The impact of dietary habits on cardiovascular risk factors and (PDF)

The impact of dietary habits on cardiovascular risk factors and other metabolic parameters of free-living populations : methodological approaches to dietary analyses Citation for published version (APA): Pounis, G. (2014). The impact of dietary habits on cardiovascular risk factors and other metabolic parameters of free-living populations : methodological approaches to dietary analyses. Maastricht University. https://doi.org/10.26481/dis.20140611gp Document status and date: Published: 01/01/2014 DOI: 10.26481/dis.20140611gp Document Version: Publisher's PDF, also known as Version of record Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. 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No part of this thesis may be reproduced, stored in a retrieval system or transmitted in any form or by any means, without the permission in writing from the author, or, when appropriate, of the publishers of the publications.  3 The impact of dietary habits on cardiovascular risk factors and other metabolic parameters of free-­‐living populations: methodological approaches to dietary analyses PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit Maastricht op gezag van de Rector Magnificus, Prof. dr. L. L. G. Soete, Volgens het besluit van het College van Decanen, In het openbaar te verdedigen op 11 June 2014, 10:00 door Georgios Pounis  4 Promotoren Prof. dr. H. ten Cate Prof. dr. G. de Gaetano, IRCCS Instituto Neurologico Mediterraneo Neuromed, Pozzilli (IS), Italy Prof. dr. L. Iacoviello, IRCCS Instituto Neurologico Mediterraneo Neuromed, Pozzilli (IS), Italy Beoordelingscommissie Prof. dr. R.P. Koopmans, (chairman) Dr. A.J. ten Cate-­‐Hoek Prof. dr. ir. P.C. Dagnelie Dr. A. Siani, Institute of Food Sciences, National Research Council, Avellino, Italy Prof. dr. J. Vermylen, Katholieke Universiteit Leuven, Belgium This thesis was printed with the generous support of my parents.  5 To My Family and Eleftheria  6  7 Contents Chapter 1. General Introduction 9-­‐12 Chapters 2-­‐7. Selected Publications 13-­‐109 Chapter 8. General Discussion 110-­‐114 Chapter 9. Conclusions 115-­‐116 Chapter 10. Summary 117 Chapter 11. Curriculum vitae 118 Chapter 12. Publications 119-­‐121 Chapter 13. Acknowledgements 122  8  9 Chapter 1. General Introduction Dietary habits have been strongly associated with primary and secondary prevention of several chronic diseases such as cardiovascular disease (CVD) and different types of cancer. The World Health Organization reports that non-­‐healthy diet is one of the 3 most important risk factors that can be prevented, together with the lack of physical activity and smoking. The evaluation of dietary habits can be performed at many levels leading to different types of public health conclusions. There are at least 4 different approaches, which are commonly used, in dietary analysis. The first tries to measure the consumption of food groups that are usually used at the local “cuisine. This method can be applied using data from 24-­‐hour dietary recalls, Food Frequency Questionnaires (FFQs) and diaries of food consumption. The most frequent conclusions of such analysis include the reporting of a possible positive or negative association of food groups’ consumption with the studied disease. These inferences can help to better evaluate the importance of such food groups for public health perspectives. The second type of dietary analysis goes quantitatively, one step further and using food composition tables to calculate the exact nutrient intake. This technique allows researchers to give specific guidelines to dieticians and related health providers about the ideal intake of nutrients in each disease or health condition. These inferences are of great importance for nutritionists especially in the process of editing specific dietary plans for a person, a patient or a group of people. The third type of dietary analysis is based on a holistic evaluation of the dietary habits. A “dietary index” is the most common “a-­‐priori” method of nutrition data management. This kind of analysis gives the opportunity to overall assess the diet and is useful in statistical analysis especially in models when it is appropriate to avoid the problem of co-­‐linearity that dietary data have. The message to public health managers is very clear since they are informed about the percentage of people that have healthy dietary habits, so that they can easily plan their policies. The last type of dietary analysis is also a holistic one but an “a-­‐posteriori” method which succeeds to derive dietary patterns from the data of the sample or to discriminate dietary  10 habits according to their impact on several diseases. Reduced Rank Regression (RRR) analysis, principal components analysis and discriminant analysis are the three major analyses, respectively, and they are performed using FFQs. Besides the aforementioned 4 types of dietary analysis, valuable conclusions could also be extracted by studying dietary habits in a clinical environment. This could be considered as a fifth approach, based on the different nature of the data derived from the study design. The evidences extracted from this approach are considered as of great importance since the study approach limits the bias presented in studying associations between food or nutrients and health outcomes. The five approaches in dietary analysis reported above introduce different types of scientific conclusions to research questions, in the level of food groups’ consumption, nutrient intakes and dietary patterns adherence. However, intergraded nutritional analysis is of crucial importance especially when the association of dietary habits with chronic diseases such as CVD is studied. Thus, this thesis will examine the complex impact of dietary habits on major cardiovascular risk factors and other metabolic parameters of free-­‐living populations, using different methodological approaches to dietary analysis, in order to get more integrated conclusions. Antioxidant vitamins and phytochemicals intake has been considered as crucially important in CVD prevention through different biological mechanisms. The overall assessment of antioxidants consumption in human diet seems important. An original article using data from the Moli-­‐sani study analyzed and described the dietary index Food Antioxidant Content (FAC)-­‐score (Chapter 2). The association of FAC-­‐score with clinical biomarkers of CVD was also tested. By this way, the first and the third type of dietary analysis were used. Health-­‐related quality of life (HRQL) has been considered a valid predictor of CVD and overall mortality. Healthy eating seems to contribute to establishing a better quality of life. Thus, FAC-­‐score was studied in the context of Mediterranean pattern adherence for its role in establishing better quality of life using data of the Moli-­‐sani study (Chapter 3). The first and third dietary analyses were integrally used again.  11 Mushroom, as a food group, could be considered as a good source of selenium, an important antioxidant component of the diet. The role of selenium on glucose levels is somehow controversial. Thus a third analysis conducted in the Moli-­‐sani population aimed at evaluating the association of mushroom consumption and dietary selenium intake with blood glucose levels (Chapter 4). Such analyses concerning food group consumption (through mushroom intake) and nutrient intake (through dietary selenium) exhausted the first and second kind of dietary analysis mentioned in the thesis. Folate status has been negatively associated with cerebrovascular disease, an important category of CVD. Differences in folate intake and status have been observed among EU countries. The evaluation of folate dietary intake as well as the extraction of dietary patterns associated with better folate status seems important. In the IMMIDIET population possible differences in folate status in two EU Countries (Italy and England) were assessed in relation to dietary habits and/or other lifestyle parameters (Chapter 5). By analyzing folate intake as a nutrient in relation to folate serum levels and by identifying a dietary pattern that accounts mostly for the variation in plasma folate, the second and the fourth type of dietary analysis were conducted. A further study on the supplemental intake of folate as a single nutrient was performed using data from a randomized, double blind clinical trial. Major aim was to compare the efficacy of a diet particularly rich in natural folate compared with that of two different protocols of folic acid pharmacological supplementation, in subjects with “moderate” hyperhomocysteinemia (Chapter 6). Studying dietary habits in clinical environment fulfilled the use of the fifth type of dietary analysis in explaining the association of CVD risk factors and metabolic parameters with human diet. Finally, the IMMIDIET study was used again to test the role of dietary habits on CVD using a holistic approach in dietary analysis. Growing evidence suggests that blood fatty acids (FAs) are major biomarkers/-­‐predictors and even causal factors in many diseases, in particular cardiovascular disease. Differences in blood FAs profile among populations with different lifestyle have partly been attributed to differences in food intake. This analysis aimed at evaluating the main plasma and red blood cell FAs in three European populations and assessing the role of dietary patterns in explaining variations in their levels (Chapter 7). By  12 the analysis of dietary patterns associated with better the n-­‐3 fatty acids profile the fourth type of dietary analysis was conducted.  13 Chapter 2. Consumption of healthy foods at different content of antioxidant vitamins and phytochemicals and metabolic risk factors for cardiovascular disease in men and women of the Moli-­‐sani study Pounis G, Costanzo S, di Giuseppe R, de Lucia F, Santimone I, Sciarretta A, Barisciano P, Persichillo M, de Curtis A, Zito F, Di Castelnuovo AF, Sieri S, Benedetta Donati M, de Gaetano G, Iacoviello L. Consumption of healthy foods at different content of antioxidant vitamins and phytochemicals and metabolic risk factors for cardiovascular disease in men and women of the Moli-­‐sani study. Eur J Clin Nutr 2013; 67: 207-­‐13. doi: 10.1038/ejcn.2012.201.  14 ORIGINAL ARTICLE Consumption of healthy foods at different content of antioxidant vitamins and phytochemicals and metabolic risk factors for cardiovascular disease in men and women of the Moli–sani study G Pounis1, S Costanzo1, R di Giuseppe1, F de Lucia1, I Santimone1, A Sciarretta1, P Barisciano1, M Persichillo1, A de Curtis1, F Zito1, AF Di Castelnuovo1, S Sieri2, M Benedetta Donati1, G de Gaetano1 and L Iacoviello1 on behalf of the Moli-sani Project Investigators BACKGROUND/OBJECTIVES: To categorize healthy food groups into categories of low-antioxidant (LAC) or high-antioxidant vitamins and phytochemicals content (HAC) and comparatively associate them with metabolic risk factors for cardiovascular disease (CVD). SUBJECTS/METHODS: A total of 6879 women (55±12 years) and 6892 men (56±12 years) were analyzed from the Moli–sani cohort, randomly recruited from the general population. The European Prospective Investigation into Cancer and Nutrition Food Frequency Questionnaire was used for dietary assessment. The antioxidant content of each food group was evaluated using Istituto Nazionale di Ricerca per gli Alimenti e la Nutrizione and United States Department of Agriculture (USDA) food composition tables. Healthy foods, according to a Mediterranean dietary pattern, were categorized into HAC or LAC; total food antioxidant content (FAC) score was constructed for a comparative evaluation of the consumption of these two groups. RESULTS: In men, an increase in FAC score, which represents an increased consumption of HAC with respect to LAC foods, was associated with a decrease in systolic blood pressure, diastolic blood pressure and C-reactive protein (CRP) (b ¼ � 0.5, P ¼ 0.02, b ¼ � 0.3, P ¼ 0.02 and b ¼ � 0.03, P ¼ 0.03, respectively). Logistic regression analyses showed that in men 15% (30 units) increase in FAC score was associated with 6% decrease in the likelihood of having hypertension (odds ratio (OR) ¼ 0.94, 95% confidence interval (CI) 0.91–0.98) and 3% decrease in the likelihood of having a high CRP risk level (OR ¼ 0.97, 95% CI 0.94–0.99). No significant associations were observed in women. CONCLUSIONS: A possible greater protective role of healthy HAC as compared with healthy LAC foods on hypertension and inflammation was detected in men. These results stress the importance of studying healthy foods according to their content in antioxidant vitamins and phytochemicals, in primary prevention of CVD. European Journal of Clinical Nutrition (2013) 67, 207–213; doi:10.1038/ejcn.2012.201; published online 19 December 2012 Keywords: antioxidants; vitamins; phytochemicals; cardiovascular disease; inflammation INTRODUCTION The content in antioxidant vitamins and phytochemicals of a healthy diet such as the Mediterranean diet has long been recognized as beneficial for inflammation-related illnesses.1,2 Atherosclerosis progression is directly associated with the inflammation processes through several biological mechanisms, which are related to metabolic risk factors for cardiovascular disease (CVD) such as hypertension, hypercholesterolemia, hypertriglyceridemia and diabetes.3–5 Antioxidant vitamins and flavonoids contained in several foods were associated in epidemiological and clinical studies with a decrease in the oxidative stress caused by these risk factors.6–8 In particular, the oxidative stress reduction hypothesis of antioxidant vitamins and phytochemicals is supported by epidemiological and observational evidence that encouraged belief in and their use.9,10 Consumption of fruits and vegetables, rich in vitamin C and other antioxidant compounds, has been associated with a reduction in CVD mortality.11 These associations have been established through the anti-inflammatory properties of these nutrients depicted in the reduction of inflammatory biomarkers such as C-reactive protein (CRP), interleukin-6 and tumor necrosis factor alpha.12 In a US population survey, consumption of flavonoids was inversely related to CRP levels even after adjustment for total fruit and vegetable consumption.13 Antioxidant and phytochemical compounds are normally present in plant foods such as fruits, vegetables, vegetable oils and seeds, which represent the main food groups of the Mediterranean diet and have been recognized as protective against CVD and its risk factors.14,15 The Mediterranean dietary pattern may best fulfill requirements for an anti-inflammatory diet, at least in the Western world.12 However, the density of each food or food group in these healthy protective nutrients may differ. This may cause different impacts on CVD or on its risk factors prevention over the protective effect of healthy foods. It is common for health operators to suggest patients to consume healthy foods, but in most cases their recommendations do not provide information about the antioxidant and phyto- chemicals content of such foods. This lack of information could 1Laboratory of Genetic and Environmental Epidemiology, Research Laboratories, Fondazione di Ricerca e Cura ‘Giovanni Paolo II’, Universita` Cattolica del Sacro Cuore, Campobasso, Italy and 2Nutritional Epidemiology Unit, National Cancer Institute, Milan, Italy. Correspondence: Professor L Iacoviello, Laboratory of Genetic and Environmental Epidemiology, Research Laboratories, Fondazione di Ricerca e Cura ‘Giovanni Paolo II’, Universita` Cattolica del Sacro Cuore, Largo Gemelli 1, Campobasso 86100, Italy. E-mail: [email protected] Received 17 July 2012; revised 1 October 2012; accepted 8 October 2012; published online 19 December 2012 European Journal of Clinical Nutrition (2013) 67, 207–213 & 2013 Macmillan Publishers Limited All rights reserved 0954-3007/13 www.nature.com/ejcn