The American Heart Association has recently developed the Life's Essential 8 (LE8) score to encourage prevention of cardiovascular disease (CVD). This study assessed the distribution of LE8 in the ...Spanish adult population and its association with all-cause and CVD death.
We used data from 11 616 individuals aged 18 years and older (50.5% women) from the ENRICA study, recruited between 2008 and 2010 and followed up until 2020 to 2022. The LE8 score includes 8 metrics (diet, physical activity, nicotine exposure, sleep health, body mass index, blood lipids and glucose, and blood pressure) and ranges from 0 to 100. The association of LE8 score with mortality was summarized with hazard ratios (HR), obtained from Cox regression.
In total, 13.2% of participants (range, 6.1%-16.9% across regions) had low cardiovascular health (LE8 ≤ 49). During a median follow-up of 12.9 years, 908 total deaths occurred, and, during a median follow-up of 11.8 years, 207 CVD deaths were ascertained. After adjustment for the main potential confounders and compared with being in the least healthy (lowest) quartile of LE8, the HR (95%CI) of all-cause mortality for the second, third and fourth quartiles were 0.68 (0.56-0.83), 0.63 (0.51-0.78), and 0.53 (0.39-0.72), respectively. The corresponding figures for CVD mortality, after accounting for competing mortality risks, were 0.62 (0.39-0.97), 0.55 (0.32-0.93), and 0.38 (0.16-0.89).
A substantial proportion of the Spanish population showed low cardiovascular health. A higher LE8 score, starting from the second quartile, was associated with lower all-cause and CVD mortality.
La American Heart Association ha desarrollado el índice Life's Essential 8 (LE8) para promover la prevención de la enfermedad cardiovascular (ECV). Este estudio examinó la distribución del LE8 en la población adulta española y su asociación con la mortalidad general y por ECV.
Se analizaron datos de 11.616 personas de edad ≥ 18 años (el 50,5% mujeres) del estudio ENRICA, reclutadas en 2008-2010 y seguidas hasta 2020-2022. El LE8 incluye 8 parámetros (dieta, actividad física, exposición a la nicotina, sueño, índice de masa corporal, lípidos y glucosa en sangre y presión arterial) y se puntúa de 0 a 100. La asociación entre LE8 y mortalidad se resumió mediante hazard ratio obtenidas de modelos de Cox.
El 13,2% de los participantes (del 6,1 al 16,9% según la comunidad autónoma) mostraron mala salud cardiovascular (LE8 ≤ 49). Tras una mediana de 12,9 años de seguimiento, ocurrieron 908 muertes totales y, durante una mediana de 11,8 años de seguimiento, 207 muertes por ECV. Tras ajustar por los principales factores de confusión y comparados con el cuartil más bajo (menos saludable) de LE8, los HR (IC 95%) de mortalidad general en el segundo, el tercer y el cuarto cuartil fueron, respectivamente, 0,68 (0,56-0,83), 0,63 (0,51-0,78) y 0,53 (0,39-0,72). Los resultados correspondientes a la mortalidad cardiovascular, considerando riesgos competitivos de muerte, fueron 0,62 (0,39-0,97), 0,55 (0,32-0,93) y 0,38 (0,16-0,89).
Una proporción sustancial de los españoles mostraron mala salud cardiovascular. Una mayor puntación de LE8, desde el segundo cuartil, se asocia con menores mortalidad general y cardiovascular.
Avoiding high protein intake in older adults with chronic kidney disease (CKD) may reduce the risk of kidney function decline, but whether it can be suboptimal for survival is not well ...known.ImportanceAvoiding high protein intake in older adults with chronic kidney disease (CKD) may reduce the risk of kidney function decline, but whether it can be suboptimal for survival is not well known.To estimate the associations of total, animal, and plant protein intake with all-cause mortality in older adults with mild or moderate CKD and compare the results to those of older persons without CKD.ObjectiveTo estimate the associations of total, animal, and plant protein intake with all-cause mortality in older adults with mild or moderate CKD and compare the results to those of older persons without CKD.Data from 3 cohorts (Study on Cardiovascular Health, Nutrition and Frailty in Older Adults in Spain 1 and 2 and the Swedish National Study on Aging and Care in Kungsholmen in Sweden) composed of community-dwelling adults 60 years or older were used. Participants were recruited between March 2001 and June 2017 and followed up for mortality from December 2021 to January 2024. Those with no information on diet or mortality, with CKD stages 4 or 5, or undergoing kidney replacement therapy and kidney transplant recipients were excluded. Data were originally analyzed from June 2023 to February 2024 and reanalyzed in May 2024.Design, Setting, and ParticipantsData from 3 cohorts (Study on Cardiovascular Health, Nutrition and Frailty in Older Adults in Spain 1 and 2 and the Swedish National Study on Aging and Care in Kungsholmen in Sweden) composed of community-dwelling adults 60 years or older were used. Participants were recruited between March 2001 and June 2017 and followed up for mortality from December 2021 to January 2024. Those with no information on diet or mortality, with CKD stages 4 or 5, or undergoing kidney replacement therapy and kidney transplant recipients were excluded. Data were originally analyzed from June 2023 to February 2024 and reanalyzed in May 2024.Cumulative protein intake, estimated via validated dietary histories and food frequency questionnaires.ExposuresCumulative protein intake, estimated via validated dietary histories and food frequency questionnaires.The study outcome was 10-year all-cause mortality, ascertained with national death registers. Chronic kidney disease was ascertained according to estimated glomerular filtration rates, urine albumin excretion, and diagnoses from medical records.Main Outcomes and MeasuresThe study outcome was 10-year all-cause mortality, ascertained with national death registers. Chronic kidney disease was ascertained according to estimated glomerular filtration rates, urine albumin excretion, and diagnoses from medical records.The study sample consisted of 8543 participants and 14 399 observations. Of the 4789 observations with CKD stages 1 to 3, 2726 (56.9%) corresponded to female sex, and mean (SD) age was 78.0 (7.2) years. During the follow-up period, 1468 deaths were recorded. Higher total protein intake was associated with lower mortality among participants with CKD; adjusted hazard ratio (HR) for 1.00 vs 0.80 g/kg/d was 0.88 (95% CI, 0.79-0.98); for 1.20 vs 0.80 g/kg/d, 0.79 (95% CI, 0.66-0.95); and for 1.40 vs 0.80 g/kg/d, 0.73 (95% CI, 0.57-0.92). Associations with mortality were comparable for plant and animal protein (HRs, 0.80 95% CI, 0.65-0.98 and 0.88 95% CI, 0.81-0.95 per 0.20-g/kg/d increment, respectively) and for total protein intake in participants younger than 75 years vs 75 years or older (HRs, 0.94 95% CI, 0.85-1.04 and 0.91 95% CI, 0.85-0.98 per 0.20-g/kg/d increment in total protein intake, respectively). However, the hazards were lower among participants without CKD than in those with CKD (HRs, 0.85 95% CI, 0.79-0.92 and 0.92 95% CI, 0.86-0.98 per 0.20-g/kg/d increment, respectively; P = .02 for interaction).ResultsThe study sample consisted of 8543 participants and 14 399 observations. Of the 4789 observations with CKD stages 1 to 3, 2726 (56.9%) corresponded to female sex, and mean (SD) age was 78.0 (7.2) years. During the follow-up period, 1468 deaths were recorded. Higher total protein intake was associated with lower mortality among participants with CKD; adjusted hazard ratio (HR) for 1.00 vs 0.80 g/kg/d was 0.88 (95% CI, 0.79-0.98); for 1.20 vs 0.80 g/kg/d, 0.79 (95% CI, 0.66-0.95); and for 1.40 vs 0.80 g/kg/d, 0.73 (95% CI, 0.57-0.92). Associations with mortality were comparable for plant and animal protein (HRs, 0.80 95% CI, 0.65-0.98 and 0.88 95% CI, 0.81-0.95 per 0.20-g/kg/d increment, respectively) and for total protein intake in participants younger than 75 years vs 75 years or older (HRs, 0.94 95% CI, 0.85-1.04 and 0.91 95% CI, 0.85-0.98 per 0.20-g/kg/d increment in total protein intake, respectively). However, the hazards were lower among participants without CKD than in those with CKD (HRs, 0.85 95% CI, 0.79-0.92 and 0.92 95% CI, 0.86-0.98 per 0.20-g/kg/d increment, respectively; P = .02 for interaction).In this multicohort study of older adults, higher intake of total, animal, and plant protein was associated with lower mortality in participants with CKD. Associations were stronger in those without CKD, suggesting that the benefits of proteins may outweigh the downsides in older adults with mild or moderate CKD.Conclusions and RelevanceIn this multicohort study of older adults, higher intake of total, animal, and plant protein was associated with lower mortality in participants with CKD. Associations were stronger in those without CKD, suggesting that the benefits of proteins may outweigh the downsides in older adults with mild or moderate CKD.
Abstract Context Modern causal inference methods – although core to epidemiological reasoning – may be difficult to master and less intuitive than Hill’s classical considerations. We developed a ...‘How-Questions’ (HQ) framework to integrate Hill's classical considerations with modern causal inference methods in observational studies. Methods First, we extracted the main causal considerations from contemporary philosophy of science: characteristics of empirical associations, universality, depth, and degree of corroboration of a theory. From these, we developed a HQ framework based on six domains formulated as questions: (1) how valid? , (2) how time-ordered? , (3) how big? , (4) how shaped? , (5) how replicable? , and (6) how explainable? Then, we qualitatively checked whether Hill's classical considerations and key selected modern causal inference methods were compatible with the HQ framework. Lastly, as a proof-of-concept, we applied the HQ framework to two observational studies of current topics in epidemiology. Findings Both Hill’s considerations and key selected modern causal inference methods were compatible with the six domains of the HQ framework. (1) The how-valid domain is addressed by considering the same internal validity issues in Hill’s and modern methods, namely confounding, selection and measurement biases; modern methods use more formalized techniques, including quantitative bias analyses/sensitivity analyses (QBA/SA). (2) The how-time-ordered domain is addressed by considering reverse causation in Hill’s; modern methods may use G methods within the context of longitudinal data analyses and time-varying exposures. (3) The how-big domain is addressed by strength of association in Hill’s; modern methods first consider estimands and may use QBA/SA to assess robustness of effect estimates. (4) The how-shaped domain is represented by biological gradient in Hill’s; modern methods may use generalized propensity scores to estimate dose-response functions. (5) The how-replicable domain is addressed in Hill’s by consistency of study findings with existing evidence; modern methods may use triangulation of different study designs and consider generalizability and transportability concepts. (6) The how-explainable domain is addressed by biological plausibility in Hill’s and by mediation/interaction analyses in modern methods. The application of the HQ framework to two observational studies provides a proof-of-concept and suggests its potential usefulness to integrate Hill’s considerations with modern causal inference methods. Perspective We found that the six dimensions of the HQ framework integrated Hill’s classical considerations with modern causal inference methods for observational studies. Apart from its potential pedagogical value, the HQ framework may provide a holistic view for the causal assessment of observational studies in epidemiology.
Abstract Background and Aims Limiting protein intake in older adults with chronic kidney disease (CKD) may reduce the risk of its progression, but whether it can adversely impact nutritional status ...and overall health is not well known. We aimed to study the associations of total, animal, and plant protein intake with all-cause mortality in older adults with CKD and replicated the analyses in those without CKD for comparison. Method We used data from three cohorts (Seniors-ENRICA 1 and Seniors-ENRICA 2 in Spain and SNAC-K in Sweden) of community-dwelling adults ≥60 years (2 555 with CKD and 6014 without). According to estimated glomerular filtration rates, urine albumin excretion, and diagnoses from electronic health records, 98% of participants with CKD were in stages 2 and 3. Cumulative protein intake was estimated via validated dietary histories and food frequency questionnaires. Vital status was ascertained with national death registers. Associations were estimated with Cox proportional hazards regression models, adjusted for sociodemographic, lifestyle, morbidity, and dietary variables. Results After a median follow-up of 10 years, 1 901 deaths were recorded. Higher total protein intake was associated with lower mortality among participants with CKD hazard ratio (95% confidence interval) for 1.15 and 1.35 g/kg/day versus 1.0 g/kg/day = 0.93 (0.88, 0.98) and 0.85 (0.76, 0.95), respectively. Low total protein intake was more detrimental to the youngest old (<75 years) and high total protein was less beneficial. Plant protein showed a stronger protective association with mortality than animal protein 0.73 (0.59, 0.90) and 0.91 (0.85, 0.98) per 0.2 g/kg/day increment, respectively. Among participants without CKD, most hazard ratios were lower, especially in the oldest old, but no significant interactions between protein intake, CKD, and mortality arose. Conclusion Higher protein intake might have a positive impact on mortality in older adults with mild or moderate CKD, particularly plant protein. Recommendations for these patients may not differ substantially from those without CKD.
Abstract
Background
Frailty is a geriatric syndrome that entails high risk of hospitalization, disability, and death. While adherence to Mediterranean diet has been associated with lower risk of ...frailty, the joint effect of diet and lifestyle is uncertain. This study examined the association between a Mediterranean lifestyle (diet, customs, and traditions) and frailty incidence in older adults.
Methods
We analyzed data from 1 880 individuals aged ≥ 60 from the prospective Seniors-ENRICA-1 cohort. Adherence to the Mediterranean lifestyle was assessed at baseline with the 27-item MEDLIFE index (higher scores representing better adherence), divided into 3 blocks: (1) “Mediterranean food consumption,” (2) “Mediterranean dietary habits” (practices around meals),” and (3) “Physical activity, rest, social habits and conviviality.” Frailty was ascertained as the presence of ≥ 3 of the 5 Fried criteria: (a) Exhaustion; (b) Muscle weakness; (c) Low physical activity; (d) Slow walking speed; and (e) Unintentional weight loss. Main statistical analyses were performed using logistic regression models, adjusting for the main confounders.
Results
After a 3.3-year follow-up, 136 incident frailty cases were ascertained. Compared with participants in the lowest tertile of the MEDLIFE score, the OR (95% CI) for frailty was 0.88 (0.58-1.34) for the second tertile, and 0.38 (0.21-0.69) for the third tertile (p-trend = .003). Blocks 1 and 3 of the MEDLIFE score were independently associated with lower frailty risk. Most items within these blocks showed a tendency to reduced frailty.
Conclusions
Higher adherence to a Mediterranean lifestyle was associated with lower risk of frailty.
Not having social support has been associated with poor sleep, but most prospective studies were based on social support in the workplace, did not account for baseline sleep characteristics or did ...not assess sleep duration. Moreover, no previous research has evaluated the relationship between social network and sleep outcomes in an older Spanish population.
1444 individuals aged ≥60 years were followed between 2012 and 2015. At baseline (2012), a poor social network index (SNI) was computed by summing the following dichotomous indicators: not being married; living alone; not having daily contact with family, friends or neighbors; being alone ≥8h/day; lacking someone to go for a walk with; not having emotional support; lacking instrumental support. Higher values in SNI indicate less social support. In 2012 and 2015, information was collected on sleep duration (hours/day) and on symptoms of sleep disturbance: bad overall sleep; difficulty falling asleep, awakening during nighttime, early awakening with difficulty getting back to sleep, use of sleeping pills, feeling restless in the morning, being asleep at daytime, and having an Epworth Sleepiness Scale>10. Poor sleep duration was defined as short (<6 h) or long (>9 h) nighttime sleep, and poor sleep quality as having ≥4 indicators of sleep disturbance. Linear or logistic regression models were used to assess the relationship of SNI with changes in sleep duration and in number of sleep disturbance indicators, or with the risk of developing poor nighttime sleep or poor sleep quality.
Compared to individuals in the lowest (best) quartile of the SNI in 2012, those in the second, third and fourth quartiles, respectively, displayed a mean (95%confidence interval 95% CI) change of 2.32 (-7.58-12.22), -2.70 (-13.19-7.79) and -13.04 (-23.41- -2.67) minutes in sleep duration from 2012 to 2015; p for trend=0.02. A 1-point increase in the SNI at baseline was associated with an increased risk of short nighttime sleep (Odds Ratio OR and 95% CI: 1.22 (1.05-1.42)), poor sleep quality (OR: 1.13; 95% CI: 1.00-1.30), and of the indicator of sleep disturbance "early awakening with difficulty getting back to sleep" (OR: 1.20; 95% CI: 1.07-1.35).
A poorer social network is associated with a higher risk of short sleep and poor sleep quality in older adults.
The aim of this cross-sectional study was to describe the prevalence of total, known and unknown diabetes mellitus and impaired fasting glucose (IFG) in the population of Murcia (SE Spain), a ...Mediterranean area with a high prevalence of obesity. Therefore, 2562 subjects (≥20 years) were selected by stratified random sampling and a survey was carried out by telephone, together with a physical examination and biochemical determinations. The ADA-1997 diagnostic criteria were used. The crude prevalence of total diabetes was 11% (9.5–12.6%), known diabetes 7.8% (6.5–9.2%), unknown diabetes 3.2% (2.4–4.2%) and IFG 4.9% (3.9–6.1%). Both total diabetes and IFG were higher in men than in women, with prevalence rates increasing with age. People with diabetes and IFG had higher BMI, blood pressure, total cholesterol, LDL-cholesterol and triglyceride values than the rest of the population. No difference in the prevalence of diabetes was observed between the rural and urban populations. The prevalence of diabetes in Murcia is high compared to the rest of Spain and the world, suggesting that the possible benefits attributed to some characteristics of the diet of this Mediterranean population are not sufficient to counteract the risk factors associated with the disease.
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