D.B. Panagiotakos

The epidemiology of Type 2 diabetes mellitus in Greek adults: the ATTICA study

Aims  Individuals with Type 2 diabetes are at high risk for coronary heart disease, and may benefit from aggressive lifestyle modification. We evaluated the prevalence of Type 2 diabetes, in a Greek adult population, in relation to physical activity and dietary habits.

Dietary patterns and 5-year incidence of cardiovascular disease: a multivariate analysis of the ATTICA study.

BACKGROUND AND AIMS The 5-year incidence of cardiovascular disease (CVD) in relation to dietary habits, among men and women from Greece, was evaluated. METHODS AND RESULTS From May 2001 to December 2002, 1514 men and 1528 women (>18 years) without any clinical evidence of CVD, living in the Attica area, Greece, were enrolled in the ATTICA study. In 2006, a group of experts performed the 5-year follow-up (941 of the 3042 participants were lost). Development of CVD (coronary heart disease, acute coronary syndromes, stroke, or other CVD) during the follow-up period was defined according to WHO ICD-10 criteria. Principal components analysis was applied, and 15 dietary patterns were extracted (71% of total information explained) from 26 foods or food groups. The 5-year incidence of CVD was 11.0% in men and 6.1% in women (p<0.001); the case fatality rate was 1.6%. Multi-adjusted analysis revealed that the dietary pattern that was mainly characterized by cereals, small fish, hardtack and olive oil intake, was associated with lower CVD risk (HR per 1 unit=0.72, 95% CI 0.52-1.00); the pattern that was characterized by fruits, vegetables intake and olive oil use in daily cooking was associated with lower CVD risk (HR per 1 unit=0.80, 95% CI 0.66-0.97); while patterns that were mainly characterized by sweets, red meat, margarine, salty nuts intake, and hard cheese, as well as alcohol intake, were associated with higher CVD risk (HR per 1 unit=1.26, 95% CI 1.01-1.56, and HR per 1 unit=1.32, 95% CI 1.05-1.66, respectively). CONCLUSIONS Multivariate statistical methods revealed dietary patterns based on empirical epidemiological data which were associated with the development of CVD.

Mediterranean diet and coronary heart disease: Is obesity a link? – A systematic review

AIMS Adherence to a healthy dietary pattern, such as the Mediterranean diet, exerts a beneficial role regarding the development of coronary heart disease. In addition, several studies support the protective role of the Mediterranean diet as far as obesity is concerned. This review, examining results from prospective cohort and cross-sectional studies, as well as clinical trials, aims to clarify whether the beneficial effect of the Mediterranean dietary pattern on coronary heart disease is due to the impact of this diet on weight loss and obesity status or an independent effect. DATA SYNTHESIS 35 original-research studies that were published in English until 2009, selected through a computer-assisted literature search are discussed, from which 3 were prospective, 11 were cross-sectional studies, and 21 were clinical trials. CONCLUSION Although not all studies show a protective effect of the Mediterranean diet on body weight and obesity, the evidence suggests a possible beneficial role of this dietary pattern. Thus the Mediterranean diet protects against the development of coronary heart disease not only because of its beneficial role regarding cardiovascular risk factors, but also due to a possible effect on body weight and obesity.

Dietary antioxidant capacity is inversely associated with diabetes biomarkers: The ATTICA study

BACKGROUND AND AIMS Elevated dietary antioxidant activity has been regarded as providing potential benefits to health. The present work aimed at evaluating the association of glycemic indices with total dietary antioxidant capacity in healthy adults. METHODS AND RESULTS The ATTICA study consisted of men and women, randomly selected from all areas of Attica region in Greece. In this work, a random sub-sample from the ATTICA studys database was studied, consisting of 551 men (41 ± 11 years) and 467 women (38 ± 11 years), with complete nutritional and biochemical information. Dietary habits were evaluated using a validated food-frequency questionnaire. The dietary antioxidant capacity was based on published values for Italian foods measured by three different assays: ferric-reducing antioxidant power (FRAP), total radical-trapping antioxidant parameter (TRAP) and Trolox equivalent antioxidant capacity (TEAC). Inverse, age-energy adjusted correlations were observed between FRAP and log-glucose (r = -0.149, p = 0.001), log-insulin (r = -0.221, p = 0.001) and log-HOMA-IR (r = -0.186, p = 0.001) concentration, as well as with TRAP and TEAC. After controlling for age, gender, body mass index, physical activity status, smoking habits and energy intake, multi-adjusted analysis confirmed the previous relationships only among participants who were not on the Mediterranean dietary pattern. CONCLUSIONS Although more prospective studies are required, the data presented support the view that dietary modification towards higher consumption of antioxidants should be implemented in public health strategies, in order to better control glycemic markers in individuals, and prevent the development of diabetes at the population level.

Inflammatory cytokine gene variants in coronary artery disease patients in Greece.

ObjectiveAbundant evidence supports the central role of inflammatory cytokines in immune responses mediating the pathogenesis of atherosclerosis, coronary artery disease, and its complications, such as myocardial infarction and unstable angina. MethodsWe investigated the association of genetic polymorphisms of the inflammatory cytokines, IL-10, TGF-&bgr;1, IFN-&ggr;, IL-6, and TNF-&agr; with the clinical presentation of coronary artery disease in 26 patients with stable angina, 45 patients with unstable angina and 58 patients who had experienced nonfatal myocardial infarction. Genotyping was performed by the sequence-specific primer polymerase chain reaction method. ResultsA significant difference in the frequencies of -174G/C IL-6 alleles was observed, with the low in-vitro producing -174*C allele predominating in patients with myocardial infarction, compared with stable angina and unstable angina patients, after the analysis of genotypes (P=0.024 and 0.022, respectively), phenotypes [P=0.0099, odds ratio (OR)=0.271, 95% confidence interval (CI)=0.1012–0.7292; P=0.03, OR=0.40, respectively] and haplotypes (P=0.007, OR=3.028, 95% CI=1.347–6.806; P=0.0096, OR=2.368, 95% CI=1.262–4.444; respectively). In addition, a predominance of the -1082ACC/ATA IL-10 genotype in the myocardial infarction group compared with the unstable angina group and the -874 A/A IFN-&ggr; genotype in the stable angina group compared with the unstable angina and the myocardial infarction group, was found. No significant differences in the distribution of genotypes, phenotypes and haplotypes in the three study groups, for the TNF-&agr;-308 A/G and TGF-&bgr;1-codon 25 G/C, codon 10 T/C polymorphisms were detected. ConclusionOur data provide evidence that the IL-6-174G/C polymorphism may be involved in the pathogenesis of coronary artery disease, contributing to genetic susceptibility for myocardial infarction.

Adherence to Mediterranean diet and 10-year incidence (2002–2012) of diabetes: correlations with inflammatory and oxidative stress biomarkers in the ATTICA cohort study

The purpose of this work was to investigate the links between oxidative stress, inflammation and coagulation and their effect on Mediterranean diet–diabetes relationship.

Adherence to the Mediterranean diet and serum uric acid: the ATTICA study

Objective: The present study aimed to explore potential associations between adherence to a Mediterranean diet and serum uric acid (UA) levels. Methods: The sample consisted of 2380 men and women free of cardiovascular or renal disease who participated in the ATTICA study. Dietary intake was assessed using a food frequency questionnaire (FFQ) and adherence to the Mediterranean diet was evaluated with the MedDietScore. Serum UA was measured and hyperuricaemia was defined as UA concentration > 7.0 mg/dL in men or > 6.0 mg/dL in women. Results: MedDietScore was inversely associated with UA levels (b-coefficient per quartile of the score = –0.07 ± 0.03, p = 0.02) independently of sex, presence of overweight, hypertension, or abnormal glucose metabolism, and alcohol or coffee intake. Those at the fourth quartile of MedDietScore had a 70% lower likelihood of having hyperuricaemia [odds ratio (OR) 0.30, 95% confidence interval (CI) 0.11–0.82] compared to those at the first quartile, after adjustment for several confounders. According to stratified analyses by sex, body mass index (BMI) status, hypertension, abnormal glucose, alcohol and coffee intake, the inverse association between serum UA and MedDietScore remained significant in women (b-coefficient = –0.194 ± 0.055, p < 0.001), overweight subjects (b-coefficient = –0.103 ± 0.047, p = 0.02), in those with normal glucose metabolism (b-coefficient = –0.074 ± 0.037, p = 0.04), and in those abstaining from alcohol (b-coefficient = –0.212 ± 0.073, p = 0.004) and coffee (b-coefficient = –0.221 ± 0.096, p = 0.02). Conclusion: Adherence to the Mediterranean diet is associated with lower serum UA levels and lower likelihood of hyperuricaemia. These findings support a potential role of this dietary pattern in the prevention and treatment of hyperuricaemia and gout.

Effects of alcohol consumption and the metabolic syndrome on 10-year incidence of diabetes: the ATTICA study.

AIM The purpose of this prospective study was to investigate the effect of alcohol consumption on the 10-year diabetes incidence. METHODS In 2001-2002, a random sample of 1514 men (18-89 years old) and 1528 women (18-87 years old) was selected to participate in the ATTICA study (Athens metropolitan area, Greece). Among various other characteristics, average daily alcohol intakes (abstention, low, moderate, high) and type of alcoholic drink were evaluated. Diabetes was defined according to American Diabetes Association criteria. During 2011-2012, the 10-year follow-up was performed. RESULTS The 10-year incidence of diabetes was 13.4% in men and 12.4% in women. After making various adjustments, those who consumed up to 1 glass/day of alcohol had a 53% lower diabetes risk (RR=0.47; 95% CI: 0.26, 0.83) compared with abstainers, while trend analysis revealed a significant U-shaped relationship between quantity of alcohol drunk and diabetes incidence (P<0.001 for trend). Specific types of drinks were not associated with diabetes incidence; however, a one-unit increase in ratio of wine/beer/vodka vs. other spirits was associated with an 89% lower risk of diabetes (RR=0.11; 95% CI: 0.02, 0.67). The protective effect of low alcohol consumption on diabetes incidence was more prominent among individuals with stricter adherence to the Mediterranean diet (RR=0.08; 95% CI: 0.011, 0.70) and without the metabolic syndrome (RR=0.34; 95% CI: 0.16, 0.70). CONCLUSION This work revealed the protective effect of modest alcohol consumption of particularly wine and beer against the long-term incidence of diabetes, possibly due to their pleiotropic health effects.

Lipoprotein-associated phospholipase A2 (Lp-PLA2) activity, platelet-activating factor acetylhydrolase (PAF-AH) in leukocytes and body composition in healthy adults

BackgroundLipoprotein-associated phospholipase A2 (Lp-PLA2) also known as serum platelet activating factor acetylhydrolase (PAF-AH) activity constitutes a novel risk marker for cardiovascular disease. Leukocytes constitute one main cellular source of circulating Lp-PLA2. The aim of the present study was to evaluate the association of both serum and leukocyte PAF-AH activities with fat distribution and lean tissue. One hundred healthy volunteers without cardiovascular disease history participated in this study (n = 52 men, 44 ± 13 years and n = 48 women, 43 ± 13 years). Body composition was assessed with dual-energy X-ray absorptiometry, while anthropometrical indices were also measured. The activity of Lp-PLA2 and levels of lipid and glycemic parameters were determined in fasting samples.ResultsMean Lp-PLA2 activity was 24.8 ± 4.5 and 19.6 ± 5.0 nmol/min/mL in men and women, respectively (P < 0.001). Mean activity of PAF-AH in leukocyte homogenates was 386 ± 127 pmol/min/mg and 292 ± 92 pmol/min/mg in men and women, correspondingly (P < 0.001). In multiple regression models upper and total adiposity measures were positively associated with Lp-PLA2 activity in men after adjusting for LDL-cholesterol, age, smoking, hs-CRP and physical activity, whereas no associations were found with PAF-AH leukocyte homogenates activity. Hierarchical analysis revealed that the variables with the highest explanatory ability of Lp-PLA2 activity in men, were DXA deriving L1–L4 region of interest and arms fat (increase in R2 = 0.136, P = 0.005 and increase in R2 = 0.118, P = 0.009, respectively), followed by trunk fat and total fat. In women, no association of body composition variables with Lp-PLA2 nor PAF-AH leukocyte homogenates activity was found.ConclusionLp-PLA2 activity is differentiated across levels of adiposity and topology of adipose tissue, whereas no association was found regarding PAF-AH leukocyte homogenates activity. Our findings suggest that Lp-PLA2 may compensate for the adiposity-associated increases in inflammatory and oxidative burden, in men.

Exploring the path of Mediterranean diet on 10-year incidence of cardiovascular disease: The ATTICA study (2002–2012)

BACKGROUND AND AIMS A Mediterranean diet has been associated with lower all-cause and cardiovascular disease (CVD) morbidity and mortality, but the clinical and behavioral pathway has not been well understood and appreciated. The aim of this work was to explore the path between adherence to a Mediterranean-type diet, lifestyle behaviors, clinical status, and a 10-year incidence of CVD. METHODS AND RESULTS The ATTICA study was carried out in the Athens area during 2001-2002 and included 3042 participants free of CVD at baseline (49.8% men, aged 18-89). Adherence to a Mediterranean diet was assessed using the MedDietScore (range 0-55). During 2011-2012, 2583 out of the 3042 participants were found during the 10-year follow-up (15% lost to follow-up). Adherence to a Mediterranean diet decreased CVD risk (relative Risk (RR) per 1/55 unit = 0.96, 95% confidence interval (CI): 0.93, 1.00), independently of various sociodemographic, lifestyle, and clinical factors. Subgroup analyses revealed that participants with an unhealthy lifestyle (i.e., smokers, and obese and sedentary persons) remained protected from CVD through a greater adherence to a Mediterranean diet (RR for smokers = 0.92, 95%CI: 0.88, 0.97; RR for obese participants = 0.90, 95%CI: 0.82, 0.979; and RR for sedentary participants = 0.95, 95%CI: 0.90, 0.99). Path analysis revealed that adherence to a Mediterranean diet not only decreases the levels of C-reactive protein and interleukin-6 but also has an independent protective role against CVD risk per se (total effect of the MedDietScore on CVD = -0.003, 95%CI: -0.005 to 0.000). CONCLUSION Adherence to a Mediterranean diet confers a considerable reduction on CVD risk, independent of various factors. Therefore, even subjects with unhealthy lifestyle behaviors may benefit from adherence to this diet, suggesting another dimension to prevention strategies.