ARTICLE IN PRESS Appetite ■■ (2014) ■■–■■
Contents lists available at ScienceDirect
Appetite j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a p p e t
Research report
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
Eating behaviors and their relationship with cardiovascular disease. A case/case-control study ☆ Zoe Konidari a, Christina-Maria Kastorini a,b, Haralampos J. Milionis b, Eftychia Bika b, Vassilios Nikolaou c, Konstantinos N. Vemmos d, John A. Goudevenos b, Q1 Demosthenes B. Panagiotakos a,* a b c d
Department of Nutrition and Dietetics, Harokopio University, 70 Eleftheriou Venizelou Str., 17671 Athens, Greece School of Medicine, University of Ioannina, University Campus, 45110 Ioannina, Greece Cardiology Clinic, “Hellenic Red Cross” Hospital, 1 Erithrou Stavrou & Athanasaki Str., 11526 Athens, Greece Acute Stroke Unit, Department of Clinical Therapeutics, Alexandra Hospital, 80 Vas. Sofias Ave., 11528 Athens, Greece
A R T I C L E
I N F O
Article history: Received 22 January 2014 Received in revised form 23 April 2014 Accepted 5 May 2014 Available online
Q2 Keywords: Acute coronary syndrome Ischemic stroke Eating practices Eating behaviors
Q3
A B S T R A C T
The aim of the present work was to evaluate the combined role of eating behaviors and to investigate their effect on the likelihood of developing an acute coronary syndrome (ACS) or an ischemic stroke. During 2009–2010, 1000 participants were enrolled; 250 consecutive patients with a first ACS (83% males, 60 ± 12 years) and 250 control subjects, as well as 250 consecutive patients with a first ischemic stroke (56% males, 77 ± 9 years) and 250 controls. The controls were population-based and age–sex matched with the patients. Detailed information regarding their anthropometric data, medical records and lifestyle characteristics (dietary and smoking habits, physical activity, psychological state and eating practices) – using a special questionnaire – were recorded. Five eating behaviors were selected to compose an eating behavior score for the purposes of this work: adherence to the Mediterranean diet (using the MedDietScore), frequency of breakfast consumption, eating while being stressed, eating while working and skipping meals. Eating behaviors with beneficial health effects were scored with 0, while those with negative effects were assigned score 1. The total range of the score was between 0 and 5. Higher scores reveal “unhealthier” eating practices. After controlling for potential confounding factors, each unit increase of the eating behavior score was associated with 70% (95%CI: 1.29–2.22) higher likelihood of developing an ACS. Insignificant associations were observed regarding ischemic stroke. The overall adoption of specific “unhealthy” eating practices seems to have a detrimental effect on cardiovascular health, and especially coronary heart disease. © 2014 Published by Elsevier Ltd.
Introduction 47
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☆
Acknowledgments: The authors would like to thank the field investigators of the study: Kallirroi Kalantzi, Aggeliki Ioannidi, Ekavi Georgousopoulou, Evangelia Ntziou, Markella Symeopoulou, Eirini Trichia, Stavroula Bitsi, Vissarion Euthimiou, Dimitrios Kantas, Michael Kostapanos, Vaia Salma, Antonis Kramvis, Glykeria Papagiannopoulou, Alexandra Litsardopoulou, Alexia Katsarou, Fani Lioliou, Labros Papadimitriou, Konstantina Siganou, Ioanna Kousoula, Eleni Koroboki, Anastasia Vemmou, Paraskevi Savvari and Vassiliki Vlachaki. Zoe Konidari and Christina-Maria Kastorini contributed equally to this work. Christina-Maria Kastorini has received scholarships for her PhD thesis by the National Scholarships Foundation and the Hellenic Atherosclerosis Society. This study was financially supported by the Hellenic Cardiological Society (2012-2013). The sponsor had no role in the study design, collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. Conflict of interest: None declared. * Corresponding author. E-mail address: [email protected] (D.B. Panagiotakos).
Diet exerts a crucial role on cardiovascular health. This is emphasized by the recent acknowledgement of the adoption of a healthy diet as the cornerstone of cardiovascular disease (CVD) prevention (Perk et al., 2012). A healthy diet is not only associated with favorable effects on many CVD risk factors, such as blood cholesterol levels, blood pressure, diabetes mellitus and obesity, but can also reduce the risk of developing CVD through independent ways (Perk et al., 2012). Nonetheless, in addition to dietary habits, the context of eating (i.e., eating behaviors), may be of significant importance. In more detail, people consume their food integrating their dietary choices in a frame of eating behaviors. These behaviors could be considered as an integral part of dietary habits and thus it is possible to interact with them, influencing human health. For example, regular breakfast consumption has been related to a lower body mass index (BMI), a healthier diet, and a better metabolic profile (Timlin &
http://dx.doi.org/10.1016/j.appet.2014.05.005 0195-6663/© 2014 Published by Elsevier Ltd.
Please cite this article in press as: Zoe Konidari, et al., Eating behaviors and their relationship with cardiovascular disease. A case/case-control study, Appetite (2014), doi: 10.1016/j.appet.2014.05.005
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Pereira, 2007), while skipping meals has been suggested to induce the opposite effects (Cho, Dietrich, Brown, Clark, & Block, 2003; Farshchi, Taylor, & Macdonald, 2005). Furthermore, eating while watching television has been associated with increased waist circumference (Cleland, Schmidt, Dwyer, & Venn, 2008), as well as unhealthy dietary choices (Horodynski, Stommel, Brophy-Herb, & Weatherspoon, 2010). However, the way eating behaviors affect CVD risk has not been thoroughly examined. It has been recently revealed that some eating behaviors, like eating while being stressed or while watching television, were associated with the likelihood of ACS or ischemic stroke presence (Kastorini et al., 2013). However, people do not adopt isolated eating practices, but a set of eating behaviors that may play a role on CVD development. With this in mind and due to the fact that eating behaviors may have a synergistic and/ or antagonistic effect on cardiovascular health, their influence should be examined through a holistic approach, in accordance with the one proposed for dietary habits (Panagiotakos, Pitsavos, & Stefanadis, 2006). Thus, the aim of the present work was to investigate the overall effect that eating practices may exert on ACS and ischemic stroke. Methods Design and sampling procedure The study was multicenter, case-control, with individual (onefor-one) matching by age (within ± 3 years) and sex. From October 2009 to December 2010, 250 of the 296 consecutive patients with a first ACS event (n = 209 with acute myocardial infarction and n = 41 with unstable angina), and 250 of the 319 consecutive patients with ischemic stroke, who entered in the cardiology or pathology clinics or the emergency units of three major General Hospitals, in Greece (i.e., University General Hospital of Ioannina, “Hellenic Red Cross” Korgialeneio-Benakeio Hospital, Athens and Alexandra Hospital, Athens) agreed to participate in the study (participation rate 81.3%). All patients were diagnosed by physicians as lacking any suspicion of previous CVD. Patients with chronic neo-plasmatic disease or chronic inflammatory disease, as well as individuals with recent changes in their dietary habits were also excluded. For the stroke patients who were unable to communicate, the information was obtained by a valid surrogate respondent (first degree relative living in the same home with the patient and is aware of the participant’s dietary habits and medical history). Moreover, 500 control subjects without any history of CVD (250 matched one-for-one with ACS patients and another 250 matched one-for-one with stroke patients) were selected concurrently with the patients on a volunteer, population basis, and from the same region of the patients. Controls were without any clinical symptoms or suspicions of CVD in their medical history, as this was assessed by a physician. Based on the a priori statistical power analysis that was performed, the sample size of the 500 enrolled patients (250 ACS, 250 stroke) and 500 age- and sex-matched healthy subjects was adequate to evaluate two-sided hypotheses of odds ratios (ORs) equal to 1.20 for a 1-unit increase of a continuous covariate (e.g., eating behavior score), achieving statistical power equal to 82% at 0.05 significance level (P-value). In order to achieve more robust estimates of the effect sized measures, bootstrap resampling method was also applied (see details in statistical analysis section). Bioethics The study was approved by the ethics committee of the University Hospital of Ioannina and was carried out in accordance with the Declaration of Helsinki (1989) of the World Medical AssociaQ4 tion. Prior to the collection of any information, participants (or valid surrogate respondents) were informed about the aims and proce-
dures of the study and were asked to provide their signed consents. Diagnosis of ACS or stroke Regarding the ACS patients, their clinical symptoms were evaluated at hospital entry and a 12-lead electrocardiogram was performed by a cardiologist. The evidence of myocardial cell death was assessed through blood tests and measurement of the levels of troponin I and the MB fraction of total creatinine phosphokinase (Thygesen, Alpert, White, & on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction, 2007). Unstable angina was defined by the occurrence Q5 of one or more angina episodes at rest within the preceding 48hours, corresponding to class III of the Braunwald classification (Braunwald, 1997). Ischemic strokes were defined through symptoms of neurologic dysfunction of acute onset of any severity, consistent with focal brain ischemia and imaging/laboratory confirmation of an acute vascular ischemic pathology (Kidwell & Warach, 2003). Dietary assessment and evaluation of eating practices and dietary behaviors Usual eating practices and dietary habits of the past year were assessed through a 90-item, validated semi-quantitative foodfrequency questionnaire (FFQ) that has been previously described (Bountziouka et al., 2012; Kastorini, Milionis, Goudevenos, & Panagiotakos, 2011). Level of adherence to the Mediterranean diet was assessed using a validated 11-item composite index, the MedDietScore (Panagiotakos et al., 2006). The theoretical range of the MedDietScore was between 0 and 55. Higher values of this score indicate greater adherence to the Mediterranean diet. Regarding eating practices: frequency of breakfast consumption (rarely, 1–2 times/week, 3–5 times/week, almost every day) and frequency of skipping a meal (29.9 kg/m2, respectively. Medical history and clinical status In all participants detailed medical history was recorded, including family history of CVD, as well as personal and family history of hypertension, hypercholesterolemia, hypertriglyceridemia and diabetes. Patients whose average blood pressure levels were greater or equal to 140/90 mmHg or were under antihypertensive medication were classified as having hypertension. Hypercholesterolemia was defined as total serum cholesterol concentrations ≥200 mg/dL (≥5.2 mmol/L) or the use of lipid-lowering agents, and diabetes
Please cite this article in press as: Zoe Konidari, et al., Eating behaviors and their relationship with cardiovascular disease. A case/case-control study, Appetite (2014), doi: 10.1016/j.appet.2014.05.005
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mellitus was defined as fasting blood glucose concentrations ≥126 mg/dL (≥7 mmol/L) or the use of antidiabetic medication. Psychological status Previously translated and validated versions of the Zung Depression Rating Scale (ZUNG-DRS, range 20–80) (Fountoulakis et al., 2001; Zung, 1965) and the Spielberger Trait Anxiety Inventory (STAI Q6 form Y-2, range 20–80) (Fountoulakis et al., 2006; Spielberger, 1970) were used for the assessment of depressive symptoms and trait anxiety, respectively. Lifestyle characteristics Current smokers were defined as those who smoked at least one cigarette per day and former smokers as those who had stopped smoking more than 1 year before the interview; the rest of the participants were defined as noncurrent smokers. Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ) index (Craig et al., 2003) that has been validated for the Greek population (Papathanasiou et al., 2009). According to their physical activity levels, participants were classified as inactive or physically active (moderate or vigorous active). Eating behavior assessment In order to capture the combined effect of eating behaviors and avoid potential collinearity on the regression models, a score was developed based on the frequency of practicing five eating behaviors. In more detail, the eating behaviors selected to compose the eating behavior score were: (i) adherence to Mediterranean diet, (ii) breakfast consumption, (iii) food consumption under stress conditions, (iv) food consumption while working and finally, (v) skipping a meal due to at least one of the following reasons: work obligations, intention to lose weight and absence of hunger. Eating behaviors that were believed to be beneficial for cardiovascular health were assigned score 0, while those believed to be detrimental were assigned score 1. In particular, high and moderate adherence to Mediterranean diet were scored with 0 (i.e., MedDietScore >34 or 30– 33, respectively), while low adherence (MedDietScore ≤29) with 1 (Panagiotakos et al., 2006), breakfast consumption at least 5 times/ week was scored with 0, while breakfast consumption 30) Physical activity Smoking habits Never smoker Current smoker Former smoker Depression (ZUNG-DRS score: 20–80) Normal (20–49) Mild depression (50–59) Moderate marked depression ( 60–69) Severe depression (70–80) Anxiety (STAI Y-2 score: 20–80) Low anxiety (20–39) Moderate anxiety (40–59) Severe anxiety (60–80)
ACS controls n = 250
ACS patients n = 250
Stroke controls n = 250
Stroke patients n = 250
60 ± 12 208 (83.2%) 39 (16.7%)** 90 (37.7%)** 100 (45.5%)** 29 (12.4%)** 27.23 ± 3.50 63 (26.3%) 132 (55%) 45 (18.8%) 203 (82.5%)**
60 ± 12 208 (83.2%) 81 (36.2%) 148 (62.2%) 165 (71.4%) 58 (26.1%) 27.82 ± 4.29 57 (24.9%) 116 (50.7%) 56 (24.5%) 150 (64.1%)
73 ± 9 139 (55.6%) 38 (16.7%)** 137 (56.8%)** 119 (54.1%)* 50 (21.5%)* 27.35 ± 4.24 73 (30%) 120 (49.4%) 50 (20.6%) 181 (74.8%)**
77 ± 9 139 (55.6%) 51 (31.3%) 206 (84.4%) 159 (68.5%) 71 (32.9%) 26.72 ± 3.57 79 (33.1%) 124 (51.9%) 36 (15.0%) 99 (47.1%)
108 (43.2%)** 63 (25.2%) 79 (31.6%) 35.07 ± 7.90** 233 (94.7%) 12 (4.9%) 1 (0.4%) 0 (0%) 36.55 ± 9.26** 158 (64.5%)** 84 (34.3%) 3 (1.2%)
56 (22.4%) 127 (50.8%) 67 (26.8%) 38.50 ± 8.50 203 (89.4%) 22 (9.7%) 2 (0.9%) 0 (0%) 40.52 ± 10.05 109 (48.7%) 105 (46.9%) 10 (4.5%)
139 (55.8%) 47 (18.9%) 63 (25.3%) 38.01 ± 8.57** 224 (91.8%)** 18 (7.4%) 2 (0.8%) 0 (0%) 38.65 ± 9.86** 135 (54.9%)** 106 (43.1%) 5 (2%)
151 (60.4%) 49 (19.6%) 50 (20%) 46.30 ± 8.23 121 (57.1%) 86 (40.6%) 5 (2.4%) 0 (0%) 45.66 ± 7.17 37 (17.9%) 167 (80.7%) 3 (1.4%)
Data are expressed as mean ± SD or frequencies (n, %). P-values derived from Student’s t-test or the chi-square test. CVD, cardiovascular disease. * P < 0.05, ** P < 0.001 compared with the ACS or stroke control group, respectively.
33 34 35 36 37 38 39 40 41 42 43
symptomatology (65% and 55% higher likelihood of having an ACS, respectively) (Table 3). Stroke patients Unadjusted analyses revealed that each unit increase in the eating behavior score was associated with higher likelihood of having an ischemic stroke. However, the association was no longer significant after controlling for potential confounding factors (family history of CVD, diabetes mellitus, hypertension, hypercholesterolemia, physical activity, smoking habits, anxiety or depression) (Table 3).
Discussion This study is one of the first in the literature that examined the overall effect of eating practices on cardiovascular health. Results of the present work offer novel information concerning CVD and highlight the role of nonpharmacological means for its prevention and management. Five basic eating practices common in the modern lifestyle were combined and their relationship with ACS and ischemic stroke was evaluated. According to the results of the present work, unhealthier eating practices were associated with higher like-
44 45 46
Table 2 Eating practices and behaviors of the study participants.
47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72
Mediterranean diet (MedDietScore: 0–55) Low adherence (0–29) Moderate adherence (30–33) Good adherence (34–55) Breakfast consumption ≥5 times/week
Contents lists available at ScienceDirect
Appetite j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a p p e t
Research report
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
Eating behaviors and their relationship with cardiovascular disease. A case/case-control study ☆ Zoe Konidari a, Christina-Maria Kastorini a,b, Haralampos J. Milionis b, Eftychia Bika b, Vassilios Nikolaou c, Konstantinos N. Vemmos d, John A. Goudevenos b, Q1 Demosthenes B. Panagiotakos a,* a b c d
Department of Nutrition and Dietetics, Harokopio University, 70 Eleftheriou Venizelou Str., 17671 Athens, Greece School of Medicine, University of Ioannina, University Campus, 45110 Ioannina, Greece Cardiology Clinic, “Hellenic Red Cross” Hospital, 1 Erithrou Stavrou & Athanasaki Str., 11526 Athens, Greece Acute Stroke Unit, Department of Clinical Therapeutics, Alexandra Hospital, 80 Vas. Sofias Ave., 11528 Athens, Greece
A R T I C L E
I N F O
Article history: Received 22 January 2014 Received in revised form 23 April 2014 Accepted 5 May 2014 Available online
Q2 Keywords: Acute coronary syndrome Ischemic stroke Eating practices Eating behaviors
Q3
A B S T R A C T
The aim of the present work was to evaluate the combined role of eating behaviors and to investigate their effect on the likelihood of developing an acute coronary syndrome (ACS) or an ischemic stroke. During 2009–2010, 1000 participants were enrolled; 250 consecutive patients with a first ACS (83% males, 60 ± 12 years) and 250 control subjects, as well as 250 consecutive patients with a first ischemic stroke (56% males, 77 ± 9 years) and 250 controls. The controls were population-based and age–sex matched with the patients. Detailed information regarding their anthropometric data, medical records and lifestyle characteristics (dietary and smoking habits, physical activity, psychological state and eating practices) – using a special questionnaire – were recorded. Five eating behaviors were selected to compose an eating behavior score for the purposes of this work: adherence to the Mediterranean diet (using the MedDietScore), frequency of breakfast consumption, eating while being stressed, eating while working and skipping meals. Eating behaviors with beneficial health effects were scored with 0, while those with negative effects were assigned score 1. The total range of the score was between 0 and 5. Higher scores reveal “unhealthier” eating practices. After controlling for potential confounding factors, each unit increase of the eating behavior score was associated with 70% (95%CI: 1.29–2.22) higher likelihood of developing an ACS. Insignificant associations were observed regarding ischemic stroke. The overall adoption of specific “unhealthy” eating practices seems to have a detrimental effect on cardiovascular health, and especially coronary heart disease. © 2014 Published by Elsevier Ltd.
Introduction 47
48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63
☆
Acknowledgments: The authors would like to thank the field investigators of the study: Kallirroi Kalantzi, Aggeliki Ioannidi, Ekavi Georgousopoulou, Evangelia Ntziou, Markella Symeopoulou, Eirini Trichia, Stavroula Bitsi, Vissarion Euthimiou, Dimitrios Kantas, Michael Kostapanos, Vaia Salma, Antonis Kramvis, Glykeria Papagiannopoulou, Alexandra Litsardopoulou, Alexia Katsarou, Fani Lioliou, Labros Papadimitriou, Konstantina Siganou, Ioanna Kousoula, Eleni Koroboki, Anastasia Vemmou, Paraskevi Savvari and Vassiliki Vlachaki. Zoe Konidari and Christina-Maria Kastorini contributed equally to this work. Christina-Maria Kastorini has received scholarships for her PhD thesis by the National Scholarships Foundation and the Hellenic Atherosclerosis Society. This study was financially supported by the Hellenic Cardiological Society (2012-2013). The sponsor had no role in the study design, collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. Conflict of interest: None declared. * Corresponding author. E-mail address: [email protected] (D.B. Panagiotakos).
Diet exerts a crucial role on cardiovascular health. This is emphasized by the recent acknowledgement of the adoption of a healthy diet as the cornerstone of cardiovascular disease (CVD) prevention (Perk et al., 2012). A healthy diet is not only associated with favorable effects on many CVD risk factors, such as blood cholesterol levels, blood pressure, diabetes mellitus and obesity, but can also reduce the risk of developing CVD through independent ways (Perk et al., 2012). Nonetheless, in addition to dietary habits, the context of eating (i.e., eating behaviors), may be of significant importance. In more detail, people consume their food integrating their dietary choices in a frame of eating behaviors. These behaviors could be considered as an integral part of dietary habits and thus it is possible to interact with them, influencing human health. For example, regular breakfast consumption has been related to a lower body mass index (BMI), a healthier diet, and a better metabolic profile (Timlin &
http://dx.doi.org/10.1016/j.appet.2014.05.005 0195-6663/© 2014 Published by Elsevier Ltd.
Please cite this article in press as: Zoe Konidari, et al., Eating behaviors and their relationship with cardiovascular disease. A case/case-control study, Appetite (2014), doi: 10.1016/j.appet.2014.05.005
64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81
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Pereira, 2007), while skipping meals has been suggested to induce the opposite effects (Cho, Dietrich, Brown, Clark, & Block, 2003; Farshchi, Taylor, & Macdonald, 2005). Furthermore, eating while watching television has been associated with increased waist circumference (Cleland, Schmidt, Dwyer, & Venn, 2008), as well as unhealthy dietary choices (Horodynski, Stommel, Brophy-Herb, & Weatherspoon, 2010). However, the way eating behaviors affect CVD risk has not been thoroughly examined. It has been recently revealed that some eating behaviors, like eating while being stressed or while watching television, were associated with the likelihood of ACS or ischemic stroke presence (Kastorini et al., 2013). However, people do not adopt isolated eating practices, but a set of eating behaviors that may play a role on CVD development. With this in mind and due to the fact that eating behaviors may have a synergistic and/ or antagonistic effect on cardiovascular health, their influence should be examined through a holistic approach, in accordance with the one proposed for dietary habits (Panagiotakos, Pitsavos, & Stefanadis, 2006). Thus, the aim of the present work was to investigate the overall effect that eating practices may exert on ACS and ischemic stroke. Methods Design and sampling procedure The study was multicenter, case-control, with individual (onefor-one) matching by age (within ± 3 years) and sex. From October 2009 to December 2010, 250 of the 296 consecutive patients with a first ACS event (n = 209 with acute myocardial infarction and n = 41 with unstable angina), and 250 of the 319 consecutive patients with ischemic stroke, who entered in the cardiology or pathology clinics or the emergency units of three major General Hospitals, in Greece (i.e., University General Hospital of Ioannina, “Hellenic Red Cross” Korgialeneio-Benakeio Hospital, Athens and Alexandra Hospital, Athens) agreed to participate in the study (participation rate 81.3%). All patients were diagnosed by physicians as lacking any suspicion of previous CVD. Patients with chronic neo-plasmatic disease or chronic inflammatory disease, as well as individuals with recent changes in their dietary habits were also excluded. For the stroke patients who were unable to communicate, the information was obtained by a valid surrogate respondent (first degree relative living in the same home with the patient and is aware of the participant’s dietary habits and medical history). Moreover, 500 control subjects without any history of CVD (250 matched one-for-one with ACS patients and another 250 matched one-for-one with stroke patients) were selected concurrently with the patients on a volunteer, population basis, and from the same region of the patients. Controls were without any clinical symptoms or suspicions of CVD in their medical history, as this was assessed by a physician. Based on the a priori statistical power analysis that was performed, the sample size of the 500 enrolled patients (250 ACS, 250 stroke) and 500 age- and sex-matched healthy subjects was adequate to evaluate two-sided hypotheses of odds ratios (ORs) equal to 1.20 for a 1-unit increase of a continuous covariate (e.g., eating behavior score), achieving statistical power equal to 82% at 0.05 significance level (P-value). In order to achieve more robust estimates of the effect sized measures, bootstrap resampling method was also applied (see details in statistical analysis section). Bioethics The study was approved by the ethics committee of the University Hospital of Ioannina and was carried out in accordance with the Declaration of Helsinki (1989) of the World Medical AssociaQ4 tion. Prior to the collection of any information, participants (or valid surrogate respondents) were informed about the aims and proce-
dures of the study and were asked to provide their signed consents. Diagnosis of ACS or stroke Regarding the ACS patients, their clinical symptoms were evaluated at hospital entry and a 12-lead electrocardiogram was performed by a cardiologist. The evidence of myocardial cell death was assessed through blood tests and measurement of the levels of troponin I and the MB fraction of total creatinine phosphokinase (Thygesen, Alpert, White, & on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction, 2007). Unstable angina was defined by the occurrence Q5 of one or more angina episodes at rest within the preceding 48hours, corresponding to class III of the Braunwald classification (Braunwald, 1997). Ischemic strokes were defined through symptoms of neurologic dysfunction of acute onset of any severity, consistent with focal brain ischemia and imaging/laboratory confirmation of an acute vascular ischemic pathology (Kidwell & Warach, 2003). Dietary assessment and evaluation of eating practices and dietary behaviors Usual eating practices and dietary habits of the past year were assessed through a 90-item, validated semi-quantitative foodfrequency questionnaire (FFQ) that has been previously described (Bountziouka et al., 2012; Kastorini, Milionis, Goudevenos, & Panagiotakos, 2011). Level of adherence to the Mediterranean diet was assessed using a validated 11-item composite index, the MedDietScore (Panagiotakos et al., 2006). The theoretical range of the MedDietScore was between 0 and 55. Higher values of this score indicate greater adherence to the Mediterranean diet. Regarding eating practices: frequency of breakfast consumption (rarely, 1–2 times/week, 3–5 times/week, almost every day) and frequency of skipping a meal (29.9 kg/m2, respectively. Medical history and clinical status In all participants detailed medical history was recorded, including family history of CVD, as well as personal and family history of hypertension, hypercholesterolemia, hypertriglyceridemia and diabetes. Patients whose average blood pressure levels were greater or equal to 140/90 mmHg or were under antihypertensive medication were classified as having hypertension. Hypercholesterolemia was defined as total serum cholesterol concentrations ≥200 mg/dL (≥5.2 mmol/L) or the use of lipid-lowering agents, and diabetes
Please cite this article in press as: Zoe Konidari, et al., Eating behaviors and their relationship with cardiovascular disease. A case/case-control study, Appetite (2014), doi: 10.1016/j.appet.2014.05.005
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mellitus was defined as fasting blood glucose concentrations ≥126 mg/dL (≥7 mmol/L) or the use of antidiabetic medication. Psychological status Previously translated and validated versions of the Zung Depression Rating Scale (ZUNG-DRS, range 20–80) (Fountoulakis et al., 2001; Zung, 1965) and the Spielberger Trait Anxiety Inventory (STAI Q6 form Y-2, range 20–80) (Fountoulakis et al., 2006; Spielberger, 1970) were used for the assessment of depressive symptoms and trait anxiety, respectively. Lifestyle characteristics Current smokers were defined as those who smoked at least one cigarette per day and former smokers as those who had stopped smoking more than 1 year before the interview; the rest of the participants were defined as noncurrent smokers. Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ) index (Craig et al., 2003) that has been validated for the Greek population (Papathanasiou et al., 2009). According to their physical activity levels, participants were classified as inactive or physically active (moderate or vigorous active). Eating behavior assessment In order to capture the combined effect of eating behaviors and avoid potential collinearity on the regression models, a score was developed based on the frequency of practicing five eating behaviors. In more detail, the eating behaviors selected to compose the eating behavior score were: (i) adherence to Mediterranean diet, (ii) breakfast consumption, (iii) food consumption under stress conditions, (iv) food consumption while working and finally, (v) skipping a meal due to at least one of the following reasons: work obligations, intention to lose weight and absence of hunger. Eating behaviors that were believed to be beneficial for cardiovascular health were assigned score 0, while those believed to be detrimental were assigned score 1. In particular, high and moderate adherence to Mediterranean diet were scored with 0 (i.e., MedDietScore >34 or 30– 33, respectively), while low adherence (MedDietScore ≤29) with 1 (Panagiotakos et al., 2006), breakfast consumption at least 5 times/ week was scored with 0, while breakfast consumption 30) Physical activity Smoking habits Never smoker Current smoker Former smoker Depression (ZUNG-DRS score: 20–80) Normal (20–49) Mild depression (50–59) Moderate marked depression ( 60–69) Severe depression (70–80) Anxiety (STAI Y-2 score: 20–80) Low anxiety (20–39) Moderate anxiety (40–59) Severe anxiety (60–80)
ACS controls n = 250
ACS patients n = 250
Stroke controls n = 250
Stroke patients n = 250
60 ± 12 208 (83.2%) 39 (16.7%)** 90 (37.7%)** 100 (45.5%)** 29 (12.4%)** 27.23 ± 3.50 63 (26.3%) 132 (55%) 45 (18.8%) 203 (82.5%)**
60 ± 12 208 (83.2%) 81 (36.2%) 148 (62.2%) 165 (71.4%) 58 (26.1%) 27.82 ± 4.29 57 (24.9%) 116 (50.7%) 56 (24.5%) 150 (64.1%)
73 ± 9 139 (55.6%) 38 (16.7%)** 137 (56.8%)** 119 (54.1%)* 50 (21.5%)* 27.35 ± 4.24 73 (30%) 120 (49.4%) 50 (20.6%) 181 (74.8%)**
77 ± 9 139 (55.6%) 51 (31.3%) 206 (84.4%) 159 (68.5%) 71 (32.9%) 26.72 ± 3.57 79 (33.1%) 124 (51.9%) 36 (15.0%) 99 (47.1%)
108 (43.2%)** 63 (25.2%) 79 (31.6%) 35.07 ± 7.90** 233 (94.7%) 12 (4.9%) 1 (0.4%) 0 (0%) 36.55 ± 9.26** 158 (64.5%)** 84 (34.3%) 3 (1.2%)
56 (22.4%) 127 (50.8%) 67 (26.8%) 38.50 ± 8.50 203 (89.4%) 22 (9.7%) 2 (0.9%) 0 (0%) 40.52 ± 10.05 109 (48.7%) 105 (46.9%) 10 (4.5%)
139 (55.8%) 47 (18.9%) 63 (25.3%) 38.01 ± 8.57** 224 (91.8%)** 18 (7.4%) 2 (0.8%) 0 (0%) 38.65 ± 9.86** 135 (54.9%)** 106 (43.1%) 5 (2%)
151 (60.4%) 49 (19.6%) 50 (20%) 46.30 ± 8.23 121 (57.1%) 86 (40.6%) 5 (2.4%) 0 (0%) 45.66 ± 7.17 37 (17.9%) 167 (80.7%) 3 (1.4%)
Data are expressed as mean ± SD or frequencies (n, %). P-values derived from Student’s t-test or the chi-square test. CVD, cardiovascular disease. * P < 0.05, ** P < 0.001 compared with the ACS or stroke control group, respectively.
33 34 35 36 37 38 39 40 41 42 43
symptomatology (65% and 55% higher likelihood of having an ACS, respectively) (Table 3). Stroke patients Unadjusted analyses revealed that each unit increase in the eating behavior score was associated with higher likelihood of having an ischemic stroke. However, the association was no longer significant after controlling for potential confounding factors (family history of CVD, diabetes mellitus, hypertension, hypercholesterolemia, physical activity, smoking habits, anxiety or depression) (Table 3).
Discussion This study is one of the first in the literature that examined the overall effect of eating practices on cardiovascular health. Results of the present work offer novel information concerning CVD and highlight the role of nonpharmacological means for its prevention and management. Five basic eating practices common in the modern lifestyle were combined and their relationship with ACS and ischemic stroke was evaluated. According to the results of the present work, unhealthier eating practices were associated with higher like-
44 45 46
Table 2 Eating practices and behaviors of the study participants.
47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72
Mediterranean diet (MedDietScore: 0–55) Low adherence (0–29) Moderate adherence (30–33) Good adherence (34–55) Breakfast consumption ≥5 times/week
