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 Single nutrients/ foods Dietary Patterns defined a priori defined a posteriori Hypothesis-oriented approach (a priori knowledge) Exploratory approach (data at hand) Indexes and scores Principal component analysis Factor analysis Cluster analysis Mediterranean Diet Score (MDS) Mediterranean Adequacy Index (MAI) Mediterranean dietary pattern Healthy Diet Indicator (HDI) Healthy Food Index (HFI) Europe Adapted from: Schulze et al. Br J Nutr 2006; 95: 860-69

Adherence to a Mediterranean diet was poor in all Portuguese regions … 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” Atlantic Ocean Mediterranean Sea European Center of Atlantic Diet, Viana do Castelo, Portugal 2001 Varela G et al, Madrid 2004 Fundación 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.

EPICardis study – a population-based case-control study 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). Community participants aged ≥ 18 years Baseline evaluation of the EPIPorto cohort (1999-2003) - Who had no previous clinical or silent infarction (n=2196) Controls

Data collection [by questionnaire and physical examination] Mini-Mental State Examination test [in those ≥ 65 years; subjects excluded when scoring < 24 points] Age | Education | Marital status | Occupational activity Social and demographic characteristics Dislipidemia | Diabetes | Hypertension | Personal history of cardiovascular diseases Family history of acute myocardial infarction | Use of medication | Gynecological history Personal and family medical history   Smoking status | Physical activity | Diet Lifestyles

Food Frequency Questionnaire [previous 12 months] (http://higiene.med.up.pt/freq.php) 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

 Possible range score: 0 to 9 Food components and scoring of the Southern European Atlantic Diet (SEAD) index 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

↓ 33% p-trend=0.003 OR=0.67 (0.51-0.88) Quartile 1 ≤ 3 points [lower adherence] Quartile 2 4 points Quartile 3 5 points Quartile 4 ≥ 6 points [higher adherence] * 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 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 SEAD scoring based on: upper vs. 1st quartile p-trend Sex-specific quartiles of food consumption OR=0.61 (0.46-0.80) <0.001 Frequency of food consumption OR=0.58 (0.43-0.79) <0.001

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) <0.001 Red 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.

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