vegetables and fish, were associated with better health rated perception.

The role of yogurt consumption in the risk of developing overweight, obesity, or metabolic syndrome has been the subject of epidemiologic studies over the last 10 y. A comprehensive literature search on MEDLINE and ISI Web of Knowledge from 1966 through June 2016 was conducted to examine the relation between yogurt consumption and weight gain, as well as the risk of overweight, obesity, or metabolic syndrome, in prospective cohort studies. Ten articles met all the inclusion criteria and were included in our systematic review. Of the 10 cohort studies, 3 analyzed the relation between yogurt consumption and the risk of overweight or obesity, 8 analyzed changes in waist circumference or weight changes, 3 studied the association with the risk of developing metabolic syndrome, and 1 studied the probability of abdominal obesity reversion. Although an inverse association between yogurt consumption and the risk of developing overweight or obesity was not fully consistent or always statistically significant, all studies but one showed in their point estimates inverse associations between yogurt consumption and changes in waist circumference, changes in weight, risk of overweight or obesity, and risk of metabolic syndrome during follow-up, although not all estimates were statistically significant ( 2 studies). Prospective cohort studies consistently suggested that yogurt consumption may contribute to a reduction in adiposity indexes and the risk of metabolic syndrome. Therefore, there is a need for more prospective studies and high-quality randomized clinical trials to confirm this apparent inverse association.

Living in a geographically higher altitude affects oxygen availability. The possible connection between environmental factors and the development of metabolic syndrome (MetS) feature is not fully understood, being the available epidemiological evidence still very limited. The aim of the present study was to evaluate the longitudinal association between altitude and incidence of MetS and each of its components in a prospective Spanish cohort, The Seguimiento Universidad de Navarra (SUN) project. Our study included 6860 highly educated subjects (university graduates) free from any MetS criteria at baseline. The altitude of residence was imputed with the postal code of each individual subject residence according to the data of the Spanish National Cartographic Institute and participants were categorized into tertiles. MetS was defined according to the harmonized definition. Cox proportional hazards models were used to assess the association between the altitude of residence and the risk of MetS during follow-up. After a median follow-up period of 10 years, 462 incident cases of MetS were identified. When adjusting for potential confounders, subjects in the highest category of altitude (>456 m) exhibited a significantly lower risk of developing MetS compared to those in the lowest tertile (<122 m) of altitude of residence [Model 2: Hazard ratio = 0.75 (95% Confidence interval: 0.580.97); p for trend = 0.029]. Living at geographically higher altitude was associated with a lower risk of developing MetS in the SUN project. Our findings suggest that geographical elevation may be an important factor linked to metabolic diseases.

Background: The increasing burden of type 2 diabetes mellitus makes the continuous surveillance of its prevalence and incidence advisable. Electronic health records (EHRs) have great potential for research and surveillance purposes; however the quality of their data must first be evaluated for fitness for use. The aim of this study was to assess the validity of type 2 diabetes diagnosis in a primary care EHR database covering more than half a million inhabitants, 97% of the population in Navarra, Spain. Methods: In the Navarra EPIC-InterAct study, the validity of the T90 code from the International Classification of Primary Care, Second Edition was studied in a primary care EHR database to identify incident cases of type 2 diabetes, using a multi-source approach as the gold standard. The sensitivity, specificity, positive predictive value, negative predictive value and the kappa index were calculated. Additionally, type 2 diabetes prevalence from the EHR database was compared with estimations from a health survey. Results: The sensitivity, specificity, positive predictive value and negative predictive value of incident type 2 diabetes recorded in the EHRs were 98.2, 99.3, 92.2 and 99.8%, respectively, and the kappa index was 0.946. Overall prevalence of type 2 diabetes diagnosed in the EHRs among adults (35-84 years of age) was 7.2% (95% confidence interval [CI] 7. 2-7.3) in men and 5.9% (95% CI 5.8-5.9) in women, which was similar to the prevalence estimated from the health survey: 8.5% (95% CI 7.1-9.8) and 5.5% (95% CI 4.4-6.6) in men and women, respectively. Conclusions: The high sensitivity and specificity of type 2 diabetes diagnosis found in the primary care EHRs make this database a good source for population-based surveillance of incident and prevalent type 2 diabetes, as well as for monitoring quality of care and health outcomes in diabetic patients.

Background and aims Evidence on the association yogurt consumption and obesity is not conclusive. The aim of this study was to prospectively evaluate the association between yogurt consumption, reversion of abdominal obesity status and waist circumference change in elderly. Methods and results 4545 individuals at high cardiovascular risk were prospectively followed. Total, whole-fat and low-fat yogurt consumption were assessed using food frequency questionnaires. Generalized estimating equations were used to analyze the association between yogurt consumption and waist circumference change (measured at baseline and yearly during the follow-up). Logistic regression models were used to evaluate the odds ratios (ORs) and 95% CIs of the reversion rate of abdominal obesity for each quintile of yogurt consumption compared with the lowest quintile. After multivariable adjustment, the average yearly waist circumference change in the quintiles of whole-fat yogurt consumption was: Q1: 0.00, Q2: 0.00 (¿0.23 to 0.23), Q3: ¿0.15 (¿0.42 to 0.13), Q4: 0.10 (¿0.21 to 0.42), and Q5: ¿0.23 (¿0.46 to ¿0.00) cm; p for trend = 0.05. The ORs for the reversion of abdominal obesity for whole-fat yogurt consumption were Q1: 1.00, Q2: 1.40 (1.04¿1.90), Q3: 1.33 (0.94¿1.89), Q4: 1.21 (0.83¿1.77), and Q5: 1.43 (1.06¿1.93); p for trend = 0.26. Conclusion Total yogurt consumption was not significantly associated with reversion of abdominal obesity status and a lower waist circumference. However, consumption of whole-fat yogurt was associated with changes in waist circumference and higher probability for reversion of abdominal obesity. Therefore, it seems that whole-fat yogurt has more beneficial effects in management of abdominal obesity in elderly population at high cardiovascular risk.

Objective: This study aims to assess the relationship of adherence to the Mediterranean dietary pattern, as well as the presence of menopausal symptoms, with overweight/obesity in Spanish perimenopausal and postmenopausal women. Methods: Participants in this cross-sectional study were 8,954 Spanish perimenopausal or postmenopausal women. Anthropometric measurements were recorded, and all women were interviewed to assess their adherence to the Mediterranean dietary pattern, using a validated questionnaire and the Menopause and Health subscale of the validated Cervantes Scale. A logistic regression model was used to investigate the association between categories of adherence to the Mediterranean diet and the odds of being overweight/obese. Multinomial logistic regression was used to study the association between menopausal symptoms and the odds of being overweight/obese (reference categories: participants in the low-adherence category and participants with no menopausal problems). Results: After adjustment for relevant confounders, the odds ratio (95% CI) for being overweight/obese among women in the highest category of adherence to the Mediterranean dietary pattern was 0.68 (0.60-0.78; P for trend <0.001). The odds ratio (95% CI) for being overweight/obese was 3.05 (1.98-4.71) for the category "severe problems" in comparison with the category "no problems." Conclusions: Higher adherence to a healthy dietary pattern (Mediterranean diet) is inversely associated with overweight/obesity in perimenopausal and postmenopausal women. The occurrence of low to severe problems during perimenopause or postmenopause is positively associated with overweight/obesity. Therefore, high adherence to the Mediterranean dietary pattern and a body mass index of 25kg/m or lower might improve quality of life in women at these stages.

Background: The role of yogurt consumption in the development of metabolic syndrome (MetS) is not fully understood and the available epidemiologic evidence is scarce. The aim of our study was to assess the association between total, whole-fat, or low-fat yogurt consumption and the risk of developing MetS.Methods: Yogurt consumption was assessed at baseline through a 136-item validated FFQ. MetS was defined following the harmonized definition for MetS according to the AHA and the IDF criteria. Logistic regression models were used.Results: During the first 6-y of follow-up of the SUN cohort, 306 incident cases of MetS were identified. Frequent consumption [>= 875 g/week (>= 7 servings/week) versus <= 250 g/week (2 servings/week)] of total, whole-fat and low-fat yogurt consumption showed non-significant inverse associations with MetS [OR = 0.84 (95% CI: 0.60-1.18); 0.98 (95% CI: 0.68-1.41); and 0.63 (95% CI: 0.39-1.02) respectively]. Only one component of the MetS, central adiposity, was inversely associated with total and whole-fat yogurt consumption [OR = 0.85 (95% CI: 0.74-0.98) and 0.85 (95% CI: 0.73-0.99) respectively]. In the joint assessment of exposure to total yogurt consumption and fruit consumption, those in the highest category of total yogurt consumption, and having a high fruit consumption (above the median = 264.5 g/day) exhibited a significantly lower risk of developing MetS [OR = 0.61 (95% CI: 0.38-0.99)] compared with those in the lowest category of total ...

Background/ Objectives: To evaluate the association between the carbohydrate quality (CQI) and weight change or incident overweight/obesity (BMI¿25 kg/m2) in the ¿Seguimiento Universidad de Navarra (SUN)¿ cohort. Subjects/ Methods: 8 741 participants initially free of overweight/obesity were followed¿up for a median of 7.9 years. We evaluated at baseline the CQI following 4 criteria: dietary fibre intake, glycemic index (GI), whole grains/total grains ratio and solid carbohydrates/total carbohydrates ratio. Subjects were classified into quintiles according to CQI. Weight was recorded at baseline and updated every 2 years during follow¿up. Results: Increasing CQI of diet was not significantly associated with lower weight gain, although participants in the highest quintile had the lowest average crude weight gain (+211 g/year). We observed 1 862 incident cases of overweight/obesity during followup. CQI was significantly associated (p for trend 0.006) with lower risk of overweight/obesity: adjusted OR for the 4rd and 5th quintiles: 0.81 (95% CI 0.66 to 0.99), and 0.74 (95% CI 0.60 to 0.92), respectively. Conclusions: In this Mediterranean cohort, CQI showed a significant inverse association with the incidence of overweight/obesity, which highlights that carbohydrate intake guidelines related to obesity prevention should be focused in improving the CQI of the diet.

We evaluated the effectiveness of oral sodium citrate versus intravenous (IV) sodium bicarbonate for CI-AKI prophylaxis as well as their influence on kidney injury biomarkers. Material and Methods: A randomized, controlled, single-center study including 130 hospitalized patients (62.3% men), who were randomized to receive sodium bicarbonate (1/6 men, 3 ml/kg/h for 1 h; n = 43), oral sodium citrate (75 ml/10 kg divided into 4 doses; n = 43) or nonspecific hydration (n = 44) before contrast administration, was conducted. Serum creatinine and kidney injury biomarkers (cystatin C, neutrophil gelatinase-associated lipocalin, interleukin-8, F2-isoprostanes and cardiotrophin-1 [CT-1]) were assessed. Results: Incidence of CI-AKI was 9.2% with no differences found between hydration groups: 7.0% in sodium bicarbonate group, 11.6% in oral sodium citrate group and 9.1% in the nonspecific hydration group. Urinary creatinine and urinary CT-1/creatinine ratio decreased 4 h after contrast infusion (p < 0.001), but none of the biomarkers assessed were affected by the treatments. Conclusions: There were no differences in hydration with oral sodium citrate and IV sodium bicarbonate for the prophylaxis of CI-AKI. Therefore, oral hydration represents a safe, inexpensive and practical method for preventing CI-AKI in low-risk patients. No effect on biomarkers for kidney injury could be demonstrated.

Background: The association between consumption of dairy products and the risk of developing metabolic syndrome (MetS) is unclear. Objective: The purpose of this study was to evaluate the associations between consumption of dairy products (total and different subtypes) and incident MetS in a Mediterranean population at high cardiovascular disease risk. Methods: We prospectively analyzed 1868 men and women (55-80 y old) without MetS at baseline, recruited from different PREDIMED (Prevencion con Dieta Mediterranea) centers between October 2003 and June 2009 and followed up until December 2010. MetS was defined according to updated, harmonized criteria. At baseline and yearly thereafter, we determined anthropometric variables, dietary habits by a 137-item validated food-frequency questionnaire, and blood biochemistry. Multivariable-adjusted HRs of MetS or its components were estimated for each of the 2 upper tertiles (vs. the lowest one) of mean consumption of dairy products during the follow-up. Results: During a median follow-up of 3.2 y, we documented 930 incident MetS cases. In the multivariable-adjusted model, HRs (95% CIs) of MetS for the comparison of extreme tertiles of dairy product consumption were 0.72 (0.61,0.86) for low-fat dairy, 0.73 (0.62, 0.86) for low-fat yogurt, 0.78 (0.66, 0.92) for whole-fat yogurt, and 0.80 (0.67, 0.95) for low-fat milk. The respective HR for cheese was 1.31 (1.10, 1.56). Conclusions: Higher consumption of low-fat dairy products, yogurt (total, low-fat, and whole-fat yogurt) and low-fat milk was associated with a reduced risk of MetS in individuals at high cardiovascular disease risk from a Mediterranean population. Conversely, higher consumption of cheese was related to a higher risk of MetS.

DESIGN: The SUN Project is a dynamic, prospective, multipurpose cohort of Spanish university graduates with an overall retention rate of 90%. The study population encompassed 8569 Spanish university graduates (mean age: 37 y) who were initially free of overweight or obesity. Self-reported weight (previously validated) was collected at baseline and updated every 2 y during the follow-up period. Fructan consumption and GOS consumption were assessed with the use of a validated semiquantitative 136-item food-frequency questionnaire and were updated after 10 y. Time-dependent Cox proportional hazards models were used to estimate HRs and 95% CIs for incident overweight and to adjust for potential confounding factors. RESULTS: During follow-up (median: 9 y), 1964 incident cases of overweight were identified. After potential confounders were adjusted for, risk of overweight was 15% lower in participants in the highest quartile of fructan consumption (¿2.3 g/d) (95% CI: 0.74, 0.97; P-trend = 0.019). Subjects in the highest quartile of GOS consumption (¿0.45 g/d) had 17% lower risk of overweight (95% CI: 0.74, 0.94; P-trend = 0.001). CONCLUSIONS: Higher prebiotic consumption was associated with lower risk of overweight in a cohort of initially normal-weight, middle-aged adults. This potential protection has been previously scarcely assessed; therefore, additional longitudinal studies are needed to confirm our results.

OBJECTIVE: To evaluate the association of snacking between main meals with the risk of developing metabolic syndrome. DESIGN: A dynamic prospective cohort study (the SUN Project; Seguimiento Universidad de Navarra). Snack consumption was evaluated using the question: 'Do you have the habit of snacking between main meals?' Metabolic syndrome was defined according to the updated harmonizing criteria. We estimated multivariable-adjusted relative risks (RR) of metabolic syndrome and their 95 % confidence intervals using Poisson regression models. An exploratory factor analysis was also used to identify patterns of snacking. SETTING: University of Navarra, Spain. SUBJECTS: The study included 6851 university graduates, initially free of metabolic syndrome, and followed-up them for a median of 8·3 years. RESULTS: Among our participants, 34·6 % reported usual snacking between main meals. The cumulative incidence of metabolic syndrome was 5·1 % (9·5 % among men and 2·8 % among women). Snacking between main meals was significantly associated with higher risk for developing metabolic syndrome after multivariable adjustment (RR=1·44; 95 %CI 1·18, 1·77). Higher adherence to an 'unhealthy snacking pattern' was also independently associated with increased incidence of metabolic syndrome (fourth quartile of adherence compared with non-snacking: RR=1·68; 95 % CI 1·23, 2·29; P for trend <0·001). CONCLUSIONS: Our findings suggest that avoidance of snacking between main meals can be included among the preventive approaches to reduce the risk of metabolic syndrome development, especially when snacks contain foods of poor nutritional quality.

Background Polychlorinated biphenyls (PCB) are persistent organic pollutants (POP) that are consumed because of their bioaccumulation through the food chain. Recent studies have suggested the implication of POPs in the development of metabolic diseases such as type 2 diabetes and obesity. However, this relationship is not entirely consistent, and has not been investigated in longitudinal studies. The purpose of this study was to prospectively examine the association between dietary intake of PCBs and the incidence of obesity in the Seguimiento Universidad de Navarra (SUN) Project. Methods Our study included 12¿313 participants without obesity at baseline, who were followed-up for a median of 8.1¿years. Dietary intakes of PCBs, expressed as WHO toxic equivalents, were assessed at baseline through a 136-item semiquantitative food-frequency questionnaire. The published concentration levels of PCBs measured in samples of food consumed in Spain were used to estimate intakes. Multivariable Cox regression models were fitted to estimate HRs and 95% CI for incident obesity. Results During follow-up, we observed 621 incident cases of obesity. After adjustment for total energy intake and additional adjustment for potential confounders, participants in the fifth quintile of PCBs intake were at higher risk of becoming obese (adjusted HR: 1.58; (95% CI 1.21 to 2.06)) compared to those in the first quintile. The linear trend test was statistically significant (p<0.001). Conclusions Dietary intake of PCBs as estimated using a food frequency questionnaire was associated with a higher incidence of obesity. Nevertheless, further longitudinal studies are needed to confirm our results.

Abstract: The nutritional status and lifestyle of women in preconception, pregnancy and lactation determine maternal, fetal and child health. The aim of this cross-sectional study was to evaluate dietary patterns and lifestyles according the perinatal physiological status in a large sample of Spanish women. Community pharmacists that were previously trained to collect the data recruited 13,845 women. General information, anthropometric measurements, physical activity, unhealthy habits and dietary data were assessed using a validated questionnaire. Mean values and percentages were used as descriptive statistics. The t-test, ANOVA or chi-squared test were used to compare groups. A score that included dietary and behavioral characteristics was generated to compare lifestyles in the three physiological situations. The analysis revealed that diet quality should be improved in the three stages, but in a different manner. While women seeking a pregnancy only met dairy recommendations, those who were pregnant only fulfilled fresh fruits servings and lactating women only covered protein group requirements. In all cases, the consumption allowances of sausages, buns and pastries were exceeded. Food patterns and unhealthy behaviors of Spanish women in preconception, pregnancy and lactation should be improved, particularly in preconception. This information might be useful in order to implement educational programs for each population group.

Reported associations between the consumption of fried foods and the incidence of obesity or weight gain make it likely that fried food consumption might also be associated with the development of hypertension. However, evidence from long-term prospective studies is scarce. Therefore, the aim of the present study was to longitudinally evaluate this association in a prospective cohort. The SUN (Seguimiento Universidad de Navarra) project is a Mediterranean cohort study of university graduates conducted in Spain, which started in December 1999 and is still ongoing. In the present study, we included 13,679 participants (5059 men and 8620 women), free of hypertension at baseline with a mean age of 36·5 (SD 10·8) years. Total fried food consumption was estimated at baseline. The outcome was the incidence of a medical diagnosis of self-reported hypertension during the follow-up period. To assess the association between the consumption of fried foods and the subsequent risk of developing incident hypertension during the follow-up period, Cox regression models were used. During a median follow-up period of 6·3 years, 1232 incident cases of hypertension were identified. After adjusting for potential confounders, the adjusted hazard ratios for developing hypertension were 1·18 (95% CI 1·03, 1·36) and 1·21 (95% CI 1·04, 1·41) for those consuming fried foods 2-4 and >4 times/week, respectively, compared with those consuming fried foods < 2 times/week (P for trend = 0·009). In conclusion, frequent consumption of fried foods at baseline was found to be associated with a higher risk of hypertension during the follow-up period in a Mediterranean cohort of university graduates.

METHODS: After a median of 6.5 years of follow-up, we included 10,532 or 9,470 participants without chronic disease or obesity at baseline for analyzing the association between the incidence of obesity and nocturnal sleep duration or having siesta. Sleeping hours and siesta were assessed at baseline. Weight was recorded at baseline and every 2 years during the follow-up. The outcome was the incidence of obesity during follow-up among participants with initial BMI <30 kg/m(2). RESULTS: During follow-up we observed 446 new cases of obesity in the analysis of nocturnal sleep duration. Sleeping less than 5 h at night was associated with a higher risk of becoming obese compared to sleeping between 7 and <8 h (HR 1.94; 95% CI 1.19-3.18; p for quadratic trend = 0.06) after adjusting for potential confounders. During follow-up, we observed 396 incident cases of obesity in the analysis of siesta. Those who took a siesta for 30 min/day had a 33% lower risk of becoming obese (HR 0.67; 95% CI 0.46-0.96; p for quadratic trend = 0.13) compared to those who did not take siesta. CONCLUSION: Our results suggest that short nocturnal sleep duration could be a modifiable risk factor for obesity. It is possible that this association may be stronger among men and subjects who experienced previous weight gain. Additionally, siesta might be a novel and independent protective factor for obesity; however, confirmatory studies are needed.

Background and aims: The consumption of fried foods is believed to be linked with obesity and higher weight gain, however, the evidence from long-term randomized trials or prospective epidemiological studies is scarce. Therefore, the aim of our study was to prospectively evaluate the association between the consumption of fried foods and weight change and the incidence of overweight/obesity in a Mediterranean cohort. Methods and results: Prospective cohort study of 9850 men and women with a mean age of 38.1 years (SD 11.4) were followed-up for a median of 6.1 years to assess average yearly change in body weight, and incidence of overweight/obesity. The consumption of fried foods was associated with higher weight gain, but the differences were of small magnitude and statistically non-significant. The incidence of overweight/obesity during follow-up was also assessed in the subset of 6821 participants with initial body mass index <25 kg/m(2) (initially free of overweight/obesity), after adjusting for potential confounders, the odds ratio for developing overweight/obesity among participants who consumed fried foods >4 times/week was 1.37 (95% confidence interval: 1.08 to 1.73) in comparison with those who consumed fried foods <2 times/week (p for trend = 0.02). Conclusion: In this Mediterranean prospective cohort, a more frequent consumption of fried foods at baseline was associated with a higher risk of subsequently developing overweight/obesity during follow-up.

We observed 341 incident cases of MS. Consumers of ¿7 drinks/wk presented a significantly higher risk of developing MS (aOR: 1.80; 95% CI: 1.22-2.66; p < 0.001) compared with non-drinkers. In addition, alcohol drinkers (¿7 drinks/wk) had higher risk of hypertriglyceridemia (aOR: 2.07; 95% CI: 1.46-2.93) and impaired fasting glucose (aOR: 1.54; 95% CI: 1.16-2.04). Beer consumption was associated with higher risk for MS (p for trend = 0.027) and higher risk of hypertriglyceridemia (aOR: 1.81; 95% CI: 1.02-3.20), but with lower risk of low HDL-cholesterol criterion (aOR: 0.21; 95% CI: 0.05-0.89) for ¿7 drinks/wk versus no consumption. Non-significant association was observed between wine or liquor consumption and MS. CONCLUSIONS: Consumption of at least seven alcoholic drinks per week was associated with a higher risk of developing MS among subjects initially free of any MS criteria.

Background: Longitudinal studies assessing the long-term association between alcohol intake and depression are scarce. The type of beverage may also be important. Therefore we aimed to prospectively evaluate the influence of alcohol intake on incident depression in a Mediterranean cohort. Methods: We assessed 13,619 university graduates (mean age: 38 years, 42% men) participating in a Spanish prospective epidemiological cohort (the SUN Project), initially free of depression. They were recruited between 1999-2008 and biennially followed-up during 2001-2010. At baseline, a 136-item validated food-frequency questionnaire was used to assess alcohol intake. Wine was the preferred beverage. Participants were classified as incident cases of depression if they reported a new clinical diagnosis of depression by a physician and/or initiated the use of antidepressant drugs. Cox regression and restricted cubic splines analyses were performed over 82,926 person-years. Results: Only among women, an U-shaped relationship between total alcohol intake and depression risk was found (P=0.01). Moderate alcohol intake (5-15 g/day) was associated with lower risk (Hazard Ratio: 0.62; 95% Confidence Interval: 0.43-0.89). No association was apparent for higher intakes of alcohol or for any specific type of alcoholic beverage. Conclusions: Moderate alcohol intake might protect against depression among women. Further confirmatory studies are needed.

Magnesium is the second most predominant intracellular cation and it is an important cofactor in over 300 enzymatic reactions. It is a calcium antagonist and a voltage-dependant blocker of the N-methyl-D-aspartate channel, which plays a role in the entrance of calcium into the neuron. Other mechanisms also add biological plausibility to neuro-protective properties for magnesium, including an inverse association with major depression. A higher magnesium intake has been related to lower depressive symptoms. However, epidemiological evidence on this issue is scarce. Our aim was to prospectively evaluate the association between dietary magnesium intake and depression incidence in a cohort of 12,939 Spanish university graduates initially free of depression (Seguimiento Universidad de Navarra Cohort Study). Total magnesium intake was assessed with a validated, semiquantitative FFQ and incident depression was ascertained through self-reports of a new clinical diagnosis of depression done by a medical doctor and/or the habitual use of antidepressive drugs. The self-report was validated against the Diagnostic and Statistical Manual of Mental Disorders (4th edition) criteria in a subsample of the cohort. Cox regression models were used to obtain HR of incident depression during follow-up according to baseline quintiles of magnesium intake using the lowest quintile as the reference category. After a median follow-up of 6.3 y, 737 new cases of depression were identified. No association between magnesium intake and depression was found, with multivariate-adjusted HR = 1 (reference), 1.00 (95% CI: 0.78-1.27), 1.00 (0.76-1.31), 0.95 (0.70-1.30), and 1.11 (0.77-1.59) for increasing categories (quintiles 1-5) of total magnesium intake. No dose-response relationship was found (P-trend = 0.59). Results were robust through different sensitivity analyses, including nutrient density or residual models. In conclusion, our findings do not suggest an inverse association between magnesium intake and depressive disorder. J. Nutr. 142: 1053-1059, 2012.

Objective: The effects of alcohol on body weight might be modulated by the total amount of alcohol intake and type of alcoholic beverage. However, available results are contradictory. There is a scarcity of studies on this topic in Mediterranean areas where wine consumption is high. We prospectively evaluated the association between the type of alcoholic beverage intake and weight change in a Mediterranean cohort. Methods: We followed for an average of 6.1 y 9318 adults without previous chronic disease at baseline. Validated data on diet including alcohol consumption were collected at baseline. Weight was recorded at baseline and updated every 2 y during follow-up. The outcomes were average weight gained every year and incidence of overweight/obesity after a 6-y follow-up. Results: During follow-up, 1006 incident cases of overweight/obesity were identified in participants with normal weight at baseline. Beer and spirits consumption (>= 7 drinks/wk) was associated with a +119 g/y (95% confidence interval +27 to +212) higher average yearly weight gain after adjusting for relevant confounders. It was also associated with a higher risk of developing overweight/obesity compared with non-drinkers. No association between wine consumption and yearly weight change or the risk of developing overweight/obesity was apparent. Conclusion: The type of alcoholic beverage can modulate the effect of alcohol intake on the risk of developing overweight/obesity.