Fish consumption, omega-3 fatty acid intake, and risk of pain: the Q5 Seniors-ENRICA-1 cohort

Background & aims: Omega-3 fatty acids have anti-inflammatory and analgesic (anti-nociceptive) actions. However, the relation of habitual omega-3 fatty acidintake andfish consumption -itsmain food source-with pain remains largely unknown.We examined the association offish consumption andmarine omega-3 fatty acid intake with pain incidence and worsening over 5 years among older adults. Methods: Data were taken from the Seniors-ENRICA-1 cohort, which included 950 individuals aged 60 years in Spain. Habitual fish consumption and marine omega-3 fatty acid intake during the previous year were assessed in 2008e2010 and 2012 with a validated diet history. Painwas assessed in 2012 and 2017 with a scale developed from the Survey on Chronic Pain in Europe, ranging from 0 (no pain) to 6 (highest pain), according to its severity, frequency, and number of locations. Analyses on pain incidence were conducted in the 524 participants free of pain at baseline, while those on pain worsening were performed in the overall cohort, and both were adjusted for sociodemographic variables, lifestyle, morbidity, and diet quality. Results: Higher oily fish consumption was associated with reduced pain incidence and worsening over 5 years [fully adjusted odds ratios (95% confidence interval) ¼ 0.68 (0.50,0.94) and 0.70 (0.55,0.88) for every 25 g/day increment (1.5 servings/week), respectively]. Total and white fish consumption were not associated with pain. Higher marine omega-3 fatty acid intake was inversely associated with pain worsening [odds ratio (95% confidence interval) per 0.5 g/day increment ¼ 0.83 (0.72,0.96)]. The corresponding associations for eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were 0.53 (0.33,0.87) and 0.73 (0.57,0.94). Conclusions: In this cohort of Spanish older adults, increased oily fish consumption was inversely associated with pain incidence and worsening over 5 years, while higher marine omega-3 fatty acid intake (and that of EPA and DHA) was linked to less pain worseningThe present study was supported by Instituto de Salud Carlos III, State Secretary of RþDþI, and FEDER/FSE (FIS grants 18/287, and 19/ 319), as well as the Funding REACT EU Program (Comunidad de Madrid and the European Regional Development Fund-ERDF, European Union) (FACINGLCOVID-CM project). Adri an Carballo-Casla holds an FPI contract with the Universidad Autonoma de Madrid. The funding agencies played no role in study design, data collection, and analysis, interpretation of results, manuscript preparation, or in the decision to submit this manuscript for publicatio

Association between a Mediterranean lifestyle and growth differentiation factor 15: The seniors ENRICA-2 cohort

Background: Growth Differentiation Factor 15 (GDF-15) is a marker of inflammation and oxidative stress that has been associated with multiple age-related chronic diseases. Since lifestyle is key for preventing these adverse health outcomes, we examined the association between a Mediterranean lifestyle and GDF-15 serum concentrations in Spanish older adults. Methods: We used cross-sectional data from 2502 older adults participating in the Seniors ENRICA-2 cohort. Adherence to the Mediterranean lifestyle was assessed with the 27-item MEDLIFE index, divided into three blocks: 1) “Mediterranean food consumption, 2) Mediterranean dietary habits, 3) Physical activity, rest, social habits, and conviviality”. Analyses of the association between the MEFLIFE index and GDF-15 concentrations were performed using multivariable linear regression models adjusting for the main potential confounders. Results: The MEDLIFE index was inversely associated with GDF-15. Compared with participants in the lowest quartile of the MEDLIFE score, GDF-15 mean percentage differences (95% CI) were − 3.0% (− 8.0, 2.3) for the second quartile, − 8.7% (− 13.0, − 4.1) for the third quartile, and − 10.1% (− 15.0, − 4.9) for the fourth quartile (ptrend<0.001). Block 3 of MEDLIFE, and particularly doing sufficient physical activity, adequate sleep duration, and participating in collective sports, was individually linked to lower concentrations of GDF-15. Results remained similar after excluding participants with cardiovascular disease, type 2 diabetes, or obesity. Conclusions: A Mediterranean lifestyle was associated with reduced levels of GDF-15, suggesting that a combination of multiple lifestyles may be an integral approach to reduce chronic inflammation and disease burden in older adultsThis work was supported by the Institute of Health Carlos III; the Secretary of R+D+I; the European Regional Development Fund/European Social Fund (FIS grants 19/319, 20/00896); the National Plan on Drugs (grant 2020/17); Fundacion ´ Soria Melguizo (MITOFUN project); Ministry of Science, Innovation and Universities (RYC 2018-02069I to MSP); Universidad Autonoma ´ de Madrid (FPI contract to JMR); FACINGLCOVID-CM project, Funding REACT EU Program (Comunidad de Madrid, European Regional Development Fund). Reagents for measuring Growth Differentiation Factor 15 have been provided by Roche Diagnostics International through a Research Agreement with the FUAM (Fundacion ´ de la Universidad Autonoma ´ de Madrid). The funding agencies had no role in study design, data collection and analysis, interpretation of results, manuscript preparation or the decision to submit this manuscript for publicatio

The inflammatory potential of diet and pain incidence: a cohort study in older adults

This article has been accepted for publication in The Journals of Gerontology: Series A Published by Oxford University PressBackground: Pain is a highly prevalent and on-the-rise symptom with heavy associated healthcare and social burdens among older adults, yet evidence regarding its prevention is inadequate. The growing knowledge on how diet regulates inflammation may be utilized for pain prevention. Objective: To examine the association of 3-year changes in the inflammatory potential of diet (2008-2010 to 2012) with pain incidence over the subsequent 3 years (2012 to 2014-2015) among older adults. Methods: We used data from 820 individuals aged ≥60 years and free of pain in 2012, drawn from the Seniors-ENRICA cohort study in Spain. Food consumption was collected with a validated diet history, and the inflammatory potential of diet was estimated via the a priori empirical dietary inflammatory index (EDII) and the a posteriori dietary inflammatory index (DII). The frequency, severity (impact on daily activities), and number of locations of incident pain were combined into a scale that classified subjects as suffering from no pain, intermediate pain, and highest pain. The associations were summarized with relative risk ratios (RRR) and their 95% confidence interval (CI), estimated with multinomial logistic regression, and adjusted for potential sociodemographic, lifestyle, and morbidity confounders. Results: Shifting the diet towards a higher inflammatory potential was associated with a subsequent increased risk of intermediate pain [fully adjusted RRR (95% CI) per 1-point increment in the EDII=1.30 (1.03,1.65)] and highest pain [DII=1.14 (1.03,1.26)]. The three components of the pain scale followed similar trends, the most consistent one being with moderate-to-severe pain [EDII=1.26 (1.04,1.54); DII=1.12 (1.01,1.24)]. The association of increasing DII with highest incident pain was only apparent among the least physically active subjects [1.35 (1.17,1.56) vs 0.96 (0.83,1.10); p for interaction <0.001]. Conclusions: An increase in the inflammatory potential of diet was associated with higher pain incidence over the following years. Future studies in older adults should assess the efficacy of pain prevention interventions targeting the inflammatory potential of dietThe present study was supported by Instituto de Salud Carlos III, State Secretary of R+D+I and FEDER/FSE (FIS grants 16/1512, 18/287, and 19/319

Associations of physical activity type, volume, intensity, and changes over time with all-cause mortality in older adults: The Seniors-ENRICA cohorts

Objective: To assess the association of physical activity (PA) type, volume, intensity, and changes over time with all-cause mortality in older adults. Methods: We used data from 3518 and 3273 older adults recruited in the Seniors-ENRICA-1 and 2 cohorts. PA was assessed with the EPIC questionnaire. Participants reported how many hours they spent a week in walking, cycling, gardening, do-it-yourself (DIY), sports, and housework. Then, time at each intensity (moderate PA [MPA], vigorous PA [VPA], moderate-to-vigorous PA [MVPA] and total PA) was calculated. Changes in PA were calculated from the date of the baseline interview to Wave 1. All-cause mortality was ascertained up January 31, 2022. Analyses were performed with Cox regression models, adjusting for the main confounders. Results: Walking, gardening, sports, and housework was associated with lower mortality (ranged 20%–46%). Also, MPA, VPA, MVPA was associated with lower risk of mortality (ranged 28%–53%). Analyses of PA change showed that, compared no PA participation (at baseline nor Wave 1), maintain walking, sports, and housework (ranged 28%–53%) and maintaining MPA, VPA, and MVPA (ranged 32%–36%) levels was linked to decreased mortality risk. Those who increased, maintained, or even decreased total PA had lower mortality (57%, 52%, and 36%, respectively) than those with consistently very low PA. Conclusions: The lower mortality was observed in those with a high baseline level of total PA. Maintaining PA levels such as walking, gardening, and housework, or at all analyzed intensities, was related to lower mortalit

Plant-based diets and risk of frailty in community-dwelling older adults: the Seniors-ENRICA-1 cohort

Frailty is a geriatric syndrome that leads to increased risk of hospitalization, disability, and death. The effect of plant-based diets defined by the quality of their plant foods is unclear. Our objective is to study the association between two plant-based diet indices and the occurrence of frailty among community-dwelling older adults in Spain. We analyzed data from 1880 individuals aged ≥ 60 years from the Spanish Seniors ENRICA-1 cohort. We used a validated diet history to build two indices: (a) the healthful Plant-based Diet Index (hPDI) where healthy plant foods received positive scores, whereas less-healthy plant foods and animal foods received reverse scores; and (b) the unhealthful Plant-based Diet Index (uPDI), with positive scores to less-healthy plant foods and reverse scores to animal and healthy plant foods. Incident frailty was defined with the Fried phenotype. Study associations were summarized with odds ratios (OR) and 95% confidence intervals (CI) obtained from multivariable logistic models. After 3.3 years of follow-up, 136 incident frailty cases were ascertained. Comparing the highest vs. the lowest tertile of adherence, the OR [95% CI] for frailty was 0.43 (0.25–0.74; p-trend =.003) for the hPDI, and 2.89 (1.73–4.84; p-trend <.001) for the uPDI. Higher consumption of healthy plant foods was inversely associated with frailty (0.39 [0.23–0.66; p-trend < 0.001]); higher consumption of unhealthy plant foods was associated with higher frailty risk (2.40 [1.23–4.71; p-trend =.01]). In older adults, the hPDI was associated with lower risk of frailty, while the opposite was found for the uPDIOpen Access funding provided thanks to the CRUE-CSIC agreement with Springer Nature. This work was supported by the Institute of Health Carlos III; the Secretary of R+D+I; the European Regional Development Fund/European Social Fund (FIS grant numbers 19/319, 20/896, FI29/00162 to MDV); the National Plan on Drugs (grant number 2020/17); Fundación Soria Melguizo (MITOFUN project); Ministry of Science, Innovation and Universities (grant number RYC 2018- 02069I to MSP); Universidad Autónoma de Madrid (FPI contract to ACC). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscrip

Mediterranean lifestyle index and 24-h systolic blood pressure and heart rate in community-dwelling older adults

Specifc foods, nutrients, dietary patterns, and physical activity are associated with lower blood pressure (BP) and heart rate (HR), but little is known about the joint efect of lifestyle factors captured in a multidimensional score. We assessed the association of a validated Mediterranean-lifestyle (MEDLIFE) index with 24-h-ambulatory BP and HR in everyday life among community-living older adults. Data were taken from 2,184 individuals (51% females, mean age: 71.4 years) from the SeniorsENRICA-2 cohort. The MEDLIFE index consisted of 29 items arranged in three blocks: 1) Food consumption; 2) Dietary habits; and 3) Physical activity, rest, and conviviality. A higher MEDLIFE score (0–29 points) represented a better Mediterranean lifestyle adherence. 24-h-ambulatory BP and HR were obtained with validated oscillometric devices. Analyses were performed with linear regression adjusted for the main confounders. The MEDLIFEhighest quintile (vs Q1) was associated with lower nighttime systolic BP (SBP) (-3.17 mmHg [95% CI: -5.25, -1.08]; p-trend=0.011), greater nocturnal-SBP fall (1.67% [0.51, 2.83]; p-trend=0.052), and lower HR (-2.04 bpm [daytime], -2.33 bpm [nighttime], and -1.93 bpm [24-h]; all p-trend<0.001). Results were similar for each of the three blocks of MEDLIFE and by hypertension status (yes/no). Among older adults, higher adherence to MEDLIFE was associated with lower nighttime SBP, greater nocturnal-SBP fall, and lower HR in their everyday life. These results suggest a synergistic BP-related protection from the components of the Mediterranean lifestyle. Future studies should determine whether these results replicate in older adults from other Mediterranean and non-Mediterranean countriesThis work was supported by FIS grants 19/319, 20/00896, and 22/1164 from the Carlos III Health Institute, the Secretary of R+D+I, and the European Regional Development Fund/European Social Fund; and by International; REACT EU Program. Comunidad de Madrid and European Regional Development Fund (ERDF), European Union: FACINGLCOVID-CM project, Comunidad de Madrid and European Regional Development Fund (ERDF), European Union. MSP holds a Ramón y Cajal contract (RYC2018–025069-I) from the Spanish Ministry of Science, Innovation and Universitie

Alcohol consumption patterns and unhealthy aging among older lifetime drinkers from Spain

Background: The protective health effects of light alcohol consumption are debated due to potential selection biases, reverse causation and confounding. We examined cross-sectional and prospective associations of alcohol consumption patterns with unhealthy aging among older drinkers addressing these methodological issues. Methods: 2081 lifetime drinkers aged 65 + years from the Seniors-ENRICA-2 cohort followed-up for 2.4 years were classified as occasional (average lifetime alcohol intake [g/day] ≤1.43), low-risk (men: >1.43–20; women: >1.43–10), moderate-risk (men: >20–40; women: >10–20) and high-risk drinkers (men: >40; women: >20; or binge drinkers). A Mediterranean drinking pattern (MDP) was defined as occasional/low-risk drinking, wine preference and drinking only with meals. Unhealthy aging was measured with a 52-item health deficit accumulation index (DAI), with higher values indicating more health deficits. Results: A 10-g/day increment in lifetime average alcohol intake was cross-sectionally associated with a higher DAI among all drinkers (mean difference [95% confidence interval] = 0.35 [0.16, 0.53]) and moderate-/high-risk drinkers (0.41 [0.17, 0.65]), but not among occasional/low-risk drinkers. Also, the DAI was 1.35 (0.06, 2.65) points higher in high-risk versus low-risk drinkers and 2.07 (0.59, 3.60) points higher in non-adherers versus adherers to the MDP. Most associations strengthened when restricting analyses to individuals with lower disease burden and did not generally remain after 2.4 years. Conclusions: We found no evidence of a beneficial association between low-risk alcohol consumption and unhealthy aging, but a detrimental one for high-risk drinking, which strengthened when accounting for reverse causation, although attenuated over the follow-up likely due to selective attrition of those less resilient to the harmful effects of alcoholThis work was supported by the Plan Nacional sobre Drogas, Ministry of Health of Spain, Spain (grant 2020/17), Instituto de Salud Carlos III, State Secretary of R+D+I and FEDER/FSE, Spain (FIS grants 18/287, 19/319), the Fundacion ´ Francisco Soria Melguizo, Spain (MITOFUN project grant) and the REACT EU Program, Comunidad de Madrid, Spain and the European Regional Development Fund (ERDF), European Union (FACINGLCOVID-CM project). Adrian ´ Carballo-Casla has an FPI contract from the Universidad Autonoma ´ de Madrid. Mercedes Sotos-Prieto holds a Ramon ´ y Cajal contract (RYC-2018–025069-I) from the Ministry of Science, Innovation and Universities. Reagents for measuring Growth Differentiation Factor 15 have been provided by Roche Diagnostics International through a Research Agreement with the FUAM (Fundacion ´ de la Universidad Autonoma ´ de Madrid). The funding agencies had no role in study design, data collection and analysis, interpretation of results, manuscript preparation or the decision to submit this manuscript for publicatio

Alcohol consumption patterns and growth differentiation factor 15 among life-time drinkers aged 65+ years in Spain: a cross-sectional study

Aims: To examine the association of alcohol consumption patterns with growth differentiation factor 15 (GDF-15) in older drinkers, separately among individuals with cardiovascular disease (CVD)/diabetes and those without them, as GDF-15 is a strong biomarker of chronic disease burden. Design: Cross-sectional study. Setting: Population-based study in Madrid (Spain). Participants: A total of 2051 life-time drinkers aged 65+ years included in the Seniors-ENRICA-2 study in 2015–17. Participants’ mean age was 71.4 years and 55.4% were men. Measurements: According to their average life-time alcohol intake, participants were classified as occasional (≤ 1.43 g/day), low-risk (men: > 1.43–20 g/day; women: > 1.43–10 g/day), moderate-risk (men: > 20–40 g/day; women: > 10–20 g/day) and high-risk drinkers (men: > 40 g/day; women: > 20 g/day; or binge drinkers). We also ascertained wine preference (> 80% of alcohol derived from wine), drinking with meals and adherence to a Mediterranean drinking pattern (MDP) defined as low-risk drinking, wine preference and one of the following: drinking only with meals; higher adherence to the Mediterranean diet; or any of these. Findings: In participants without CVD/diabetes, GDF-15 increased by 0.27% [95% confidence interval (CI) = 0.06%, 0.48%] per 1 g/day increment in alcohol among high-risk drinkers, but there was no clear evidence of association in those with lower intakes or in the overall group, or across categories of alcohol consumption status. Conversely, among those with CVD/diabetes, GDF-15 rose by 0.19% (95% CI = 0.05%, 0.33%) per 1 g/day increment in the overall group and GDF-15 was 26.89% (95% CI = 12.93%, 42.58%) higher in high-risk versus low-risk drinkers. Drinking with meals did not appear to be related to GDF-15, but among those without CVD/diabetes, wine preference and adherence to the MDP were associated with lower GDF-15, especially when combined with high adherence to the Mediterranean diet. Conclusions: Among older life-time drinkers in Madrid, Spain, high-risk drinking was positively associated with growth differentiation factor 15 (a biomarker of chronic disease burden). There was inconclusive evidence of a beneficial association for low-risk consumptionFundacion Francisco Soria Melguizo, Grant/ Award Number: MITOFUN project; Instituto de Salud Carlos III, State Secretary of R+D+I and FEDER/FSE, Grant/Award Numbers: 16/ 1512, 16/609, 18/287, 19/319; Plan Nacional sobre Drogas, Ministry of Health of Spain, Grant/Award Number: 2020/17; Roche Diagnostics International; REACT EU Program, Comunidad de Madrid and European Regional Development Fund (ERDF), European Union: FACINGLCOVID-CM project, Comunidad de Madrid and European Regional Development Fund (ERDF), European Union; Universidad Autonoma de Madrid; Ministry of Science, Innovation and Universities, Grant/Award Number: RYC-2018-025069-

Association between the Mediterranean lifestyle, metabolic syndrome and mortality: a whole-country cohort in Spain

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliationsBackground: Evidence is limited about the joint health effects of the Mediterranean lifestyle on cardiometabolic health and mortality. The aim of this study was to evaluate the association of the Mediterranean lifestyle with the frequency of the metabolic syndrome (MS) and the risk of all‑cause and cardiovascular mortality in Spain. Methods: Data were taken from ENRICA study, a prospective cohort of 11,090 individuals aged 18 + years, representative of the population of Spain, who were free of cardiovascular disease (CVD) and diabetes at 2008–2010 and were followed‑up to 2017. The Mediterranean lifestyle was assessed at baseline with the 27‑item MEDLIFE index (with higher score representing better adherence). Results: Compared to participants in the lowest quartile of MEDLIFE, those in the highest quartile had a multivariable‑adjusted odds ratio 0.73 (95% confidence interval (CI) 0.5, 0.93) for MS, 0.63. (0.51, 0.80) for abdominal obesity, and 0.76 (0.63, 0.90) for low HDL‑cholesterol. Similarly, a higher MELDIFE score was associated with lower HOMA‑IR and highly‑sensitivity C‑reactive protein (P‑trend < 0.001). During a mean follow‑up of 8.7 years, 330 total deaths (74 CVD deaths) were ascertained. When comparing those in highest vs. lowest quartile of MEDLIFE, the multivariable‑adjusted hazard ratio (95% CI) was 0.58 (0.37, 0.90) for total mortality and 0.33 (0.11, 1.02) for cardiovascular mortality. Conclusions: The Mediterranean lifestyle was associated with lower frequency of MS and reduced all‑cause mortality in Spain. Future studies should determine if this also applies to other Mediterranean countries, and also improve cardiovascular health outside the Mediterranean basinThis work was supported by FIS grants 16/609, 16/1512, 18/287, 19/319 and PI20/00896 (Instituto de Salud Carlos III, State Secretary of R+D+I and FEDER/FSE), the Salamander Project (JPI-A Healthy Diet for a Healthy Life, State Secretary of R+D+I PCIN-2016-145), and the Cátedra de Epidemiología y Control del Riesgo Cardiovascular at UAM (#820024). Mercedes Sotos Prieto holds a Ramón y Cajal contract (RYC-2018-025069-I) from the Ministry of Science, Innovation and Universities and FEDER/FSE. The funding agencies had no role in study design, data collection and analysis, interpretation of results, manuscript preparation or in the decision to submit this manuscript for publicatio

Cambios en los comportamientos de salud, salud mental y física entre los adultos mayores bajo severas restricciones de confinamiento durante la pandemia de COVID-19 en España

We used data from 3041 participants in four cohorts of community-dwelling individuals aged ≥65 years in Spain collected through a pre-pandemic face-to-face interview and a telephone interview conducted between weeks 7 to 15 after the beginning of the COVID-19 lockdown. On average, the confinement was not associated with a deterioration in lifestyle risk factors (smoking, alcohol intake, diet, or weight), except for a decreased physical activity and increased sedentary time, which reversed with the end of confinement. However, chronic pain worsened, and moderate declines in mental health, that did not seem to reverse after restrictions were lifted, were observed. Males, older adults with greater social isolation or greater feelings of loneliness, those with poorer housing conditions, as well as those with a higher prevalence of chronic morbidities were at increased risk of developing unhealthier lifestyles or mental health declines with confinement. On the other hand, previously having a greater adherence to the Mediterranean diet and doing more physical activity protected older adults from developing unhealthier lifestyles with confinement. If another lockdown were imposed during this or future pandemics, public health programs should specially address the needs of older individuals with male sex, greater social isolation, sub-optimal housing conditions, and chronic morbidities because of their greater vulnerability to the enacted movement restrictionsThe Seniors-ENRICA-2 study was supported by Instituto de Salud Carlos III (Spain), State Secretary of R+D+I and FEDER/FSE research grants PI16/609, PI18/287, and 19/319; CIBERESP (16/01); and Cátedra de Epidemiología y Control del Riesgo Cardiovascular at UAM (#820024). ELS was supported by a Juan de la Cierva Contract from the Ministy of Universities. DMG and MSP were supported by supported by a “Ramon y Cajal”contract. Edad con Salud was funded by the Seventh Framework Programme (grant number 223071-COURAGE Study); the Insti tuto de Salud Carlos III (grants number PS09/00295(JMH), PS09/01845 (JLA), PI12/01490 (JMH), PI13/00059 (JLA), PI16/00212 (JMH), PI16/00218 (MM), PI16/01073 (JLA)); the European Regional Development Fund (ERDF) “A Way to Build Europe” (grant numbers PI12/01490, PI13/00059, PI16/00212 and PI16/01073);and CIBERSAM. EL was supported by the Sara Borrell postdoctoral programme (CD18/00099) from the Instituto de Salud Carlos III and co-funded by the European Union (FEDER/FSE, “Investing in your future”). BO was supported by the Miguel Servet programme (reference CP20/00040), funded by Instituto de Salud Carlos III and co-funded by European Union (ERDF/ESF, "Investing in your future"). The Toledo Study for Healthy Ageing was funded by the Spanish Ministry of Economy, Industry and Competitiveness, cofinanced by FEDER (RD120001/0043), CIBERFES (CB16/10/00464) and DIABFRAIL-LATAM (contract number 825546, Horizon 2020). The Elderly EXERNET multicenter study was supported by the Ministerio de Economía, Industria y Competitividad (DEP2016-78309-R (GVR)), the Ministerio de Educación y Ciencia (Red EXERNET DEP2005-00046 JAC)), the High Council of Sports (Consejo Superior de Deportes) of the Ministe rio de Cultura y Deportes (09/UPB/19 (JAC) and 45/UPB/20 (JAC)), CIBERFES, the 4IE+ project (0499_4IE_PLUS_4_E (NG)) funded by the Interreg V-A España-Portugal (POCTEP) 2014-2020 pro gram, and FEDER funds from the European Union (CB16/10/00477 (IA)). The funding agencies had no role in study design, data collection and analysis, interpretation of results, manuscript preparation or the decision to submit this manuscript for publicatio