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www.unav.es/preventiva
Dieta Mediterránea, riesgo cardiovascular y obesidad
http://www.unav.es/preventiva
Miguel A. Martínez-González, Universidad de Navarra
www.unav.es/preventiva
Diseño y métodos
Dieta Mediterránea y diabetes
Dieta Mediterránea y ECV
Dieta Mediterránea y obesidad
El Proyecto SUN (Seguimiento Universidad de Navarra)
Research designs
Source: Martínez JA, Martínez-González MA. Nutrition Research Methodology: the scientific method and nutritional research.
In: Gibney MJ, et al. Introduction to Human Nutrition. The Nutrition Society Textbook series. London: Blackwell Science.
COHORT
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Cohorte
prospectiva
dinámica
multipropósito
Comienzo: 1999
Mentores de HSPH:
W Willett, A Ascherio, FB Hu
Graduados universitarios de toda España
Invitación:
Universidad (alumni navarrensis)
Colegios profesionales de diversas provincias
Diseño y métodos
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Reclutamiento: Cuestionario basal (Q_0)
Seguimiento (follow-up): Cada 2 años
Q_2
Q_4
Q_6
Q_8
Q_10 (Enero-2010)
Autoreferidos Impreso o por internet
Hasta 5 mailings para seguimiento
Diseño y métodos
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www.unav.es/preventiva
1999/01 2002/03 2004/05 2006/07 2008/09 Follow-up
7500 9+
4200 7+
4200 5+
2500 3+
2000 1+
Año entrada
Tasa Retención Global >92%
Reclutamiento y seguimiento
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Int J Epidemiol 2006;35:1417-22.
Public Health Nutr 2006;9:127-31.
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Información
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Participantes según sexo y edad
0
10
20
30
40
50
60
70
<25 y 25-44 y 45-64 y >=65 y
%
Men Women
Segui-Gomez M, de la Fuente C, Vazquez Z, de Irala J, Martinez-Gonzalez MA. Cohort profile: The 'Seguimiento Universidad de Navarra' (SUN) study. Int J Epidemiol 2006;35:1417-22.
19,2
17,6
8,2
3,82,23,5
45,4
MD
Nurses
Pharmacists
Biology
Dieticians
Oth. Health Prof.
Non health Prof.
Int J Epidemiol 2006;35:1417-22.
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Métodos
Recogida de datos: actualización datos, personales, control calidad, escaneado, depósito
Análisis estadísticos variados según propósito
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¿Auto-declarados? ¿Validez?
Alonso, et al. Validation of self reported diagnosis of
hypertension in a cohort of university graduates in Spain.
BMC Public Health 2005;5:94
% of confirmed cases of HT: 82 % (73 – 93)
% of confirmed cases of not HT: 85 % (72 – 89)
¿Sesgos?
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Validación de actividad física
Public Health Nutrition 2005;8;920-7.
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Validación de diagnósticos de depresión
BMC Psychiatry 2008;8;43.
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0.73 -0.68
(-0.34 to –1.00)
-0.72
(-0.23 to –1.20)
0.52 +0.88
(+0.14 to +1.63)
+1.32
(+0.13 to +2.49)
0.90 -1.12
(-1.69 to –0.54)
-0.97
(-0.32 to –1.61)
0.85 -2.73
(-4.04 to –1.41)
-2.53
(-4.27 to –0.78)
0.33 -1.71
(-2.59 to –0.83)
-1.13
(-1.90 to –0.36)
p Women
Men
Diferencia de IMC (Kg/m2)
declarado-medido)
Diferencia de talla (cm)
(declarado-medido)
Weight difference (Kg)
(reported-measured)
Mean error (BMI)* (%)
Mean error (weight)* (%)
* (declarado-medido)/medido
Correlation coefficient: 0.991 (0.986-0.994)
Bes-Rastrollo M, Pérez Valdivieso JR, Sánchez-Villegas A, Alonso A, Martínez-González MA. Validación del peso e indice de masa corporal auto-declarados de los participantes de una cohorte de graduados universitarios. Rev Esp Obes 2005;3:183-9.
Validacion de peso e IMC
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112
114
116
118
120
122
124
126
128
<25 25 to 30 >30
BMI (kg/m2)S
BP
(ad
j. m
ean
, 9
5%
CI)
68
70
72
74
76
78
80
82
<25 25 to 30 >30
BMI (kg/m2)
DB
P (
ad
j. m
ean
, 9
5%
CI)
IMC basal y TA auto-referida (6 años de seguim.)
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Cuestionario de Frecuencia Consumo Alim. (136-items) - FFQ
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Martin-Moreno JM, Boyle P, Gorgojo L, Maisonneuve P, Fernandez-Rodriguez JC, Salvini S, Willett WC.Development and validation of a food frequency questionnaire in Spain. Int J Epidemiol 1993;22:512-9.
Validación-Reproducibilidad del FFQ
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Representativeness is a
fallacy that has plagued
epidemiologic studies for
decades. Rothman KJ. Epidemiology. An introduction
Oxford University Press, 2002, p.110.
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Low-fat dairy but not whole-fat dairy incidence of HT (SUN Cohort. Alonso, et al AJCN, 2005)
Am J Clin Nutr 2005;82:972-9.
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Low-fat dairy but not whole-fat dairy incidence of HT (SUN Cohort. Alonso, et al AJCN, 2005)
Interaction SFA-dairy (only incidence of HT if SFA intake is low) Djoussé et al, Hypertension 2006
Low-fat dairy, but not whole-fat dairy HT risk in the Women Health Study cohort (n=28 000)
Wang et al, Hypertension 2008
Low-fat dairy, but not whole-fat dairy BP Toledo et al, Br J Nutr 2009
Low-fat dairy, but not whole-fat dairy HT risk in the
Rotterdam cohort Engberink et al, AJCN 2009
Am J Clin Nutr 2005;82:972-9.
www.unav.es/preventiva
www.unav.es/preventiva
www.unav.es/preventiva
Diseño y métodos
Dieta Mediterránea y diabetes
Dieta Mediterránea y ECV
Dieta Mediterránea y obesidad
El Proyecto SUN (Seguimiento Universidad de Navarra)
www.unav.es/preventiva
•1 point if >= sex-specific Median •MUFA/SFA ratio
•Fruits & nuts
•Vegetables
•Cereals
•Legumes
•Fish
•1 point if <= sex-specific Median •Meat & poultry /meat products
•Dairy
•Alcohol: 1 point if •Men: between 10-50 g/d •Women: between 5-25 g/d
Trichopoulou score
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n = 13 464 8 084 women and 5 380 men
mean age = 38 yr (SD: 12)
initially free of diabetes
Follow-up: ~59 000 p-yr (mean follow-up: 4.4 yr)
2+ yr: 4130
4+ yr: 4424
6+ yr: 4910
Retention rate: 87%
Mediterranean Food Pattern and diabetes: The SUN Project
Outcome: confirmed cases of type-2 diabetes
(additional questionnaire + medical chart review)
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MeDiet (Trichopoulou score) <3 3-6 >6
n 2258 9657 1549
% Male 40 39 45
Age 34 38 43
BMI 23.0 23.5 23.8
% Family history of diabetes 12 14 17
% Personal history hypertension 6 9 14
% Current or ex-smoker 44 51 58
Total energy intake (kcal/d) 2286 2586 2783
Physical activity (METS-h/wk) 24 29 36
Mediterranean Food Pattern and diabetes: The SUN Project
www.unav.es/preventiva
0.31
0.49
0.78
0
0,25
0,5
0,75
1
<3 3 to 6 >6
MeDiet score <3 3-6 >6
Total fibre (g/d) 18 29 41
Olive oil (g/d) 12 19 25
Alcohol (g/d) 4 7 10
Meats (g/d) 199 187 154
Mediterranean Food Pattern and diabetes: The SUN Project
www.unav.es/preventiva
Trichopoulou Score <3 3-6 >6
Rate/1000 0.88 0.52 0.32
crude IRR 1 (ref.) 0.6 (0.3-1.3) 0.4 (0.1-1.7)
age- & sex-adj. IRR 1 (ref.) 0.41 (0.19-0.87) 0.17 (0.04-0.75)
multivariate adj. IRR* 1 (ref.) 0.40 (0.18-0.90) 0.17 (0.04-0.72)
p for trend = 0.04
*Adjusted for age, sex, years of university education, BMI, energy intake,
physical activity, hours/wk sitting down, smoking, family history of
diabetes and personal history of hypertension.
Mediterranean Food Pattern and diabetes: The SUN Project
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Mediterranean Diet and Metabolic syndrome: The SUN Project
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Odds Ratios for Metabolic Syndrome according to Baseline adherence to MeDiet (SUN cohort, 6-yr follow-up)
MeDiet (Trichopoulou
score)
% Metabolic Syndrome
(incidence)
Age- and sex-adjusted analysis
Multivariate analysis
<=2 (n=535) 2.6 1 (ref.) 1 (ref.)
3 – 5 (n=1523) 2.5 0.76 (0.40, 1.45) 0.80 (0.42, 1.54)
>=6 (n=505) 0.8 0.18 (0.06, 0.56) 0.20 (0.06, 0.63)
P for trend 0.006 0.01
Adjusted for age, gender, smoking, leisure-time physical activity (METS-h/wk), and total energy intake.
Tortosa A, Bes-Rastrollo M, Sanchez-Villegas A, Basterra-Gortari FJ, Núñez-Córdoba JM, Martínez-Gonzalez MA. Mediterranean Diet inversely associated with the incidence of Metabolic Syndrome: the SUN prospective cohort. Diabetes Care 2007
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Diseño y métodos
Dieta Mediterránea y diabetes
Dieta Mediterránea y ECV
Dieta Mediterránea y obesidad
El Proyecto SUN (Seguimiento Universidad de Navarra)
Nutr Metab Cardiov Dis Jan 20. [Epub ahead of print]
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15 975
14 129
13 823
13 609 free of CVD
(5483 men & 8126 women)
100 incident CVD Events (73 men & 27 women)
306 out of kcal limits
1 846 without follow-up
214 CVD at
baseline
mean follow-up: 43 months
Mediterranean Diet and CV Disease: The SUN Project
68 AMI or Revasc. 32 Stroke
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p for trend = 0.07
Cox model (age): adjusted for smoking (3), sex, family history of CHD, hypertension,
diabetes, aspirin use, dyslipidemia, physical activity (4), BMI (3), and total energy intake.
Martinez-Gonzalez, et al. Nutr Metab Cardiov Dis 2010, Jan 20
1
0,64 0,66
0,41
0
0,2
0,4
0,6
0,8
1
Low (0-2) Low-Mod. (3-4) Mod-High(5-6) High (7-9)
MeDiet
RR
of
CV
DMediterranean Diet and CV Disease: The SUN Project
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Mediterranean Diet and CV Disease: The SUN Project
Studies conducted in the US
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Diseño y métodos
Dieta Mediterránea y diabetes
Dieta Mediterránea y ECV
Dieta Mediterránea y obesidad
El Proyecto SUN (Seguimiento Universidad de Navarra)
www.unav.es/preventiva
Mediterranean Diet and obesity: The SUN Project
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Mediterranean Diet and obesity: The SUN Project
10 376 participants
Followed-up 5.7 2 y
MeDiet: 6 scores Trichopoulou (0 to 9) Alberti-Fidanza (Med Foods/not Med Foods) Scali (0 to 14)- inverse Sánchez-Villegas (0 to 100) Panagiotakos (0 to 55) Rumawas (0 to 100)
Weight bianually Risk of gaining 3 kg or 5 kg after 2 or 4 y
Incident overweight/obesity (if BMI<25 at onset)
Average yearly weight gain
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Baseline, cross-sectional comparisons
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0,5
0,75
1
1,25
0 to 3 4 to 5 6 to 9
MeDiet (Trichopoulou)
OR
fo
r g
ain
ing
5+
kg
(9
5%
CI)
Relative Risk (Odds Ratios) of gaining 5+ kg
in 2-y follow-up or in 4-y follow-up
p<0,01
0,5
0,75
1
1,25
0 to 3 4 to 5 6 to 9
MeDiet (Trichopoulou)
OR
fo
r g
ain
ing
5+
kg
(9
5%
CI) p<0,01
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0,9
0,5
0,75
1
1,25
0 to 3 4 to 5 6 to 9
MeDiet (Trichopoulou)
HR
fo
r o
ve
rwe
igh
t/o
be
sit
y
(9
5%
CI)
Relative Risk (Hazard Ratios) of incident overweight/obesity during follow-up (baseline BMI<25)
Person-yr 13 911 14 072 8 512 Incident cases 375 412 239
Adjusted for sex, age, baseline BMI, physical activity, sedentary behavior, smoking (never, former, or current smokers), snacking, and total energy intake
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0,295
0,238
0,186
0
0,1
0,2
0,3
0,4
Lowest (<4) Mod (4-5) Highest (>5)
MeDiet (Trichopoulou)
Ye
arl
y w
eig
ht
ch
an
ge
(k
g/y
)
dif.= ―0,057
AVERAGE YEARLY WEIGHT CHANGE Longitudinal, crude (unadjusted) comparisons
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-0,2
-0,1
0
0,1
0,2
0 to 3 4 to 5 6 to 9
MeDiet (Trichopoulou)
Dif
f. in
ye
arl
y w
eig
ht
ch
an
ge
(9
5%
CI)
-0,2
-0,1
0
0,1
0,2
0 to 3 4 to 5 6 to 9
MeDiet (Trichopoulou)
Dif
f. in
ye
arl
y w
eig
ht
ch
an
ge
(9
5%
CI)
DIFFERENCES IN YEARLY WEIGHT CHANGE Longitudinal, adjusted comparison
p = 0,02 p = 0,04
*Adjusted for sex, age, baseline BMI, physical activity, sedentary
behavior, smoking (never, former, or current smokers), snacking, and
total energy intake
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Age-sex Multivariable*
Trichopoulou Score 0.04 0.02
Alberti-Fidanza 0.01 0.02
Scali <0.01 <0.01
Sánchez-Villegas <0.01 0.02
Panagiotakos 0.18 0.30
Rumawas 0.13 0.41
Statistical significance, p for trend values
Adjusted for sex, age, baseline BMI, physical activity, sedentary behavior, smoking (never, former, or current smokers), snacking, and total energy intake
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MeDiet & average yearly weight change (6 scores) Multivariable-adjusted*
-0,2
-0,1
0
0,1
0,2
0 to 3 4 to 5 6 to 9
Trichopoulou
-0,2
-0,1
0
0,1
0,2
Lowest Mod-low Mod-high Highest
Alberti-Fidanza
-0,2
-0,1
0
0,1
0,2
Lowest Mod-low Mod-high Highest
Scali
-0,2
-0,1
0
0,1
0,2
Lowest Mod-low Mod-high Highest
Sánchez-Villegas
-0,2
-0,1
0
0,1
0,2
Low Mod. High
Panagiotakos
-0,2
-0,1
0
0,1
0,2
Low Mod. High
Rumawas
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-0,3
-0,2
-0,1
0
0,1
0 to 3 4 to 5 6 to 9
MeDiet (Trichopoulou)
Dif
f. i
n y
earl
y w
eig
ht
ch
an
ge (
95
%C
I)
-0,3
-0,2
-0,1
0
0,1
0 to 3 4 to 5 6 to 9
MeDiet (Trichopoulou)
Dif
f. i
n y
earl
y w
eig
ht
ch
an
ge (
95
%C
I)
Effect modification (interaction) according to previous weight gain Multivariable-adjusted*
p<0,01
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Proyecto SUN Dpt. Medicina Preventiva y S. Pública
Universidad de Navarra
Nunez-Cordoba JM, Tortosa A, de la Fuente-Arrillaga C, Bes-Rastrollo M, Martinez-Gonzalez MA,
Benito S, Beunza JJ, Vazquez Z, Basterra-Gortari FJ.
¡Muchas gracias!
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