Effect of different types of Mediterranean diet, types and quality of breakfasts, and sourdough bread on cardiometabolic risk in a population with high cardiovascular risk

Abstract

[eng] Cardiovascular diseases are a major public health concern in Spain, where they are the leading cause of death. Lifestyle interventions, and diet in particular, are useful strategies to prevent cardiovascular disease and improve its risk factors. Dietary modifications can be broad (modifying the whole dietary pattern) or more specific (focusing on a particular meal or a specific food item). The role of many of them on classic and novel cardiovascular risk factors has not yet been studied in high cardiovascular risk populations Mediterranean diet and its combination with other lifestyle modifications (such as calorie reduction and physical activity) are known to decrease cardiovascular risk by a plethora of mechanisms. However, their specific effects on the atherogenicity of very-low-density lipoproteins intimately linked to triglyceride biology, have not been fully investigated. In addition, although the role of breakfast skipping in cardiovascular health is increasingly studied, there is limited research on how an adequate energy intake in breakfast or its nutritional composition of breakfast impact cardiometabolic risk factors. Finally, despite substantial research on key components of the Mediterranean diet, the impact of bread on cardiovascular risk has been less explored. This thesis aims to assess the effects of the Mediterranean diet, breakfast energy intake and quality, and the consumption of sourdough bread with different fermentation times on diverse set of cardiometabolic risk factors in individuals at high risk of cardiovascular disease. The first study, conducted with participants from the PREvención con DIeta MEDiterránea (PREDIMED) study and the PREDIMED-Plus study, evaluated the role of traditional and energy-restricted Mediterranean diet on the atherogenicity of very-low-density lipoproteins. After a 1-year intervention with the traditional Mediterranean diet, participants exhibited a reduction in very-low-density lipoprotein atherogenicity (lower apolipoprotein C-III levels, a trend towards lower lipoprotein lipids and apolipoprotein C-I concentrations, and an increase in the lipoprotein capacity to transfer triglycerides ex vivo) compared to those on a low-fat diet. However, no additional benefits were observed with a calorie-restricted Mediterranean diet combined with increased physical activity. The second study followed participants from the PREDIMED-Plus cohort over a period of 36 months to investigate the association of breakfast energy intake (low, high, or reference) and quality (low or high) with cardiometabolic traits, including body mass index, lipids, glucose, and kidney function. Participants who consumed 20-30 % of their daily energy intake at breakfast had lower body mass index, waist circumference, and triglyceride levels, as well as higher high-density lipoprotein cholesterol concentrations, compared to those consuming lower (less than 20%) or higher (greater than 30%) energy intake at breakfast. Higher-quality breakfasts were linked to lower waist circumference and triglycerides, higher high-density lipoprotein cholesterol, and improved kidney function. The third study was a double-blind clinical trial that examined the effects two two-month interventions of short-fermentation (2 hours) and long-fermentation (48 hours) sourdough bread on inflammation, satiety markers, and gut microbiota composition in adults with metabolic syndrome. Minimal changes in inflammation markers were observed over the two-month period. However, the joint effect of both types of sourdough bread reduced levels of soluble intercellular adhesion molecule-1 and diastolic blood pressure. The short-fermentation bread further decreased levels of plasminogen activator inhibitor-1. We observed no significant changes in diversity or abundance of gut microbiota after the intervention. This thesis enhances our understanding of how different dietary levels, ranging from overall dietary patterns to specific food choices, affect cardiovascular risk factors and metabolic health. The Mediterranean diet and breakfast quality are highlighted as key factors in regulating lipids and managing body fat. Individual foods such as sourdough bread could have effects on inflammatory and cardiometabolic markers although they remain to be fully explored.

[spa] Las enfermedades cardiovasculares son la principal causa de mortalidad. Podemos disminuir el riesgo cardiovascular mediante modificaciones dietéticas a varios niveles (patrones dietéticos, comidas y alimentos específicos). Los efectos de muchas de ellas sobre marcadores de riesgo cardiometabólico han sido poco explorados en poblaciones en alto riesgo cardiovascular. El objetivo de esta tesis es determinar el rol de la dieta mediterránea, un desayuno de calidad y el pan de masa madre sobre un conjunto de marcadores cardiometabólicos en personas en alto riesgo cardiovascular. La tesis se compone de tres estudios. El primero, con participantes de los estudios PREvención con DIeta MEDiterránea (PREDIMED) y PREDIMED-Plus, evaluó el impacto de la dieta mediterránea tradicional y con restricción calórica en la aterogenicidad de las VLDLs. Tras un año con dieta mediterránea tradicional, se observó menor aterogenicidad (menores niveles de apolipoproteína C-III, una tendencia hacia menores concentraciones de lípidos y apolipoproteína C-I y un aumento en la capacidad para transferir triglicéridos ex vivo) en comparación con la dieta baja en grasas. No se hallaron beneficios adicionales con restricción calórica. El segundo estudio investigó la relación entre la ingesta energética y la calidad del desayuno y factores de riesgo cardiometabólico. Consumir el 20-30% de la energía diaria en el desayuno se asoció con menor índice de masa corporal, perímetro de cintura y triglicéridos y HDL más alto, en comparación con aquellos que consumían >20% o <30% de la energía diaria en el desayuno. Un desayuno de mayor calidad se asoció con menor circunferencia de cintura, triglicéridos y mejor función renal. El tercer estudio, un ensayo clínico doble ciego, comparó los efectos de pan de masa madre de fermentación corta y larga en adultos con síndrome metabólico. Ambos panes redujeron los niveles de molécula de adhesión intercelular soluble-1 y la presión arterial diastólica. El pan de fermentación corta también redujo los niveles de inhibidor del activador del plasminógeno-1. No hubo cambios significativos en la microbiota intestinal. En conclusión, la dieta mediterránea y la calidad del desayuno son claves para regular los lípidos y la adiposidad. Los efectos del pan de masa madre requieren más investigación.