Phthalate exposure and the metabolic syndrome: A systematic review and meta-analysis

Phthalates are chemicals widely used in plastic-based consumer products, and human exposure is universal. They are classified as endocrine disruptors, and specific phthalate metabolites have been associated with an increased risk of cardiometabolic diseases. The aim of this study was to assess the association between phthalate exposure and the metabolic syndrome in the general population. A comprehensive literature search was performed in four databases (Web of Science, Medline, PubMed, and Scopus). We included all the observational studies that evaluate the association between phthalate metabolites and the metabolic syndrome available until January 31st, 2023. Pooled Odds Ratios (OR) and their 95% confidence intervals were calculated by using the inversevariance weighted method. Nine cross-sectional studies and 25,365 participants aged from 12 to 80 were included. Comparing extreme categories of phthalate exposure, the pooled ORs for the metabolic syndrome were: 1.08 (95% CI, 1.02–1.16, I 2 = 28%) for low molecular weight phthalates, and 1.11 (95% CI, 1.07–1.16, I 2 = 7%) for high molecular weight phthalates. For individual phthalate metabolites, the pooled ORs that achieved statistical significance were: 1.13 (95% CI, 1.00–1.27, I 2 = 24%) for MiBP; 1.89 (95% CI, 1.17–3.07, I 2 = 15%) for MMP in men; 1.12 (95% CI, 1.00–1.25, I 2 = 22%) for MCOP; 1.09 (95% CI, 0.99–1.20, I 2 = 0%) for MCPP; 1.16 (95% CI, 1.05–1.28, I 2 = 6%) for MBzP; and 1.16 (95% CI, 1.09–1.24, I 2 = 14%) for DEHP (including ΣDEHP and its metabolites). In conclusion, both low molecular weight and high molecular weight phthalates were associated with an 8 and 11% higher prevalence of the MetS, respectively. The exposure to six specific phthalate metabolites was associated with a higher prevalence of the MetSData collection was funded by the following grants: FIS PI17/1709, PI20/144 (State Secretary of R + D and FEDER/FSE), and the CIBERESP, Instituto de Salud Carlos III. Madrid, Spain. MM has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement [(No 801342 (Tecniospring INDUSTRY)] and the Government of Catalonia’s Agency for Business Competitiveness (ACCIO) ´ (TECSPR19-1-0022

Combined impact of traditional and non-traditional health behaviors on mortality: A national prospective cohort study in Spanish older adults

Background: Data on the combined effect of lifestyles on mortality in older people have generally been collected from highly selected populations and have been limited to traditional health behaviors. In this study, we examined the combined impact of three traditional (smoking, physical activity and diet) and three non-traditional health behaviors (sleep duration, sedentary time and social interaction) on mortality among older adults. Methods: A cohort of 3,465 individuals, representative of the Spanish population aged ≥60 years, was established in 2000/2001 and followed-up prospectively through 2011. At baseline, the following positive behaviors were selfreported: never smoking or quitting tobacco >15 years, being very or moderately physically active, having a healthy diet score ≥ median in the cohort, sleeping 7 to 8 h/d, spending <8 h/d in sitting time, and seeing friends daily. Analyses were performed with Cox regression and adjusted for the main confounders. Results: During an average nine-year follow-up, 1,244 persons died. Hazard ratios (95% confidence interval) for allcause mortality among participants with two, three, four, five and six compared to those with zero to one positive behaviors were, respectively, 0.63 (0.46 to 0.85), 0.41 (0.31 to 0.55), 0.32 (0.24 to 0.42), 0.26 (0.20 to 0.35) and 0.20 (0.15 to 0.28) (P for trend <0.001). The results were similar regardless of age, sex and health status at baseline. Those with six vs. zero to one positive health behaviors had an all-cause mortality risk equivalent to being 14 years younger. Adding the three non-traditional to the four traditional behaviors improved the model fit (likelihood ratio test, P <0.001) and the accuracy of mortality prediction (c-statistic: + 0.0031, P = 0.040). Conclusions: Adherence to some traditional and non-traditional health behaviors may substantially reduce mortality risk in older adults.This work was funded by grants from the FIS (ref. 12/1166) and the ‘Plan Nacional sobre Drogas’ (ref. 06/2010), and by the ‘Cátedra UAM de Epidemiología y Control del Riesgo Cardiovascular’. DMG had a “Juan de la Cierva” contract from the Spanish Ministry of Scienc

High consumption of ultra-processed food may double the risk of subclinical coronary atherosclerosis: The Aragon Workers' Health Study (AWHS)

Background: Ultra-processed food (UPF) consumption, which is increasing worldwide, has recently been associated with an increased risk of death and cardiovascular disease. We aimed to assess whether consumption of UPF is directly associated with subclinical coronary atherosclerosis in middle-aged men. Methods: A computed tomography scan was performed on 1876 men from the Aragon Workers' Health Study, recruited from January 2011 to December 2014, to assess coronary calcium. All participants were free of coronary heart disease. Dietary intake was collected by a validated 136-item semi-quantitative food frequency questionnaire. UPF was defined according to the NOVA classification. Associations between consumption of total energy-adjusted UPF and Coronary Calcium Agatston Score (CACS) - categorized into CACS of 0, > 0 and 0 and < 100). The fully adjusted ORs (95% CI) of having a CACS ≥ 100 across quartiles of energy-adjusted UPF consumption (approximately 100 g/day in the lowest quartile (ref.) and 500 g/day in the highest) were 1.00 (ref.), 1.50 (0.93, 2.42), 1.56 (0.96, 2.52), and 2.00 (1.26, 3.16), p trend.005. Conclusion: In this middle-aged worker's sample, approximately 500 g/day of UPF consumption was associated with a 2-fold greater prevalence of subclinical coronary atherosclerosis than consuming only 100 g/day, independently of total energy intake and other well-established cardiovascular risk factorsAWHS was funded through a collaboration agreement between the Aragonese Institute of Health Sciences (I+CS) of the Regional Government of Aragon, the National Cardiovascular Research Centre (CNIC) of the Carlos III Health Institute, and Opel Spain. This study was also partially supported by grants: PI17/1709 (Secretary of State for R&D and ERDF/ESF), and Integrated Projects of Excellence in Health Research Institutes PIE16/00022 (Secretary of State for R&D and ERDF/ESF), the ATHLOS Project (EU H2020-ID project: 635316), CIBERCV and CIBERESP of the Carlos III Health Institute, Madrid, Spai

Only virgin type of olive oil consumption reduces the risk of mortality. Results from a Mediterranean population-based cohort

Evidence on the association between virgin olive oil (OO) and mortality is limited since no attempt has previously been made to discern about main OO varieties. We examined the association between OO consumption (differentiating by common and virgin varieties) and total as well as cause-specific long-term mortality. 12,161 individuals, representative of the Spanish population ≥18 years old, were recruited between 2008 and 2010 and followed up through 2019. Habitual food consumption was collected at baseline with a validated computerized dietary history. The association between tertiles of OO main varieties and all-cause, cardiovascular and cancer mortality were analyzed using Cox models. After a mean follow-up of 10.7 years (129,272 person-years), 143 cardiovascular deaths, and 146 cancer deaths occurred. The hazard ratio (HR) (95% confidence interval) for all-cause mortality in the highest tertile of common and virgin OO consumption were 0.96 (0.75–1.23; P-trend 0.891) and 0.66 (0.49–0.90; P-trend 0.040). The HR for all-cause mortality per a 10 g/day increase in virgin OO was 0.91 (0.83–1.00). Virgin OO consumption was also inversely associated with cardiovascular mortality, with a HR of 0.43 (0.20–0.91; P-trend 0.017), but common OO was not, with a HR of 0.88 (0.49–1.60; P-trend 0.242). No variety of OO was associated with cancer mortality. Daily moderate consumption of virgin OO (1 and 1/2 tablespoons) was associated with a one-third lower risk of allcause as well as half the risk of cardiovascular mortality. These effects were not seen for common OO. These findings may be useful to reappraise dietary guideline

Polyphenol intake and mortality: A nationwide cohort study in the adult population of Spain

Background and aims: Polyphenols are secondary metabolites present in small quantities in plant-based food and beverages, with antioxidant and anti-inflammatory properties. Main groups of polyphenols include flavonoids, phenolic acids, stilbenes, and lignans, but their association with mortality has barely been examined. We aimed to assess the association between the intake of 23 polyphenol subgroups and all-cause, cardiovascular, and cancer mortality in a representative sample of the Spanish adult population. Methods: Population-based cohort study conducted with 12,161 individuals aged 18+ recruited in 2008–2010 and followed-up during a mean of 12.5 years. At baseline, food consumption was obtained with a validated dietary history, and the Phenol-Explorer database was used to estimate polyphenol intake. Associations were examined using Cox regression adjusted for main confounders. Results: During follow-up, 967 all-cause deaths occurred, 219 were cardiovascular, and 277 cancer. Comparing extreme categories of consumption, hazard ratios (95% CI) of total mortality for subgroups were: dihydroflavonols 0.85 (0.72–1.00; p-trend:0.046); flavonols 0.79 (0.63–0.97; p-trend:0.04); methoxyphenols 0.75 (0.59–0.94; p-trend:0.021); tyrosols 0.80 (0.65–0.98; p-trend:0.044); alkylmethoxyphenols 0.74 (0.59–0.93; p-trend:0.007); hydroxycinnamic acids 0.79 (0.64–0.98; p-trend:0.014); and hydroxyphenilacetic acids 0.82 (0.67–0.99; p-trend:0.064). For cardiovascular mortality, hazard ratios were: methoxyphenols 0.58 (0.38–0.89; p-trend:0.010); alkylmethoxyphenols 0.59 (0.39–0.90; p-trend:0.011); hydroxycinnamic acids 0.63 (0.42–0.94; p-trend:0.020); and hydroxyphenilacetic acids 0.69 (0.48–0.99; p-trend:0.044), when comparing extreme tertiles of consumption. No statistically significant associations were observed for cancer. The main food sources for these polyphenol subgroups were red wine, leafy green vegetables, olive oil, green olives, and coffee (the latter being the major contributor of methoxyphenols, alkylmethoxyphenols, and hydroxycinnamic acids). Conclusions: In the Spanish adult population, intake of specific polyphenol subgroups was prospectively associated with a 20% lower all-cause mortality risk. This decrease was mainly due to a 40% lower cardiovascular mortality risk over timeData collection was funded by the following grants: FIS PI17/ 1709, PI20/144 (State Secretary of R+D and FEDER/FSE), and the CIBERESP, Instituto de Salud Carlos III. Madrid, Spain. Additional funding was provided by the IMDEA-Food Institute, CEI UAM+CSIC, 28049, Madrid, Spai

Chocolate and health-related quality of life: A prospective study

Background Chocolate consumption has been associated with a short-term reduction in blood pressure and cholesterol, and improvement of insulin sensitivity; however, participants could not be aware of presenting hypertension or hypercholesterolemia. Moreover, the effect of chocolate on mental health is uncertain. This study assessed the association of regular chocolate consumption with the physical (PCS) and mental (MCS) components of health-related quality of life (HRQL). Materials and methods We analyzed data from a cohort of 4599 individuals recruited in 2008–2010 and followed-up once prospectively to January 2013 (follow-up mean: 3.5 years). Regular chocolate consumption was assessed at baseline with a validated diet history. HRQL was assessed with the SF-12 v.2 at baseline and at follow-up. Analyses were performed with linear regression and adjusted for the main confounders, including HRQL at baseline. Results At baseline, 72% of the study participants did not consume chocolate, 11% consumed 10 g/day and 17% >10 g/day. Chocolate consumption at baseline did not show an association with PCS and MCS of the SF-12 measured three years later. Compared to those who did not consume chocolate, the PCS scores were similar in those who consumed 10g/day (beta: -0.07; 95% confidence interval (95% CI): -0.94 to 0.80) and in those who consumed >10g/day (beta: 0.02; 95% CI:-0.71 to 0.75); corresponding figures for the MCS were 0.29; 95% CI: -0.67 to 1.26, and -0.57; 95%CI: -1.37 to 0.23. Similar results were found for sex, regardless of obesity, hypertension, hypercholesterolemia, diabetes or depression Conclusions No evidence was found of an association between chocolate intake and the physical or mental components of HRQLBaseline data collection (ENRICA study) was funded by Sanofi-Aventis. Data collection during follow-up was funded by FIS grant 09/162 (Ministry of Health of Spain). Funding specific for this analysis was obtained from FIS grants PI11/01379 and PI12/ 1166 (Ministry of Health of Spain), and from the "Cátedra UAM de Epidemiología y Control del Riesgo Cardiovascular

Social support and ambulatory blood pressure in older people

This is a non-final version of an article published in final form in Journal of Hypertension 34.10 (2016): 2045-2052. http://dx.doi.org/10.1097/HJH.0000000000001036Objective: Social support has been associated with greater nocturnal decline (dipping) in blood pressure (BP) in younger and middle-Aged individuals. However, it is uncertain if aggregated measures of social support are related to ambulatory SBP in older adults, where high SBP is frequent and clinically challenging. Methods: We studied 1047 community-living individuals aged at least 60 years in Spain. Twenty-four-hour ambulatory BP was determined under standardized conditions. Social support was assessed with a seven-item questionnaire on marital status, cohabitation, frequency of contact with relatives, or with friends and neighbors, emotional support, instrumental support, and outdoor companionship. A social support score was built by summing the values of the items that were significantly associated with SBP variables, such that the higher the score, the better the support. Results: Participants' mean age was 71.7 years (50.8% men). Being married, cohabiting, and being accompanied when out of home were the support items significantly associated with SBP variables. After adjustment for sociodemographic (age, sex, education), behavioral (BMI, alcohol, tobacco, salt consumption, physical activity, Mediterranean diet score), and clinical variables [sleep quality, mental stress, comorbidity, BP medication, and ambulatory BP levels and heart rate (HR)], one additional point in the social support score built with the abovementioned three support variables, was associated with a decrease of 0.93mmHg in night-Time SBP (P=0.039), totaling 2.8mmHg decrease for a score of 3 vs. 0. The three-item social support score was also inversely associated with the night/day SBP ratio (β=-0.006, P=0.010). Conclusion: In older adults, social support is independently associated with lower nocturnal SBP and greater SBP dipping. Further research is needed in prospective studies to confirm these resultsData collection was funded by Fondo de Investigacion Sanitaria (FIS) grants 09/1626 and 12/1166 (Ministry of Health of Spain and FEDER/FSE) and by the Catedra UAM de Epidemiologia y Control del Riesgo Cardiovascular. Specific funding for this analysis was obtained from FIS grant PI13/0232

Urinary phosphate is associated with cardiovascular disease incidence

Elevated phosphate (P) in urine may reflect a high intake of inorganic P salts from food additives. Elevated P in plasma is linked to vascular dysfunction and calcification. Objective, To explore associations between P in urine as well as in plasma and questionnaire-estimated P intake, and incidence of cardiovascular disease (CVD). Methods, We used the Swedish Mammography Cohort-Clinical, a population-based cohort study. At baseline (2004–2009), P was measured in urine and plasma in 1625 women. Dietary P was estimated via a food-frequency questionnaire. Incident CVD was ascertained via register-linkage. Associations were assessed using Cox proportional hazards regression. Results, After a median follow-up of 9.4 years, 164 composite CVD cases occurred (63 myocardial infarctions [MIs] and 101 strokes). Median P (percentiles 5–95) in urine and plasma were 2.4 (1.40–3.79) mmol/mmol creatinine and 1.13 (0.92–1.36) mmol/L, respectively, whereas dietary P intake was 1510 (1148–1918) mg/day. No correlations were observed between urinary and plasma P (r = −0.07) or dietary P (r = 0.10). Urinary P was associated with composite CVD and MI. The hazard ratio of CVD comparing extreme tertiles was 1.57 (95% confidence interval 1.05, 2.35; P trend 0.037)—independently of sodium excretion, the estimated glomerular filtration rate, both P and calcium in plasma, and diuretic use. Association with CVD for plasma P was 1.41 (0.96, 2.07; P trend 0.077). Conclusion, Higher level of urinary P, likely reflecting a high consumption of highly processed foods, was linked to CVD. Further investigation is needed to evaluate the potential cardiovascular toxicity associated with excessive intake of P beyond nutritional requirement

Consumption of fried foods and risk of coronary heart disease: Spanish cohort of the European Prospective Investigation into Cancer and Nutrition study

Objective To assess the association between consumption of fried foods and risk of coronary heart disease

Role of educational level in the relationship between Body Mass Index (BMI) and health-related quality of life (HRQL) among rural Spanish women

BACKGROUND: The impact of obesity on health-related quality of life (HRQL) has been little explored in rural areas. The goal of this study is to ascertain the association between obesity and HRQL among Spanish women living in a rural area, and the influence of their educational level. METHODS: Cross-sectional study with personal interview of 1298 women (aged 18 to 60) randomly selected from the electoral rolls of 14 towns in Galicia, a region in the north-west of Spain. HRQL was assessed using the SF-36 questionnaire. The association between body mass index (BMI) and suboptimal scores in the different HRQL dimensions was summarised using odds ratios (ORs), obtained from multivariate logistic regression models. Separate analyses were conducted for women who had finished their education younger than 16 years old and women with secondary education to assess differences in the relationship between BMI and HRQL according to educational level. RESULTS: Among women with primary or lower education, obesity was associated with a higher prevalence of suboptimal values in the following dimensions: Physical functioning (OR: 1.97; 95%CI: 1.22-3.18); Role-physical (OR: 1.81; 95%CI: 1.04-3.14); General health (OR: 1.76; 95%CI: 1.10-2.81); and Role-emotional (OR: 2.52; 95%CI: 1.27-5.03). In women with higher education, physical functioning was the only dimension associated with obesity (OR: 2.02: 95%CI 0.83-4.97). CONCLUSION: The impact of obesity on women's HRQL is greater among those with a lower educational level. This group registered higher prevalence of obesity and poorer self-perceived health.This study was funded by the Instituto de Salud Carlos III (grant 001/05).S