Purpose There is no evidence of a dietary index that measures not only the quantity but also the quality of protein. The aim is to investigate the association between a new dietary protein quality index (PQI) and micronutrient intake adequacy in a Mediterranean cohort. Design We assessed 17,535 participants' diet at baseline using a semi-quantitative FFQ. The PQI was calculated according to the ratio of protein (g/d) sources: [fish, seafood, lean meat, pulses, eggs, nuts, low-fat dairy, and whole grains]/[red and ultra-processed meats, whole-fat or semi-skimmed dairy, potatoes and refined grains]. Participants were classified into quintiles of PQI. We evaluated the intakes of Fe, Cr, I, K, Mg, Ca, P, Na, Se, Zn and vitamins A, B1, B2, B3, B6, B12, C, E and folic acid. Micronutrient adequacy was evaluated using DRIs. Logistic regression analysis was used to assess the micronutrient adequacy according to quintiles of PQI. Results In this cross-sectional analysis, a total of 24.2% and 4.3% participants did not to meet DRIs in >= 4 and >= 8 micronutrients, respectively. The odds of failing to meet >= 4 and >= 8 DRI were lower in participants in the highest quintile of protein quality (OR = 0.22; IC 95% = 0.18, 0.26; P-trend < 0.001; and OR = 0.08; IC 95% = 0.05, 0.14; P-trend < 0.001, respectively) as compared to participants in the lowest quintile. Conclusion Higher PQI was found to be strongly associated with better micronutrient intake adequacy in this Mediterranean cohort. The promotion of high-quality protein intake may be helpful for a more adequate intake of micronutrients. The odds of failing to meet certain numbers of DRIs were lower rather than saying lower risk.

Purpose We aimed to prospectively investigate the association of an overall oxidative balance score (OBS) with all-cause death and cause-specific mortality among participants in the Seguimiento Universidad de Navarra (SUN) Study, a Mediterranean cohort of Spanish graduates. Methods Using baseline information on 12 a priori selected dietary and non-dietary lifestyle pro- and antioxidants exposures-vitamins C and E, beta-carotenes, selenium, zinc, heme iron, polyphenols, total antioxidant capacity, body mass index, alcohol, smoking, and physical activity-we constructed an equally weighted OBS categorized into quartiles, with higher scores representing greater antioxidant balance. Cox proportional hazards models were fitted to evaluate the association between the OBS and mortality. Results A total of 18,561 participants (mean [SD] age, 38.5 [12.4] years; 40.8% males) were included in the analysis. During a median follow-up of 12.2 years (interquartile range 8.3-14.9), 421 deaths were identified, including 80 deaths from cardiovascular disease (CVD), 215 from cancer, and 126 from other causes. After adjustment for potential confounders, the hazard ratios and 95% confidence interval (CIs) between the highest quartile (predominance of antioxidants) vs. the lowest quartile (reference category) were 0.35 (95% CI 0.22-0.54, P-trend < 0.001) for all-cause mortality, 0.18 (95% CI 0.06-0.51, P-trend = 0.001) for CVD mortality, 0.35 (95% CI 0.19-0.65, P-trend = 0.002) for cancer mortality, and 0.45 (95% CI 0.20-1.02, P-trend = 0.054) for other-cause mortality. Conclusion Our findings suggest a strong inverse association between the OBS and all-cause, CVD, and cancer mortality. Individuals exposed to both antioxidant dietary and lifestyle factors may potentially experience the lowest mortality risk.

Several studies have tried to analyse the association between all-cause mortality and different risk factors, (especially those which are modifiable, such as smoking, diet or exercise), to develop public health preventive strategies. However, a specific analysis of predictors of premature and late mortality is needed to give more precise recommendations. Considering that there are risk factors which exert an influence on some diseases and not on others, we expect that, similarly, they may have a different impact depending on the timing of mortality, separating premature (<65 years) from late mortality (>65 years). Thus, we prospectively followed-up during a median of 12 years a cohort of 20,272 university graduates comprising an ample range of ages at inception. Time-dependent, covariate-adjusted Cox models were used to estimate adjusted hazard ratios (HR) and their 95 % confidence intervals (CI) for each predictor. The strongest independent predictor of mortality at any age was physical activity which was associated with reduced risk of total, premature and late mortality (range of HRs when comparing the highest vs. the lowest level: 0.24 to 0.48). Specific strong predictors for premature mortality were smoking, HR: 4.22 (95 % CI: 2.42-7.38), and the concurrence of >2 metabolic conditions at baseline, HR: 1.97 (1.10-3.51). The habit of sleeping a long nap (>30 min/d), with HR: 2.53 (1.30-4.91), and poor adherence to the Mediterranean Diet (<3 points in a 0 to 8 score vs. >6 points), with HR: 2.27 (1.08-4.76), were the strongest specific predictors for late mortality. Smoking, diet quality or lifestyles, probably should be differen-tially assessed as specific predictors for early and late mortality. In the era of precision medicine, this approach will allow tailored recommendations appropriate to each person's age and baseline condition.

Background & aims: The specific association of olive oil consumption with coronary heart disease (CHD) or stroke has not been totally established. Objective: to examine whether olive oil consumption is associated with subclinical atherosclerosis, the risk of total cardiovascular disease (CVD), CHD, and stroke. Methods: Three cohorts were included: AWHS (2318 men), SUN Project (18,266 men and women), and EPIC-Spain (39,393 men and women). Olive oil consumption was measured at baseline using validated questionnaires. Results: In the AWHS, 747 participants had a positive coronary artery calcium score (CACS>0), and the OR (95% CI) was 0.89 (0.72, 1.10) in those with virgin olive oil consumption >30 g/day (v. <10 g/day). In the SUN Project (follow-up 10.8 years) 261 total CVD cases occurred, and the HR was 0.57 (0.34, 0.96) for consumptions >30 g/day (v. <10 g/day). In the EPIC-Spain (follow-up 22.8 years) 1300 CHD cases and 938 stroke cases occurred; the HRs for stroke according, 0 to <10 (ref), 10 to <20, 20 to <30, and >30 g/day of olive oil consumption, were 0.84 (0.70, 1.02), 0.80 (0.66, 0.96), 0.89 (0.74, 1.07). A weaker association was observed for CHD. The association was stronger among those consuming virgin olive oil, instead of common (refined). Conclusions: Olive oil is associated with lower risk of CVD and stroke. The maximum benefit could be obtained with a consumption between 20 and 30 g/day. The association could be stronger for virgin olive oil and might operate from the early stages of the disease.

Objectives To evaluate the association between cancer screening counselling provided by medical doctors to their patients and each doctor's own anthropometrics, lifestyle, cancer screening practices, and personal and family history of cancer. Design Prospective cohort study. Setting Substudy including physicians participating in a Spanish cohort study with open enrolment. Participants Among 22 800 participants in the cohort as of May 2018, there were 2371 physicians who had replied to the cohort baseline questionnaire, had an email account and were younger than 65 years (retirement age in Spain). From this subsample, 890 replied to an online questionnaire focused on their clinical practices related to the counselling provided to their patients and to their prescription practices of preventive medications. Their mean age was 51.7 (SD 9.4) years and 48% were women. Outcome measures Frequency of counselling given to their patients on specific practices of breast, colorectal and prostate cancer screenings. Results Counselling on cancer screening to their patients was provided by 65% of physicians in a scenario of colorectal cancer, 59% for prostate cancer and 58% for breast cancer. More frequent cancer screening counselling was associated with the specialties of family medicine (OR=9.4, 95% CI 5.1 to 17.1) and internal medicine (OR=2.9, 95% CI 1.5 to 5.7) as compared with other specialties. Recommending cancer screening was associated with more frequent counselling on smoking cessation (OR=3.7, 95% CI 2.6 to 5.4), having personally attended colorectal cancer screening (OR=2.2, 95% CI 1.1 to 4.7) and prescribing blood pressure medication more often than their colleagues (OR=2.1, 95% CI 1.2 to 3.7). Conclusions Among medical doctors, cancer screening counselling was provided to their patients more frequently for doctors with family medicine or internal medicine specialties and for physicians who regularly offered counselling on certain lifestyle behaviours, and those having personally attended colorectal cancer screening. Doctors' own personal practices and knowledge of healthy lifestyles may help doctors to more frequently provide counselling on cancer screening to their patients.

Background: Dietary quality indices (DQI) are widely used in nutritional epidemiology. However, how they might change over time in a Mediterranean population is not well understood. Objective: To evaluate within-participant longitudinal changes in scores for nine a priori¿defined DQIs: Fat Quality Index (FQI), Carbohydrate Quality Index (CQI), Pro-vegetarian Dietary Pattern (PVG), Mediterranean Diet Adherence Screener (MEDAS), Mediterranean Diet Score (MDS), Dietary Approaches to Stop Hypertension (DASH), Mediterranean-DASH Intervention for Neurodegenerative Delay Diet (MIND), Prime Diet Quality Score (PDQS) and Alternate Healthy Eating Index (AHEI-2010) in the ¿Seguimiento Universidad de Navarra¿ (SUN) cohort, a well-known Mediterranean cohort of university graduates, and to identify baseline predictors of improvement in MEDAS and AHEI-2010 after 10 years of follow-up. Design: In this longitudinal cohort study, DQI scores were calculated based on responses from a validated semiquantitative food-frequency questionnaire (FFQ). Participants/setting: Spanish university graduates enrolled in the SUN cohort before March 2008, who completed the 10-year FFQ and reported total dietary intake at baseline and after 10 years of follow-up, included 2,244 men and 3,271 women, whose mean age at baseline was 36.3 years (standard deviation [SD], 10.7). ...

Background & aim: The association between ultra-processed foods (UPF) consumption and the risk of type 2 diabetes (T2D) has not been much explored. We aimed to evaluate the association between consumption of UPF and the incidence of T2D. Methods: We assessed 20,060 participants (61.5% women) from the SUN project (Seguimiento Universidad de Navarra) followed-up every two years (median follow-up 12 years). Food and drink consumption were evaluated through a validated 136-item food frequency questionnaire and grouped according to their degree of processing by the NOVA classification. Participants were categorized into tertiles of UPF consumption adjusted for total energy intake. We fitted Cox proportional hazard models with repeated dietary measurements at baseline and updating information on food consumption after 10 years of follow-up to minimise the potential effect of diet variation. Results: During 215,149 person-years of follow-up, 175 new-onset T2D cases were confirmed. Participants in the highest baseline tertile (high consumption) of UPF consumption had a higher risk of T2D as compared to those in the lowest tertile (multivariable adjusted hazard ratio [HR] 1.53, 95% confidence interval [CI]: 1.06 to 2.22) with a significant dose-response relationship (p for linear trend 1/4 0.024). The multivariable adjusted HR using repeated measurements of UPF intake was 1.65 (95% CI 1.14-2.38) when comparing extreme tertiles. Conclusions: In a highly-educated Mediterranean cohort with a low absolute risk, a higher intake of UPF was independently associated with a higher risk for T2D. These results provide more evidence to encourage the limitation of UPF consumption to reduce the population burden of T2D. (c) 2021 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. 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.

Background: Healthy lifestyle adherence is associated with lower chronic disease morbidity/mortality. The role of doctors, as counselors and role models, is essential. Among physicians participating in a prospective cohort, we investigated the behavioral counseling on diet and lifestyle provided to their patients in association with their own personal behaviors. Methods: We assessed 890 doctors aged ¿65 years participating in the 'Seguimiento Universidad de Navarra' (SUN) cohort, who replied to an online questionnaire regarding their practices on behavioral counseling and drug prescription to their patients. Data were combined with previous baseline information on their personal healthy habits. Results: Among doctors, 31% reported <10 min per visit; 73% counseled 60-100% of their patients on smoking cessation, 58% on physical activity, 54% on weight control, 51% on healthy nutrition, 44% on alcohol avoidance/reduction and 28% recommended alcohol moderate consumption. The percentage of doctors that counseled 100% of their patients about lifestyle was 43% for smoking cessation, 15% for exercise and 13% for weight control and nutrition. Better doctor's adherence to the Mediterranean dietary pattern was associated with more frequent and longer nutrition counseling. Higher practice of physical activity was associated with longer time on counseling about exercise to their patients. Among doctors both current and former smoking were inversely associated with the frequency and duration of their smoking cessation/avoidance counseling practices. Conclusions: Personal behavioral changes among doctors and better training of medical doctors on a personal healthy diet and lifestyle are likely to contribute to improve the behavioral counseling given to patients.