Geoff Middleton

Mediterranean diet- and exercise-induced improvement in age-dependent vascular activity

The aging effect on microvascular integrity, marked by endothelial dysfunction and reduction in exercise tolerance, is a major cause of CVD (cardiovascular disease). Improved dietary habits, known to reduce morbidity and mortality, are also known to attenuate those aging effects. The present study investigated the effects of combined MD (Mediterranean diet) and exercise intervention on lower- and upper-limb cutaneous microvascular functions in an older healthy population. A total of 22 sedentary healthy participants (age, 55±4 years) underwent cardiopulmonary exercise tolerance test, and were assessed for their upper- and lower-limb vascular endothelial CVC (cutaneous vascular conductance) using LDF (laser Doppler fluximetry) with endothelium-dependent [ACh (acetylcholine chloride)] and -independent [SNP (sodium nitroprusside)] vasodilation. Participants were then randomized into two groups: MD and non-MD, and followed an 8-week intervention programme, which included discontinuous treadmill running based on each individuals exertion, twice per week. Exercise training improved CVC in both groups (e.g. 0.42±0.19 compared with 1.50±1.05 and 0.47±0.26 compared with 1.15±0.59 at 1000 μCb for MD and non-MD respectively; P<0.001). This was also combined by improvement in the exercise tolerance indicated by increased VT (ventilatory threshold) in both groups [12.2±2.8 compared with 14.8±2.8 ml·(kg of body weight)(-1)·min(-1) and 11.7±2.7 compared with 14.6±3.2 ml·(kg of body weight)(-1)·min(-1) for MD and non-MD groups respectively; P<0.05]. However, the MD group showed greater improvement in endothelium-dependent vasodilation than non-MD [ANCOVA (analyses of co-variance), P=0.02]. The results of the present study suggest that compliance with MD, combined with regular moderate exercise, improves age-provoked microcirculatory endothelial dysfunction and increases exercise tolerance, both responsible for reducing cardiovascular risk in this age group.

Long-term effects of an exercise and Mediterranean diet intervention in the vascular function of an older, healthy population

BACKGROUND Preserving endothelial function and microvascular integrity is suggested to reduce cardiovascular disease risk. It was recently shown that the age-dependent decline in endothelial and microvascular integrity may be reversed when combining exercise with Mediterranean diet (MD) in an 8-week intervention. The present study investigates whether the risk-reduction improvement in microcirculatory and cardiorespiratory functions are sustained in this age-group after a 1-year follow-up. DESIGN AND METHODS Twenty sedentary healthy participants (age, 55±4years) from the original study underwent cardiopulmonary exercise tolerance test and were assessed for their upper- and lower-limb vascular endothelial cutaneous vascular conductance (CVC) using laser Doppler fluximetry (LDF) with endothelium-dependent [ACh (acetylcholine chloride)] and endothelium-independent [SNP (sodium nitroprusside)] vasodilation, 1year after completing the intervention. RESULTS Both MD and exercise groups appeared to have an improved microvascular responses, in comparison to baseline as far as ACh is concerned. Exploring the interactions between the time point and the original group, however, revealed a stronger improvement in the MD group in comparison to the exercise group, for ACh (p=0.04, d=0.41). In the upper body, the time point and group interaction for ACh, indicated a better improvement for MD, without however statistical significance (p=0.07, d=0.24). Additionally, cardiorespiratory improvement in ventilatory threshold was maintained, 1year after (12.2±3.0 vs. 13.2±3.2ml∙kg(-1)∙min(-1), p<0.05). CONCLUSIONS The original improvements from an 8-week exercise and MD intervention were still evident, particularly in the microcirculatory and cardiorespiratory assessments, 1year after the initial study. This suggests that a brief intervention combining MD with exercise in this high-risk group promises long-term health benefits.

Implementing a Mediterranean diet intervention into a RCT: Lessons learned from a non-Mediterranean based country

ObjectivesTo examine the participant experiences regarding perceived barriers and facilitators which impact on consuming the Mediterranean diet in the East of England.DesignQualitative methodology with focus groups.SettingA healthy, middle-aged population situated in the East of England. Intervention: An 8-week Mediterranean dietary intervention trial.ParticipantsEleven participants (including three co-habiting partners) in three focus groups, ranging between 50-65yrs with a mean age of 54.3yrs (±4.0)ResultsThematic analysis from the focus groups revealed that participants considered that the MD intervention had introduced a better quality of food, widening the food-horizon and allowed them to re-define cultural eating habits. They also reported several physical benefits from adapting to this diet and found the experience as positive. Whilst claiming that the MD was an enjoyable and pleasurable, the participants did express difficulty adapting to the eating pattern, finding difficulty in purchasing food items, an increase in food costs and found work, stress and time pressures undermining adherence.ConclusionThe participants’ experiences suggested that the MD was an encouraging dietary change with a middle aged non-Mediterranean based population group. Future MD interventions should tailor interventions and support participants closely, particularly with the necessary planning, organisation and purchasing involved with implementing this diet in non-Mediterranean countries. Secondly, researchers should also challenge any erroneous assumptions regarding the consumption of Mediterranean food, which may hinder implementation.

Brief Report: Implementing a Mediterranean Diet Intervention into a RCT: Lessons Learned from a Non-Mediterranean Based Country.

OBJECTIVE To assess the potential associations of branched-chain amino acids (BCAA) consumption with central obesity (CObesity) and cardiometabolic risk factors in a population of Brazilian middle-aged men. Special attention was given to leucine intake. DESIGN Cross-sectional study. SETTING Universidade Federal de Viçosa, Viçosa, Brazil. PARTICIPANTS Two-hundred ninety-six middle-aged men (Age: 50.5 ± 5.0 years; Body mass index: 25.8 ± 3.5 kg/m2). MEASUREMENTS Anthropometry, lifestyle features, blood biochemical parameters were assessed and dietary intake was estimated by a food frequency questionnaire. Participants were classified by the occurrence of CObesity, hypertriglyceridemia (HTG), hypertriglyceridemic waist phenotype (HWP) and metabolic syndrome (MetS). RESULTS Subjects in the BCAA highest tertile (≥0.17 g/kg/d) presented lower occurrence of CObesity (36.0% vs 72.4%, P<0.01, z=-5.10), HTG (17.0% vs 30.6% P<0.032, z=-2.32), HWP (23.0% vs 46.9%, P<0.01, z=-3.57) and MetS (19.0% vs 34.7%, P<0.01, z=-2.57). They also exhibited lower values for Castelli index (total cholesterol:HDL-c) and triglycerides: HDL-c ratio than those in the first tertile, regardless of interfering factors (i.e. habitual physical activity, work position, smoking habit, and energy intake). Interestingly, leucine consumption showed similar associations with cardiometabolic risk factors, as compared to BCAA consumption (P<0.05). CONCLUSION BCAA consumption was cross-sectionally and negatively associated with relevant cardiometabolic risk factors in a population of Brazilian middle-aged men. The content of leucine in BCAA consumption may have contributed to such relationship.

A qualitative exploration of stakeholder perspectives on a school-based multi-component health promotion nutrition programme.

BACKGROUND Food for Fitness is an on-going multi-component health promotion programme, delivered in primary and secondary schools by community nutrition assistants. The programme uses nutritional interventions aimed at promoting healthier eating practices for children. This service evaluation investigated the receipt and delivery of the programme, as perceived by local stakeholders who had experienced and administered the service. METHODS Semi-structured interviews and focus groups were carried out with three key stakeholder groups: health professionals (n = 9), school teachers (n = 10) and senior health officials (n = 3). Qualitative data were transcribed verbatim and received thematic analysis with deductive and inductive processes. RESULTS Stakeholders reported that the programme contributed to the development of food education and healthy-eating practices of children in the local area. Stakeholders considered that the main concern was the limited capacity and size of the service. They described problems with long-term sustainability in supporting schools with maintaining nutritional interventions, highlighting issues regarding contact, planning and organisation of several interventions. CONCLUSIONS The findings of the service evaluation inform service management, organisation and ground-level delivery. The use of stakeholder opinion provided contextualised information on the factors that impact on the implementation of the programme. The richness of the qualitative results can guide future planning and provision for similar health promotion nutrition programmes delivered in the school environment.

Supervised exercise training as an adjunct therapy for venous leg ulcers: a randomised controlled feasibility trial

Venous leg ulcers (VLUs) are typically painful and heal slowly. Compression therapy offers high healing rates; however, improvements are not usually sustained. Exercise is a low‐cost, low‐risk and effective strategy for improving physical and mental health. Little is known about the feasibility and efficacy of supervised exercise training used in combination with compression therapy patients with VLUs.

Personal goals, group performance and ‘social’ networks: participants’ negotiation of virtual and embodied relationships in the ‘Workplace Challenge’ physical activity programme

Abstract County Sports Partnerships (CSPs) epitomise the growing reliance upon building networks and partnerships in sports delivery. This study investigated how social networks were created and contested in a CSP-led programme entitled the ‘Workplace Challenge’ (WPC). The WPC used a web-platform to encourage workplace-based teams to engage in physical activity by self-recording their activity over an eight-week period. Points were awarded for activity completed and a peer-challenge facility was promoted via online league tables, prizes and the opportunity to ‘challenge’ other users. Semi-structured interviews were conducted with a total of seventeen participants recruited from one public and one private sector workplace and from a sample of participants registered as individuals. Two programme planners employed by the CSP also took part. A figurational framework was utilised to investigate participants’ negotiation of networks of embodied and virtual relationships within the programme. Findings suggest the messages promoted in the WPC were disseminated and transformed according to the organisational structure of these networks. Embodied social relationships within workplaces reinforced peer support in professional I–We identities, whereas virtual networks sometimes highlighted participants’ isolation. Moreover, emphasis upon competition within and between teams caused some participants to question their performance. Often, competition motivated engagement. For less active participants, constant comparison could prove discouraging, particularly if participants felt they had let their colleagues down. Planners of similar programmes must be cognizant of the uneven manner of programme dissemination. Contextual differences at the point of delivery including existing organisational structures and power hierarchies have an impact upon participants’ perceptions of a programme.

Exploring barriers and facilitators to eating the Mediterranean diet in England : a qualitative study

Scientific guidelines and recommendations strongly encourage a Mediterranean-like dietary pattern for primary and secondary prevention of major chronic diseases. In the United Kingdom (UK), several credible sources of dietary information have recommended consumption to the public (NHS Choices and Patient UK). The concept of how British citizens incorporate a Mediterranean diet (MD) into daily life (e.g. food availability, cost, personal preferences and preparation) has remained unexplored. Little is known on the pragmatic and cultural perspectives of adopting the MD in the UK. This study aimed to highlight the barriers and facilitators to eating the MD from a sample of participants who had recently attempted to implement the diet in the north-east of England. The investigation recruited a sample (n 11) of adult (50–65yrs) participants (n 8) that had previously enrolled on an 8-week MD intervention study. They were encouraged to attend this investigation with their co-habiting partner (n 3). Semi-structured focus groups (3) were digitally recorded and transcribed verbatim; these allowed participants to discuss their experiences regarding ‘barriers’ and ‘facilitators’ whilst attempting the MD intervention. Additional field notes supported data collection. Data were analysed through a process of thematic content analysis from the concept-driven design. Key themes highlighted that participants enjoyed the pleasurable experience, reporting several physical benefits from adapting to this diet. Furthermore, they felt that the diet introduced a better quality of food, widened the food-horizon and allowed them to redefine cultural eating habits. Participants expressed difficulty in accommodating the diet with work and stress undermining adherence along with the pressures of time and family. They also suggested that it is difficult to purchase food items and regarded the British culture as non-conducive to this pattern of eating. The table illustrates views on how adherence to the MD could be improved:

Exercise fidelity and progression in a supervised exercise programme for adults with venous leg ulcers

Despite exercise being included in the recommended advice for patients with venous leg ulcers, there is a fear shared by clinicians and patients that exercise may be either inappropriate or harmful and actually delay rather than promote healing. Therefore, before implementing a larger‐scale study exploring the effects of a supervised exercise programme in patients with venous ulcers being treated with compression therapy, it is important to assess exercise safety as well as fidelity and progression in a feasibility study. Eighteen participants randomised in the exercise group were asked to undertake 36 (3 times/week for 12 weeks) 60‐min exercise sessions, each comprising moderate‐intensity aerobic, resistance, and flexibility exercise components. For the purposes of this paper, we analysed the data collected during the exercise sessions. The overall session attendance rate was 79%, with 13 of 18 participants completing all sessions. No in‐session adverse events were reported; 100% aerobic components and 91% of resistance components were completed within the desired moderate‐intensity target. Similarly, 81% of aerobic components and 93% of flexibility components were completed within the prescribed duration targets. Our data showed that patients with venous ulcers could safely follow a supervised exercise programme incorporating moderate‐intensity aerobic, resistance, and flexibility components.

Commentary on: “Implementing a Mediterranean-Style Diet Outside the Mediterranean Region”

Dear Editor, As a team, which is probably the first to have purposely demonstrated the cardioprotective effectiveness of implementing a Mediterranean diet (MD) in the UK, we welcome an enthusiastic article promoting the MD in another non-Mediterranean country. However, to successfully raise awareness and convince policy-makers to alleviate any implementation fears, articles investigating this area need to be well-researched and have critical attention to the feasibility of implementing this particular diet into ‘westerners’ diets. This trait was missing from the article written by Murphy & Parletta for a previous edition of the journal [1]. Indeed, the endeavour of a number of researchers on this very topic was ignored. Our UK experience has shown promising effectiveness of MD in English cohorts, particularly in enhancing age-related and post-menopausal-related vascular and cardiorespiratory functions [2–4].We were also the first to describe the barriers and facilitators to implementing such diet in non-Mediterranean populations for researchers to take forward when they design their studies [5]. We have further extended this advice, by highlighting the cardiometabolic protective mechanisms associated with each MD component and associated nutraceutical, as a result of adoptingMD in order to prevent and manage metabolic diseases [6, 7]. Therefore, we feel strongly that our work should have been considered [2–4], particularly when the authors eluded to the RCT trials with explicit outcomes (page 3, initial paragraph), as it describes work-based on MD in conjunction with other lifestyle elements, which is a format most likely to be implemented in a wider scale intervention, if MD is adopted as a preferred dietary lifestyle component. In view with this omission, it is worth noting that our findings are in disagreement with the authors’ opinion of MD being a ‘low-cost’ diet, when adopted in in a nonMediterranean ‘western’ country [5]. Our participants highlighted cost, time to prepare and taste preference (especially for those who are not used to consuming olive oil) as implementation barriers [5]. Another key element of their work was the emphasis placed on the high adherence rate that they achieved 6month trial. Interestingly, we achieved a similar adherence rate (in excess of 90%), despite having less contact with the participants—we also reported longer-term microvascular benefits (12 vs. 6 months). Our pragmatic approach was based on more initial frequent contact in the first 2 months and less frequent in the months thereafter [4]. Secondly, the idea of understanding the feasibility of MD in a non-Mediterranean country has been a focus of researchers (ignored in Murphy and Parletta’s review [1]) for some time. We wish to highlight explicitly the work by Papadaki and colleagues [8–10], Logan et al. [11], Moore et al. [12], as well as the work of our team [5], which should have been considered in their article as they offer prominent and contemporary insight into the questions posed by the authors. Markos Klonizakis, Ahmad Alkhatib and Geoff Middleton contributed equally to this work.