Adherence to a priori dietary indexes and baseline prevalence of cardiovascular risk factors in the PREDIMED-Plus randomised trial

Abstract

Purpose

Cardiovascular disease remains the global leading cause of death. We evaluated at baseline the association between the adherence to eight a priori high-quality dietary scores and the prevalence of individual and clustered cardiovascular risk factors (CVRF) in the PREDIMED-Plus cohort.

Methods

All PREDIMED-Plus participants (6874 men and women aged 55–75 years, with overweight/obesity and metabolic syndrome) were assessed. The prevalence of 4 CVRF (hypertension, obesity, diabetes, and dyslipidaemia), using standard diagnoses criteria, were considered as outcomes. The adherence to eight a priori-defined dietary indexes was calculated. Multivariable models were fitted to estimate differences in mean values of factors and prevalence ratios for individual and clustered CVRF.

Results

Highest conformity to any dietary pattern did not show inverse associations with hypertension. The modified Mediterranean Diet Score (PR = 0.95; 95% CI 0.90–0.99), Mediterranean Diet Adherence Score (MEDAS) (PR = 0.94; 95% CI 0.89–0.98), the pro-vegetarian dietary pattern (PR = 0.95; 95% CI 0.90–0.99) and the Alternate Healthy Eating Index 2010 (PR = 0.92; 95% CI 0.87–0.96) were inversely associated with prevalence of obesity. We identified significant inverse trend among participants who better adhered to the MEDAS and the Prime Diet Quality Score (PDQS) in the mean number of CVRF across categories of adherence. Better adherence to several high-quality dietary indexes was associated with better blood lipid profiles and anthropometric measures.

Conclusions

Highest adherence to dietary quality indexes, especially Mediterranean-style and PDQS scores, showed marginal associations with lower prevalence of individual and clustered CVRF among elderly adults with metabolic syndrome at high risk of cardiovascular disease

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References

  1. 1.

    Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G et al (2013) Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. J Am Coll Cardiol 70:1–25

    Article  Google Scholar 

  2. 2.

    Greenland P, Knoll MD, Stamler J, Neaton JD, Dyer AR, Garside DB et al (2003) Major risk factors as antecedents of fatal and nonfatal coronary heart disease events. JAMA 290:891–897

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F et al (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 364:937–952

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Rigotti NA, Clair C (2013) Managing tobacco use: the neglected cardiovascular disease risk factor. Eur Heart J 34:3259–3267

    Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Lloyd-Jones DM, Leip EP, Larson MG, D’Agostino RB, Beiser A, Wilson PW et al (2006) Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 113:791–798

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Berry JD, Dyer A, Cai X, Garside DB, Ning H, Thomas A et al (2012) Lifetime risks of cardiovascular disease. N Eng J Med 366:321–329

    Article  CAS  Google Scholar 

  7. 7.

    Banegas JR, Graciani A, Guallar-Castillón P, León-Muñoz LM, Gutiérrez-Fisac JL, López-García E, et al (2011) Estudio de Nutrición y Riesgo Cardiovascular en España (ENRICA). Universidad Autónoma de Madrid. http://www.isfie.org/documentos/estudio_enrica.pdf. Accessed 12 Mar 2019

  8. 8.

    Guallar-Castillón P, Pérez RF, López García E, León-Muñoz LM, Aguilera MT, Graciani A et al (2014) Magnitude and management of metabolic syndrome in Spain in 2008–2010: the ENRICA study. Rev Esp Cardiol 67:367–373

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Jacobs DR Jr, Steffen LM (2003) Nutrients, foods, and dietary patterns as exposures in research: a framework for food synergy. Am J Clin Nutr 78(3 Suppl):508S–513S

    Article  CAS  Google Scholar 

  10. 10.

    Schulze MB, Hoffmann K (2006) Methodological approaches to study dietary patterns in relation to risk of coronary heart disease and stroke. Br J Nutr 95:860–869

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Willett WC, McCullough ML (2008) Dietary pattern analysis for the evaluation of dietary guidelines. Asia Pac J Clin Nutr 17:75–78

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Trichopoulos D, Lagiou P (2004) Mediterranean diet and cardiovascular epidemiology. Eur J Epidemiol 19:7–8

    CAS  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Pimenta AM, Toledo E, Rodriguez-Diez MC, Gea A, Lopez-Iracheta R, Shivappa N et al (2015) Dietary indexes, food patterns and incidence of metabolic syndrome in a Mediterranean cohort: the SUN project. Clin Nutr 34:508–514

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. 14.

    George SM, Ballard-Barbash R, Manson JE, Reedy J, Shikany JM, Subar AF et al (2014) Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women’s Health Initiative Observational Study: evidence to inform national dietary guidance. Am J Epidemiol 180:616–625

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Harmon BE, Boushey CJ, Shvetsov YB, Ettienne R, Reedy J, Wilkens LR et al (2015) Associations of key diet-quality indexes with mortality in the multiethnic cohort: the dietary patterns methods project. Am J Clin Nutr 101:587–597

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Liese AD, Krebs-Smith SM, Subar AF, George SM, Harmon BE, Neuhouser ML et al (2015) The dietary patterns methods project: synthesis of findings across cohorts and relevance to dietary guidance. J Nutr 145:393–402

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Jacobs S, Boushey CJ, Franke AA, Shvetsov YB, Monroe KR, Haiman CA et al (2017) A priori-defined diet quality indices, biomarkers and risk for type 2 diabetes in five ethnic groups: the Multiethnic Cohort. Br J Nutr 118:312–320

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Martínez-González MA, Buil-Cosiales P, Corella D, Bulló M, Fitó M, Vioque J et al (2018) Cohort profile: design and methods of the PREDIMED-Plus randomized trial. Int J Epidemiol. https://doi.org/10.1093/ije/dyy225

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Alberti KG, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA et al (2009) Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 120:1640–1645

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Willett W (2013) Nutritional epidemiology, 3rd edn. Oxford University Press, New York, p 306

    Google Scholar 

  21. 21.

    Martin-Moreno JM, Boyle P, Gorgojo L, Maisonneuve P, Fernandez-Rodriguez JC, Salvini S et al (1993) Development and validation of a food frequency questionnaire in Spain. Int J Epidemiol 22:512–519

    Article  CAS  Google Scholar 

  22. 22.

    Fernández-Ballart JD, Piñol JL, Zazpe I, Corella D, Carrasco P, Toledo E et al (2010) Relative validity of a semi-quantitative food-frequency questionnaire in an elderly Mediterranean population of Spain. Br J Nutr 103:1808–1816

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. 23.

    de la Fuente-Arrillaga C, Ruiz ZV, Bes-Rastrollo M, Sampson L, Martinez-González MA (2010) Reproducibility of an FFQ validated in Spain. Public Health Nutr 13:1364–1372

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Trichopoulou A, Costacou T, Bamia C, Trichopoulos D (2003) Adherence to a Mediterranean diet and survival in a Greek population. N Eng J Med 348:2599–2608

    Article  Google Scholar 

  25. 25.

    Benítez-Arciniega AA, Mendez MA, Baena-Díez JM, Rovira Martori MA, Soler C, Marrugat J et al (2011) Concurrent and construct validity of Mediterranean diet scores as assessed by an FFQ. Public Health Nutr 14:2015–2021

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Schröder H, Fitó M, Estruch R, Martínez-González MA, Corella D, Salas-Salvadó J et al (2011) A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women. J Nutr 141:1140–1145

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Martínez-González MA, Sánchez-Tainta A, Corella D, Salas-Salvadó J, Ros E, Arós F et al (2014) A provegetarian food pattern and reduction in total mortality in the Prevención con Dieta Mediterránea (PREDIMED) study. Am J Clin Nutr 100(Suppl 1):320S–328S

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Chiuve SE, Fung TT, Rimm EB, Hu FB, McCullough ML, Wang M et al (2012) Alternative dietary indices both strongly predict risk of chronic disease. J Nutr 142:1009–1018

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Zazpe I, Santiago S, Gea A, Ruiz-Canela M, Carlos S, Bes-Rastrollo M et al (2016) Association between a dietary carbohydrate index and cardiovascular disease in the SUN (Seguimiento Universidad de Navarra) Project. Nutr Metab Cardiovasc Dis 26:1048–1056

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Fung TT, Isanaka S, Hu FB, Willett WC (2018) International food group-based diet quality and risk of coronary heart disease in men and women. Am J Clin Nutr 107:120–129

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Molina L, Sarmiento M, Peñafiel J, Donaire D, Garcia-Aymerich J, Gomez M et al (2017) Validation of the Regicor Short Physical Activity Questionnaire for the adult population. PLoS One 12:e0168148

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. 32.

    American Diabetes Association (2017) Classification and diagnosis of diabetes. Sec. 2. In Standards of Medical Care in Diabetes—2017. Diabetes Care 40:S11–S40

    Article  Google Scholar 

  33. 33.

    National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (2002) Third Report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 106:3143–3421

    Article  Google Scholar 

  34. 34.

    Zhang J, Yu KF (1998) What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 280:1690–1691

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Newson RB (2010) Frequentist q-values for multiple-test procedures. Stata J 10:568–584

    Article  Google Scholar 

  36. 36.

    Chong S, Ding D, Byun R, Comino E, Bauman A, Jalaludin B (2017) Lifestyle changes after a diagnosis of type 2 diabetes. Diabetes Spectr 30:43–50

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Castro-Sánchez AE, Ávila-Ortíz MN (2013) Changing dietary habits in persons living with type 2 diabetes. J Nutr Educ Behav 45:761–766

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Ball L, Davmor R, Leveritt M, Desbrow B, Ehrlich C, Chaboyer W (2016) Understanding the nutrition care needs of patients newly diagnosed with type 2 diabetes: a need for open communication and patient-focussed consultations. Aust J Prim Health 22:416–422

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Burch E, Ball L, Somerville M, Williams LT (2018) Dietary intake by food group of individuals with type 2 diabetes mellitus: a systematic review. Diabetes Res Clin Pract 137:160–172

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Toledo E, Hu FB, Estruch R, Buil-Cosiales P, Corella D, Salas-Salvadó J et al (2013) Effect of the Mediterranean diet on blood pressure in the PREDIMED trial: results from a randomized controlled trial. BMC Med 11:207

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Ndanuko RN, Tapsell LC, Charlton KE, Neale EP, Batterham MJ (2016) Dietary patterns and blood pressure in adults: a systematic review and meta-analysis of randomized controlled trials. Adv Nutr 7:76–89

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Davis CR, Hodgson JM, Woodman R, Bryan J, Wilson C, Murphy KJ (2017) A Mediterranean diet lowers blood pressure and improves endothelial function: results from the MedLey randomized intervention trial. Am J Clin Nutr 105:1305–1313

    CAS  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Medina-Remón A, Tresserra-Rimbau A, Pons A, Tur JA, Martorell M, Ros E et al (2015) Effects of total dietary polyphenols on plasma nitric oxide and blood pressure in a high cardiovascular risk cohort. The PREDIMED randomized trial. Nutr Metab Cardiovasc Dis 25:60–67

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Storniolo CE, Casillas R, Bulló M, Castañer O, Ros E, Sáez GT et al (2017) A Mediterranean diet supplemented with extra virgin olive oil or nuts improves endothelial markers involved in blood pressure control in hypertensive women. Eur J Nutr 56:89–97

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Martínez-González MA, García-Arellano A, Toledo E, Salas-Salvadó J, Buil-Cosiales P, Corella D et al (2012) A 14-item Mediterranean diet assessment tool and obesity indexes among high-risk subjects: the PREDIMED trial. PLoS One 7:e43134

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. 46.

    Agnoli C, Sieri S, Ricceri F, Giraudo MT, Masala G, Assedi M et al (2018) Adherence to a Mediterranean diet and long-term changes in weight and waist circumference in the EPIC-Italy cohort. Nutr Diabetes 8:22

    Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Asghari G, Mirmiran P, Yuzbashian E, Azizi F (2017) A systematic review of diet quality indices in relation to obesity. Br J Nutr 117:1055–1065

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Razquin C, Sanchez-Tainta A, Salas-Salvadó J, Buil-Cosiales P, Corella D, Fito M et al (2017) Dietary energy density and body weight changes after 3 years in the PREDIMED study. Int J Food Sci Nutr 68:865–872

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Howarth NC, Saltzman E, Roberts SB (2001) Dietary fiber and weight regulation. Nutr Rev 59:129–139

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. 50.

    Peñalvo JL, Oliva B, Sotos-Prieto M, Uzhova I, Moreno-Franco B, León-Latre M et al (2015) Greater adherence to a Mediterranean dietary pattern is associated with improved plasma lipid profile: the Aragon Health Workers Study cohort. Rev Esp Cardiol (Engl Ed) 68:290–297

    Article  Google Scholar 

  51. 51.

    Solá R, Fitó M, Estruch R, Salas-Salvadó J, Corella D, de La Torre R et al (2011) Effect of a traditional Mediterranean diet on apolipoproteins B, A-I, and their ratio: a randomized, controlled trial. Atherosclerosis 218:174–180

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. 52.

    Damasceno NR, Sala-Vila A, Cofán M, Pérez-Heras AM, Fitó M, Ruiz-Gutiérrez V et al (2013) Mediterranean diet supplemented with nuts reduces waist circumference and shifts lipoprotein subfractions to a less atherogenic pattern in subjects at high cardiovascular risk. Atherosclerosis 230:347–353

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Esposito K, Chiodini P, Maiorino MI, Bellastella G, Panagiotakos D, Giugliano D (2014) Which diet for prevention of type 2 diabetes? A meta-analysis of prospective studies. Endocrine 47:107–116

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. 54.

    Ley SH, Hamdy O, Mohan V, Hu FB (2014) Prevention and management of type 2 diabetes: dietary components and nutritional strategies. Lancet 383:1999–2007

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. 55.

    Salas-Salvadó J, Guasch-Ferré M, Lee CH, Estruch R, Clish CB, Ros E (2016) Protective effects of the Mediterranean diet on type 2 diabetes and metabolic syndrome. J Nutr 146:920S–927S

    Article  CAS  Google Scholar 

  56. 56.

    Hébert JR (2016) Social desirability trait: biaser or driver of self-reported dietary intake? J Acad Nutr Diet 116:1895–1898

    Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    Sánchez-Taínta A, Estruch R, Bulló M, Corella D, Gómez-Gracia E, Fiol M et al (2008) Adherence to a Mediterranean-type diet and reduced prevalence of clustered cardiovascular risk factors in a cohort of 3,204 high-risk patients. Eur J Cardiovasc Prev Rehabil 15:589–593

    Article  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB (2011) The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol 57:1299–1313

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  59. 59.

    Hosseini Z, Whiting SJ, Vatanparast H (2016) Current evidence on the association of the metabolic syndrome and dietary patterns in a global perspective. Nutr Res Rev 29:152–162

    Article  PubMed  PubMed Central  Google Scholar 

  60. 60.

    Rodríguez-Monforte M, Sánchez E, Barrio F, Costa B, Flores-Mateo G (2017) Metabolic syndrome and dietary patterns: a systematic review and meta-analysis of observational studies. Eur J Nutr 56:925–947

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  61. 61.

    Andriantsitohaina R, Auger C, Chataigneau T, Étienne-Selloum N, Li H, Martínez MC et al (2012) Molecular mechanisms of the cardiovascular protective effects of polyphenols. Br J Nutr 108:1532–1549

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. 62.

    Sabaté J, Wien M (2015) A perspective on vegetarian dietary patterns and risk of metabolic syndrome. Br J Nutr 113:S136–S143

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  63. 63.

    Babio N, Balanza R, Basulto J, Bulló M, Salas-Salvadó J (2010) Dietary fibre: influence on body weight, glycemic control and plasma cholesterol profile. Nutr Hosp 25:327–340

    CAS  PubMed  PubMed Central  Google Scholar 

  64. 64.

    Babio N, Bulló M, Salas-Salvadó J (2009) Mediterranean diet and metabolic syndrome: the evidence. Public Health Nutr 12:1607–1617

    Article  PubMed  PubMed Central  Google Scholar 

  65. 65.

    Milà-Villarroel R, Bach-Faig A, Puig J, Puchal A, Farran A, Serra-Majem L et al (2011) Comparison and evaluation of the reliability of indexes of adherence to the Mediterranean diet. Public Health Nutr 14:2338–2345

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

This work is supported by the European Research Council [Advanced Research Grant 2014-2019; agreement #340918 granted to MAM-G], and the Spanish Government Official Agency for funding biomedical research-Instituto de Salud Carlos III (ISCIII) with competitive grants for the periods 2014-2016, 2015-2017, 2017-2019 and 2018-2020, through the Fondo de Investigación para la Salud (FIS), which is co-funded by the European Regional Development Fund [grants: PI13/00673, PI13/00492, PI13/00272, PI13/01123, PI13/00462, PI13/00233, PI13/02184, PI13/00728, PI13/01090, PI13/01056, PI14/01722, PI14/00636, PI14/00618, PI14/00696, PI14/01206, PI14/01919, PI14/00853, PI14/01374, PI16/00473, PI16/00662, PI16/01873, PI16/01094, PI16/00501, PI16/00533, PI16/00381, PI16/00366, PI16/01522, PI16/01120, PI17/00764, PI17/01183, PI17/00855, PI17/01347, PI17/00525, PI17/01827, PI17/00532, PI17/00215, PI17/01441, PI17/00508, PI17/01732, PI17/00926]. Additional grants: Acciones Especiales from ISCIIII, Consejería-Salud, Junta de Andalucía [PI0458/2013, PS0358/2016], Recercaixa-grant 2013 [2013ACUP00194], a SEMERGEN grant, and Generalitat Valenciana PROMETEO [grant 17/2017] and International Nut & Dried Fruit Council-FESNAD [Nº 201302]. J.K. is awarded with a Juan de la Cierva-formación research grant (FJCI-2015-24058) of the Spanish Ministry of Economy, Industry and Competitiveness and European Social Funds, and the FOLIUM program within the FUTURMed project: Talent for the medicine within the future from the Fundación Instituto de Investigación Sanitaria Illes Balears (financed by 2017 annual plan of the sustainable tourism tax and at 50% with charge to the ESF Operational Program 2014-2020 of the Balearic Islands). Fundación Patrimonio Comunal Olivarero is providing the necessary amounts of olive oil. Nuts were initially and only partially provided by Pistachios Growers and Almond Board of California, but most of the nuts were purchased with funds from the official funding agency. None of these funding sources plays any role in the design, collection, analysis, or interpretation of the data or in the decision to submit manuscripts for publication.

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Correspondence to Miguel Á. Martínez-González.

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E Ros is a consultant for the California Walnut Commission. J. Salas-Salvadó is a non-payed member of the Scientific Advisory Board of the International Nut and Dried Fruit Foundation and received research grants through his Institution of research. The other authors declare that they have no conflict of interests.

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Alvarez-Alvarez, I., Toledo, E., Lecea, O. et al. Adherence to a priori dietary indexes and baseline prevalence of cardiovascular risk factors in the PREDIMED-Plus randomised trial. Eur J Nutr 59, 1219–1232 (2020). https://doi.org/10.1007/s00394-019-01982-x

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Keywords

  • Hypertension
  • Obesity
  • Type 2 diabetes
  • Dyslipidemias
  • Dietary pattern
  • Mediterranean diet