Almudena Sánchez-Villegas

Association of the Mediterranean Dietary Pattern With the Incidence of Depression: The Seguimiento Universidad de Navarra/University of Navarra Follow-up (SUN) Cohort

CONTEXT Adherence to the Mediterranean dietary pattern (MDP) is thought to reduce inflammatory, vascular, and metabolic processes that may be involved in the risk of clinical depression. OBJECTIVE To assess the association between adherence to the MDP and the incidence of clinical depression. DESIGN Prospective study that uses a validated 136-item food frequency questionnaire to assess adherence to the MDP. The MDP score positively weighted the consumption of vegetables, fruit and nuts, cereal, legumes, and fish; the monounsaturated- to saturated-fatty-acids ratio; and moderate alcohol consumption, whereas meat or meat products and whole-fat dairy were negatively weighted. SETTING A dynamic cohort of university graduates (Seguimiento Universidad de Navarra/University of Navarra Follow-up [SUN] Project). PARTICIPANTS A total of 10 094 initially healthy Spanish participants from the SUN Project participated in the study. Recruitment began on December 21, 1999, and is ongoing. MAIN OUTCOME MEASURE Participants were classified as having incident depression if they were free of depression and antidepressant medication at baseline and reported a physician-made diagnosis of clinical depression and/or antidepressant medication use during follow-up. RESULTS After a median follow-up of 4.4 years, 480 new cases of depression were identified. The multiple adjusted hazard ratios (95% confidence intervals) of depression for the 4 upper successive categories of adherence to the MDP (taking the category of lowest adherence as reference) were 0.74 (0.57-0.98), 0.66 (0.50-0.86), 0.49 (0.36-0.67), and 0.58 (0.44-0.77) (P for trend <.001). Inverse dose-response relationships were found for fruit and nuts, the monounsaturated- to saturated-fatty-acids ratio, and legumes. CONCLUSIONS Our results suggest a potential protective role of the MDP with regard to the prevention of depressive disorders; additional longitudinal studies and trials are needed to confirm these findings.

MEDITERRANEAN DIET INVERSELY ASSOCIATED WITH THE INCIDENCE OF METABOLIC SYNDROME: THE SUN PROSPECTIVE COHORT.

There is some evidence of the beneficial role of food patterns and lifestyles on metabolic syndrome (1,2). The Mediterranean food pattern (MFP) has acquired an emerging role in cardiovascular epidemiology (3). It is characterized by a high consumption of fruits, vegetables, legumes, grains, moderate alcohol intake, a moderate-to-low consumption of dairy products and meats/meat products, and a high monounsaturated–to–saturated fat ratio. Although some cross-sectional studies have suggested that the MFP (or some of its components) may reduce the incidence of the metabolic syndrome (1,4), there are no prospective studies assessing this association. Our aim was to prospectively assess the relationship between adherence to the MFP and the subsequent development of metabolic syndrome in the Seguimiento Universidad de Navarra (SUN) dynamic cohort, composed of Spanish university graduates followed up for 6 years (5). The SUN Study uses methodology similar to that of large American cohorts (6), but recruitment is permanently open (it is designed as a dynamic cohort). Baseline assessment of participants consists of a self-administered questionnaire sent by postal mail, gathering information on lifestyle factors and including a 136-item validated food frequency questionnaire (7). Biennially mailed follow-up questionnaires are used to collect a wide variety of information about diet, lifestyle, and medical conditions (5). Among the 18,000 graduates currently participating in the SUN cohort, 5,360 members were recruited …

Adherence to a Mediterranean dietary pattern and weight gain in a follow-up study: the SUN cohort

Introduction:The promotion of Mediterranean Diets has generated some doubts, because of the concern that its high fat content might lead to the development of obesity.Methods:Longitudinal analysis of 6319 participants in the SUN cohort study. We used a validated semiquantitative food frequency questionnaire (136 items). Baseline adherence to a Mediterranean dietary pattern (MDP) was assessed using a score (score_1) including vegetables, fruits, cereals, nuts, pulses, fish, olive oil and moderate consumption of red wine (positively weighted), whereas meat and dairy products were negatively weighted. We assessed the association between the overall baseline adherence to the MDP (score_1) and subsequent weight change after 28 months of follow-up. We also built another score (score_2) to assess changes in diet during follow-up and appraised the association between the joint exposure to both scores and weight change during follow-up.Results:Participants in the first quartile of score_1 (lowest baseline adherence to MDP) showed a higher weight gain (+0.73 kg) than those in the top quartile (+0.45 kg). The results indicated an inverse dose–response relationship (P for trend=0.016). A similar inverse association was apparent when we used change in adherence to the MDP (score_2). However, both inverse associations did not remain statistically significant after adjusting for relevant confounders. Consumption of dairy products was inversely associated with weight gain.Conclusions:Although participants increased their average weight during the follow-up period, weight increments were smaller among those with a higher adherence to an ‘a priori’ defined MDP. Results did not remain statistically significant after multivariate adjustment.

Gender, age, socio-demographic and lifestyle factors associated with major dietary patterns in the Spanish Project SUN (Seguimiento Universidad de Navarra).

Objective: To ascertain the major dietary patterns in the cohort ‘SUN’ and to assess the association of several sociodemographic (including age and gender) and lifestyle variables with the adherence to these dietary patterns.Design: This study is a cross-sectional analysis of 3847 subjects (1587 men and 2260 women) belonging to a prospective cohort study based on self-reported questionnaires. A factor analysis based on 30 predefined food groups was conducted to ascertain the major dietary patterns in the cohort. Multiple regression models were fitted to assess the relationship between several sociodemographic and lifestyle variables and the adherence to these dietary patterns (measured using two scores with observed values ranging from −3.2 to +4.6 for the Western pattern and −3.1 to +5.5 for the Mediterranean pattern).Results: Two major dietary patterns were found. The first pattern was labelled as a ‘Western’ dietary pattern and the other as a ‘Spanish-Mediterranean’ dietary pattern. Younger subjects were more likely to follow a ‘Western’ dietary pattern; the coefficient representing the change for every 10 y increase in age was b=−0.24 (P<0.001) for men and b=−0.12 (P<0.001) for women. More physically active subjects were less likely to follow a ‘Western’ dietary pattern and more likely to follow a ‘Spanish-Mediterranean’ dietary pattern.Conclusion: An association between a higher level of physical activity during leisure time and adherence to a ‘Spanish-Mediterranean’ diet was apparent. However, the profile of being a young, sedentary and single male was identified as the most likely to exhibit a departure from the traditional ‘Spanish-Mediterranean’ diet and follow a ‘Western’ dietary pattern.Sponsorship: Departments of Health and Education of the Navarre Regional Government and FIS (Fondo de Investigaciones Sanitarias) of the Spanish Ministry of Health.

Relationship between body image disturbance and incidence of depression: the SUN prospective cohort

BackgroundBody image disturbance is an increasing problem in Western societies and is associated with a number of mental health outcomes including anorexia, bulimia, body dysmorphia, and depression. The aim of this study was to assess the association between body image disturbance and the incidence of depression.MethodsThis study included 10,286 participants from a dynamic prospective cohort of Spanish university graduates, who were followed-up for a median period of 4.2 years (Seguimiento Universidad de Navarra – the SUN study). The key characteristic of the study is the permanently open recruitment that started in 1999. The baseline questionnaire included information about body mass index (BMI) and the nine figure schemes that were used to assess body size perception. These variables were grouped according to recommended classifications and the difference between BMI and body size perception was considered as a proxy of body image disturbance. A subject was classified as an incident case of depression if he/she was initially free of depression and reported a physician-made diagnosis of depression and/or the use of antidepressant medication in at least one of the follow-up questionnaires. The association between body image disturbance and the incidence of depression was estimated by calculating the multivariable adjusted Odds Ratio (OR) and its 95% Confidence Interval (95% CI), using logistic regression models.ResultsThe cumulative incidence of depression during follow-up in the cohort was 4.8%. Men who underestimated their body size had a high percentage of overweight and obesity (50.1% and 12.6%, respectively), whereas women who overestimated their body size had a high percentage of underweight (87.6%). The underestimation exhibited a negative association with the incidence of depression among women (OR: 0.72, 95% CI: 0.54 – 0.95), but this effect disappeared after adjusting for possible confounding variables. The proportion of participants who correctly perceived their body size was high (53.3%) and gross misperception was seldom found, with most cases selecting only one silhouette below (42.7%) or above (2.6%) their actual BMI.ConclusionWe found no association between body image disturbance and subsequent depression in a cohort of university graduates in Spain.

Physical activity, sedentary index, and mental disorders in the SUN cohort study.

PURPOSE There is evidence to suggest a beneficial effect of physical activity on several mental disorders. METHODS The study aim was to assess the association between low physical activity during leisure time (or sedentary lifestyles) and the incidence of mental disorders in 10,381 participants, from a Spanish dynamic prospective cohort of university graduates followed up for 6 yr (the SUN study). The baseline assessment included a validated questionnaire on physical activity during leisure-time and sedentary activities. A subject was classified as an incident case of mental disorder if he or she reported a physician diagnosis of depression, anxiety or stress, and/or the use of antidepressant medication or tranquilizers in at least one of the follow-up questionnaires. RESULTS The odds ratios (OR) and 95% confidence intervals (CI) of a mental disorder for successive levels of leisure-time physical activity were 1 (reference), 1.00 (0.81, 1.23), 0.99 (0.81, 1.21), 0.72 (0.58, 0.89), and 0.81 (0.65, 1.00) (P for trend: < 0.01). The OR for subjects who spent more than 42 h.wk(-1) watching television and/or using the computer was 1.31 (95% CI = 1.01, 1.68) as compared with those spending less than 10.5 h.wk(-1). CONCLUSION Our findings suggest a joint association of leisure-time physical activity and sedentary behavior on the incidence of mental disorders.

Mediterranean Diet and Stroke: Objectives and Design of the SUN Project

Purpose: The Mediterranean diet has been postulated as a protective factor against different diseases including stroke. Thus, an epidemiological study in a Mediterranean country, such as Spain, focused on diet may offer new insights of the potential benefits of this nutritional pattern to prevent the onset of cerebrovascular diseases. Methods: The SUN (“Seguimiento Universidad de Navarra”) project is a prospective study among Spanish university alumni, aimed to identify the dietary determinants of stroke, coronary disease and other disorders. Two pilot studies have been developed. The first pilot study was focused on the understanding of the questionnaire. The second study used a random sample to assess the response proportion and the feasibility of using a mailing system for following-up the cohort. The first informative results are expected to be available after the first four years of following-up the cohort (2005). Here, we report the description of the baseline diet of the first participants in the cohort using data from 1587 men and 2260 women. Results: The outcome of our pilot studies ensure the feasibility of a mail-based cohort. In the baseline assessment, we found a high consumption of olive oil (18.5 g/person/day), red wine (28.8 g/person/day), legumes (102.5 g/person/day), vegetables (507.8 g/person/day) and fruits (316.7 g/person/day), with a great between-subject variability. Also, the values for cereals (170.4 g/person/day), dairy products (239.3 g/person/day) and meat and meat products consumption (186 g/person/day) in this cohort were estimated. The coefficients of variation ranged in women from 56 (for vegetables) to 240% (for red wine) and in men from 62 to 180% (for these same two items)/reflecting a wide heterogeneity in the diet of participants. Conclusions: Although the participation was not high (22% according to the estimates of the pilot study), it was comparable to the proportion found in large previous cohorts such as the Nurses-II Health Study (24%). The sharp contrast in dietary habits between the US and Spain together with the high between-subjects variability we have found in our Spanish cohort provides an exceptional opportunity to assess the aspects of the Mediterranean diet, which may be protective against stroke and other neurological disorders.

Nutritional medicine as mainstream in psychiatry

Psychiatry is at an important juncture, with the current pharmacologically focused model having achieved modest benefits in addressing the burden of poor mental health worldwide. Although the determinants of mental health are complex, the emerging and compelling evidence for nutrition as a crucial factor in the high prevalence and incidence of mental disorders suggests that diet is as important to psychiatry as it is to cardiology, endocrinology, and gastroenterology. Evidence is steadily growing for the relation between dietary quality (and potential nutritional deficiencies) and mental health, and for the select use of nutrient-based supplements to address deficiencies, or as monotherapies or augmentation therapies. We present a viewpoint from an international collaboration of academics (members of the International Society for Nutritional Psychiatry Research), in which we provide a context and overview of the current evidence in this emerging field of research, and discuss the future direction. We advocate recognition of diet and nutrition as central determinants of both physical and mental health.

Adherence to the Mediterranean diet, long-term weight change, and incident overweight or obesity: the Seguimiento Universidad de Navarra (SUN) cohort.

BACKGROUND The Mediterranean dietary pattern might be a potential tool for the prevention of obesity. OBJECTIVES We studied the association between adherence to 6 previously published scores used to assess the adherence to the Mediterranean diet and weight change. We also assessed the risk of relevant weight gain (≥ 5 kg) or the risk of developing overweight or obesity. DESIGN The study population included 10,376 Spanish men and women who were university graduates (mean age = 38 y) and were followed up for a mean (± SD) of 5.7 ± 2.2 y. Diet was assessed at baseline with a 136-item, previously validated food-frequency questionnaire. Weight was assessed at baseline and biennially during follow-up. RESULTS Participants with the lowest adherence (≤ 3 points) to the Mediterranean dietary score (MDS) proposed by Trichopoulou et al (range: 0-9; N Engl J Med 2003;348:2599-608) exhibited the highest average yearly weight gain, whereas participants with the highest (≥ 6 points) adherence exhibited the lowest weight gain (adjusted difference: -0.059 kg/y; 95% CI: -0.111, -0.008 kg/y; P for trend = 0.02). This inverse association was extended to other a priori-defined MDSs. The group with the highest adherence to the MDS also showed the lowest risk of relevant weight gain (≥ 5 kg) during the first 4 y of follow-up (odds ratio: 0.76; 95% CI: 0.64, 0.90). CONCLUSIONS Adherence to the Mediterranean dietary pattern is significantly associated with reduced weight gain. This dietary pattern can be recommended to slow down age-related weight gain.

Mediterranean dietary pattern and depression: the PREDIMED randomized trial.

BackgroundA few observational studies have found an inverse association between adherence to a Mediterranean diet and the risk of depression. Randomized trials with an intervention based on this dietary pattern could provide the most definitive answer to the findings reported by observational studies. The aim of this study was to compare in a randomized trial the effects of two Mediterranean diets versus a low-fat diet on depression risk after at least 3 years of intervention.MethodsThis was a multicenter, randomized, primary prevention field trial of cardiovascular disease (Prevención con Dieta Mediterránea (PREDIMED Study)) based on community-dwelling men aged 55 to 80 years and women aged 60 to 80 years at high risk of cardiovascular disease (51% of them had type 2 diabetes; DM2) attending primary care centers affiliated with 11 Spanish teaching hospitals. Primary analyses were performed on an intention-to-treat basis. Cox regression models were used to assess the relationship between the nutritional intervention groups and the incidence of depression.ResultsWe identified 224 new cases of depression during follow-up. There was an inverse association with depression for participants assigned to a Mediterranean diet supplemented with nuts (multivariate hazard ratio (HR) 0.78; 95% confidence interval (CI) 0.55 to 1.10) compared with participants assigned to the control group, although this was not significant. However, when the analysis was restricted to participants with DM2, the magnitude of the effect of the intervention with the Mediterranean diet supplemented with nuts did reach statistical significance (multivariate HR = 0.59; 95% CI 0.36 to 0.98).ConclusionsThe result suggest that a Mediterranean diet supplemented with nuts could exert a beneficial effect on the risk of depression in patients with DM2.Trial registrationThis trial has been registered in the Current Controlled Trials with the number ISRCTN 35739639