Elsevier

Clinical Nutrition

Volume 39, Issue 3, March 2020, Pages 966-975
Clinical Nutrition

Original article
Longitudinal changes in Mediterranean diet and transition between different obesity phenotypes

https://doi.org/10.1016/j.clnu.2019.04.002Get rights and content

Summary

Background & aims

Little is known about the impact of specific dietary patterns on the development of obesity phenotypes. We aimed to determine the association of longitudinal changes in adherence to the traditional Mediterranean diet (MedDiet) with the transition between different obesity phenotypes.

Methods

Data of 5801 older men and women at high cardiovascular risk from PREDIMED trial were used. Adherence to MedDiet was measured with the validated 14p-Mediterranean Diet Adherence Screener (MEDAS). Using the simultaneous combination of metabolic health- and body size-related parameters participants were categorized into one of four phenotypes: metabolically healthy and abnormal obese (MHO and MAO), metabolically healthy and abnormal non-obese (MHNO and MANO). Cox regression models with yearly repeated measures during 5-year of follow-up were built with use of Markov chain assumption.

Results

Each 2-point increase in MEDAS was associated with the following transitions: in MAO participants, with a 16% (95% CI 3–31%) greater likelihood of becoming MHO; in MHO participants with a 14% (3–23%) lower risk of becoming MAO; in MHNO participants with a 18% (5–30%) lower risk of becoming MHO. In MANO women, but not in men, MEDAS was associated with 20% (5–38%) greater likely of becoming MHNO (p for interaction by gender 0.014). No other significant associations were observed.

Conclusions

Better adherence to the traditional MedDiet is associated with transitions to healthier phenotypes, promoting metabolic health improvement in MAO, MANO (only in women), and MHO, as well as protecting against obesity incidence in MHNO subjects.

Introduction

Undoubtedly, the overspread obesity epidemic is a life-threatening phenomenon of the XXI century. However, obesity is not a homogeneous condition, hence metabolic abnormalities and chronic disease risk may vary among obese subjects [1].

In this regard, different obesity phenotypes have been described recently. Among them, the metabolically healthy obese (MHO) phenotype has attracted much attention [1], [2], [3]. Despite excessive body size, MHO subjects have a better adipose tissue function, less ectopic fat storage, and are more insulin sensitive than metabolically abnormal obese (MAO) subjects [2]. Nevertheless, the effect of being MHO on health outcomes remains controversial, as MHO phenotype has also been associated with increased mortality, cardiovascular disease (CVD), type 2 diabetes (T2D), and lower quality of life than a lean phenotype [2], [4]. Moreover, some recent studies evidenced that MHO phenotype is a transient state, in which one-to two-thirds of subjects tends to deteriorate toward MAO phenotype over time [5], [6]. Conversely, there is a subset of non-obese subjects who show an abnormal metabolic profile – the concept of metabolically abnormal non-obese (MANO) phenotype – and consequently are also at increased cardiovascular and diabetes risk, when compared to metabolically healthy subjects [3], [7]. Therefore, metabolic and body size phenotyping might be crucial to identify at risk subjects, and to optimize prevention and treatment strategies.

Until now, prevalence, nature, determinants and clinical implications of obesity phenotypes has been mainly studied, but the effect of lifestyle targeting transition from one to other phenotype has received less attention. Among limited number of studies that addressed this issue, many were only focused on MHO and MAO phenotypes [8], [9], [10], [11], [12], [13], investigated short-term study period [8], [9], [10], [11], used small sample size [8], [9], [11] or were cross-sectional comparisons of lifestyle factors among phenotypes [12], [13]. It is hence unclear whether specific dietary factors would influence the evolution or transition between obesity phenotypes.

The Mediterranean Diet (MedDiet) has been associated with less weight gain [14], [15], [16], [17], obesity prevention [14], [18], reversion or lower incidence of the metabolic syndrome (MetS) [19], [20], and reduction in the risk of developing cardiometabolic diseases such as T2D and CVD [21], [22], [23]. At such, the MedDiet has been proposed as a promising lifestyle factor to allow the transition to healthier obesity phenotypes, and reduction of long-term health risk [24].

Therefore, the aim of the present study was to evaluate the long-term association of changes in adherence to a traditional MedDiet with the possibility to transition between different obesity phenotypes defined jointly according to body size and metabolic health status, in men and women at high cardiovascular risk from the PREDIMED trial.

Section snippets

Design overview and participants

The present study was conducted within the framework of the PREDIMED study over the first 5-years of follow-up. Details on the study design have been previously described [22], [25] and are on the website http://www.predimed.es/. Briefly, PREDIMED was a multicenter, randomized, controlled, CVD primary prevention trial, conducted in Spain during 2003–2010, which compared three dietary interventions: MedDiet supplemented with extra-virgin olive oil or nuts and a control low-fat diet. Men aged

Results

Characteristics of study participants according to baseline obesity phenotypes by sex are presented in Table 1. Overall, women were older, less physically active and less educated, consumed fewer total calories, and showed fewer smoking and drinking habits than men. Compared to men, a higher proportion of women had a MAO phenotype (40% of women versus 33% of men), whereas a higher proportion of men had a MHNO phenotype (33% of men versus 21% of women). The other two phenotypes (MHO: 8% of men

Discussion

Our analyses revealed that increase in adherence to MedDiet has a potential to exert differential health benefits for all four obesity phenotypes, promoting metabolic health improvement in MAO and MANO older men and women at high CVD risk, as well as protecting against metabolic health deterioration in MHO and obesity incidence in MHNO subjects. To best of our knowledge, this study is the first to examine the long-term association of traditional MedDiet with transition between four different

Statement of authorship

K.J. and R.D. conceived this study and wrote the article. K.J., Y.A., M.M., B.N., T.E., M-G.MA., S.JV., S-S.J., E.R., R.E., A-G. A., S.H., L.J., S-M.Ll., P.X., G-B.M., D-L.A., G.JI, F.M., F.L., F.M., and R.D designed and conducted the project, and obtained the data. K.J., Y.A., B.N., T.E., and R.D. analyzed the data. All authors revised the manuscript for important intellectual content and read and approved the final manuscript. K.J. and R.D. are the guarantors of this work and, as such, had

Conflicts of interest

S-S.J. reports outside the submitted work serving on the board of and receiving grant support through his institution from the International Nut and Dried Fruit Council, and Eroski Foundation. Reports serving in the Executive Committee of the Instituto Danone Spain. Has received research support from California Walnut Commission, Sacramento CA, USA; Patrimonio Comunal Olivarero, Spain; La Morella Nuts, Spain; and Borges S.A., Spain. Reports receiving consulting fees or travel expenses from

Funding sources

The research leading to these results was supported by the official Spanish Institutions for funding scientific biomedical research, CIBER de Fisiopatología de la Obesidad y Nutrición and Instituto de Salud Carlos III, and through specific grant - Juan de la Cierva-formación research grant (FJCI-2015-24058) of the Spanish Ministry of Economy, Industry and Competitiveness and European Social Funds (ESF) [K.J.], the “FOLIUM” program within the FUTURMe`d project. Talent for the medicine within the

Acknowledgements

We thank all the volunteers for the participation and personnel for their contribution in the PREDIMED trial. We thank Maria del Pilar Sanchis and Josep Muncunill from IdISBa for the help with statistical calculations.

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