The Southern European Atlantic Diet index – definition and effects on cardiovascular health

Andreia Oliveira

Department of Clinical Epidemiology, Predictive Medicine and Public Health, Medical School

Institute of Public Health | University of Porto

Bristol | October 18, 2011

Methodological approaches to study Diet

Adapted from: Schulze et al. Br J Nutr 2006; 95: 860-69

Hypothesis-oriented approach(a priori knowledge)

Indexes and scores

defined a priori

Principal component analysisFactor analysisCluster analysis

Exploratory approach(data at hand)

defined a posteriori

Single nutrients/ foods Dietary Patterns

Mediterranean Diet Score (MDS)Mediterranean Adequacy Index (MAI)

Mediterranean dietary pattern

Healthy Diet Indicator (HDI) Healthy Food Index (HFI)

Euro

pe

Portuguese Household’s Budget Surveys

1989/1990: n=12 403

1994/1995: n=10 554

2000/2001: n=10 020

Adherence to a Mediterranean diet was poor in all Portuguese regions …

Atlantic Diet

“Diet characteristic of regions with a straight link with the Atlantic Ocean sharing a specific high consumption of fish and other sea foods, red meats, vegetables and whole foods, and wine consumption during meals”

Atla

ntic

Oce

anMediterranean Sea

European Center of Atlantic Diet, Viana do Castelo, Portugal 2001Varela G et al, Madrid 2004Fundación Española de la Nutrición, Marid 2003, 2005

Objectives

To define the Southern European Atlantic Diet (SEAD) index.

To evaluate the association of this index with the occurrence of non-fatal acute myocardial infarction id adults from Porto, Portugal.

Cases

Patients admitted consecutively to the Cardiology Department of the four hospitals providing acute coronary care in Porto (1999-2003), with a first diagnosis of acute myocardial infarction (AMI) (n=820).

- Who had no previous clinical or silent infarction (n=2196) Controls

Community participants aged ≥ 18 years

Baseline evaluation of the EPIPorto cohort (1999-2003)

EPICardis study – a population-based case-control study

Age | Education | Marital status | Occupational activityAge | Education | Marital status | Occupational activity

Social and demographic characteristicsSocial and demographic characteristics

Dislipidemia | Diabetes | Hypertension | Personal history of cardiovascular diseasesFamily history of acute myocardial infarction | Use of medication | Gynecological historyDislipidemia | Diabetes | Hypertension | Personal history of cardiovascular diseasesFamily history of acute myocardial infarction | Use of medication | Gynecological history

Personal and family medical historyPersonal and family medical history

Data collection [by questionnaire and physical examination]

Mini-Mental State Examination test [in those ≥ 65 years; subjects excluded when scoring < 24 points]

Smoking status | Physical activity | Diet Smoking status | Physical activity | Diet

LifestylesLifestyles

(http://higiene.med.up.pt/freq.php)

Food Frequency Questionnaire [previous 12 months]

Adapted software Food Processor Plus (ESHA Research, Salem-Oregon, 1997)

Lopes C, et al. J Am Diet Assoc 2007; 107: 276-86; Lopes C. [PhD thesis in Portuguese]. University of Porto; 2000

Food components and scoring of the Southern European Atlantic Diet (SEAD) index

< median a median a

1. Fresh fish 0 1

2. Cod fish 0 1

3. Red meat and pork products 0 1

4. Dairy products 0 1

5. Legumes and vegetables 0 1

6. Vegetable soup 0 1

7. Potatoes 0 1

8. Whole grain bread 0 1

0 or >1 glass/day (W)

0 or >2 glasses/day (M)

>0 and 1 glass/day (W)

>0 and 2 glasses/day (M)

9. Wine b 0 1

a Sex-specific medians in the controls were used as threshold for all food components, except wine.

b Each glass containing 125 ml of wine. W: women; M: men

Possible range score: 0 to 9

Food consumption adjusted for energy intake by the energy density model: grams per 1000 kcal/day

OR=0.67 (0.51-0.88)

Quartile 1

≤ 3 points

[lower adherence]

Quartile 3

5 points

Quartile 4

≥ 6 points

[higher adherence]

Quartile 2

4 points

p-trend=0.003 ↓ 33%

* Odds ratio adjusted for sex, age, education, total energy intake, fruits, refined cereals, white meat, smoking status, regular physical activity, family history of infarction, body mass index, and menopause and hormone replacement therapy in women.

Sensitivity analyses

Sex-specific quartiles of

food consumption

Frequency of

food consumption

Quartile 1a Quartile 2 Quartile 3 Quartile 4 < 1

time/week

1-6

times/week Daily

1. Fresh fish 1 2 3 4 1 2 3

2. Cod fish 1 2 3 4 1 2 3

3. Red meat and pork 1 2 3 4 1 2 3

4. Dairy products 1 2 3 4 1 2 3

5. Legumes and vegetables 1 2 3 4 1 2 3

6. Vegetable soup 1 2 3 4 1 2 3

7. Potatoes 1 2 3 4 1 2 3

8. Whole grain bread 1 2 3 4 1 2 3

0 or >1 (W)

0 or >2 (M)

>0 and 1 (W)

>0 and 2 (M)

0 or >1 (W)

0 or >2 (M)

>0 and 1 (W)

>0 and 2 (M)

9. Wine b 0 1 0 1

SEAD scoring based on: upper vs. 1st quartile p-trend

Sex-specific quartiles of food consumption OR=0.61 (0.46-0.80) <0.001Frequency of food consumption OR=0.58 (0.43-0.79) <0.001

a Sex-specific quartiles in the controls were used as threshold for all food components, except wine. b Each glass containing 125 ml of wine. W: women; M: men

< median a median a

1. Fresh fish 0 1

2. Cod fish 0 1

3. Red meat and pork products 1 0

4. Dairy products 0 1

5. Legumes and vegetables 0 1

6. Vegetable soup 0 1

7. Potatoes 1 0

8. Whole grain bread 0 1

0 or >1 glass/day (W)

0 or >2 glasses/day (M)

>0 and 1 glass/day (W)

>0 and 2 glasses/day (M)

9. Wine b 0 1

Additional analyses: reverse scoring for red meat and pork products + potatoes

a Sex-specific medians in the controls were used as threshold for all food components, except wine.

b Each glass containing 125 ml of wine. W: women; M: men

Reverse scoring for: upper vs. 1st quartile p-trend

Red meat and pork and potatoes OR=0.40 (0.30-0.52) <0.001Red meat and pork OR=0.45 (0.34-0.60) <0.001

Conclusions

A higher adherence to the Southern European Atlantic diet (SEAD index), culturally rooted in Northern Portugal and Galicia, was associated with a lower occurrence of non-fatal AMI events.

The reduction in consumption of potatoes, and particularly of red meat and pork products, might increase the benefit of the SEAD on coronary heart disease.

SEAD might contribute to the very low coronary mortality traditionally registered in northern Portugal and Galicia.

PhD grant from Fundação para a Ciência e a Tecnologia [SFRH/BD/31131/2006]

Research work developed at the Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School and the Public Health Institute, University of Porto