Elsevier

Atherosclerosis

Volume 275, August 2018, Pages 133-140
Atherosclerosis

Risk of peripheral artery disease according to a healthy lifestyle score: The PREDIMED study

https://doi.org/10.1016/j.atherosclerosis.2018.05.049Get rights and content

Highlights

  • An increasing healthy lifestyle score was associated with a decreasing risk of PAD.

  • Factors include non-smoking, physical activity, MedDiet and moderate alcohol use.

  • Around 80% of new cases of PAD might have been prevented.

  • Our finding should be included in health promotion messages to the general public.

Abstract

Background and aims

The PREDIMED (PREvención con DIeta MEDiterránea) is a multicentre trial analyzed as a prospective cohort study. A total of 7122 participants (aged 55–80 years) at high risk of cardiovascular disease in the PREDIMED trial were recruited in 11 centres in Spain. The prevalence of subjects with type 2 diabetes was 50%. Our objective was to determine the contribution of lifestyle factors to the development of peripheral artery disease (PAD).

Methods

Incident clinical PAD in relation to a healthy lifestyle 5-point score defined as adherence to a Mediterranean diet (MedDiet), moderate alcohol intake, regular physical activity, normal weight (BMI<25) and non-smoking was measured.

Results

Eighty-seven incident PAD cases were diagnosed during a median follow-up of 4.8 years. Compared with participants with 0 or 1 healthy lifestyle factor, the multivariable hazard ratio for PAD was 0.65 (95% confidence interval (CI) 0.37 to 1.14) for 2 factors, and 0.40 (0.22–0.72) for 3 or more. Moderate alcohol consumption, non-smoking, physical activity and following a MedDiet were significantly inversely associated with PAD whereas no association was found for normal weight (BMI<25 kg/m2). PAD risk monotonically decreased with an increasing number of lifestyle factors, and the greatest reduction was found for a score combining moderate alcohol consumption, MedDiet and physical activity or non-smoking. The multivariable-adjusted population attributable risk percent for the combination of these 4 factors was 80.5% (95% CI: 21.3%–95.1%).

Conclusions

Our results demonstrate that a simple healthy lifestyle score is associated with a substantially reduced risk of PAD in a high cardiovascular risk population with a high prevalence (50%) of subjects with type 2 diabetes.

Introduction

Peripheral artery disease (PAD) is the third leading atherosclerotic disease after myocardial infarction (MI) and stroke, affecting more than 200 million people worldwide [1]. The global burden of PAD has increased over the last 2 decades both in terms of disability and mortality [2], as well as economic cost [3].

Moreover, the increasing prevalence of diabetes [1], and a higher survival rate of patients after a cardiovascular event, may lead to a greater manifestation of PAD [4].

In addition to age and type 2 diabetes, major traditional risk factors associated with PAD include tobacco, hypertension and hypercholesterolemia [[5], [6], [7], [8]]. Moreover, the combined effect of these risk factors increases dramatically the risk of PAD [9]. Lifestyle modifications are currently the most cost-effective interventions to reduce the burden of this disease [7]. In this context, a current recommendation to improve cardiovascular health is the promotion of the greatest number of cardiovascular health behaviours or factors [10]. The challenge is to identify the ideal cardiovascular health metrics associated with a lowest risk of PAD.

A number of healthy lifestyle factors are associated with a lower risk of PAD [7] [8], [11]. Smoking cessation is one of the interventions with greatest health impact since the magnitude of the association with PAD is higher than with other cardiovascular diseases [12]. Additionally, intake of healthy nutrients and foods [13], including moderate alcohol consumption [14], as well as different healthy dietary patterns have been associated with a lower risk of PAD [6,[15], [16], [17], [18]]. Physical activity is also strongly related to a lower probability of PAD [19,20]. Previous studies have assessed the association between a combination of risk factors and the risk of PAD. However, the combined effect of a healthy lifestyle associated with the risk of PAD remains unknown.

We aimed to prospectively assess whether a healthy lifestyle (HLS) score, captured by a combination of non-smoking, regular physical activity, body mass index (BMI) < 25 kg/m2, good adherence to a Mediterranean diet (MedDiet), and moderate alcohol consumption, is associated with a lower risk of PAD in a population at high vascular risk from the PREDIMED trial, where 50% of participants were type 2 diabetics.

Section snippets

Study population

The design and methods have been previously described [21,22]. The PREDIMED study (Prevención con Dieta Mediterránea) was a multicentre, randomized trial conducted in Spain to assess the effect of a MedDiet on cardiovascular disease (http://www.isrctn.com/ISRCTN35739639). Participants were men (aged 55–80 years) and women (aged 60–80 years) without cardiovascular disease at the beginning of the study, but who had type 2 diabetes (T2D) or at least three of the following risk factors: smoking,

Results

Among the 7122 participants, 87 incident cases of PAD were clinically diagnosed during a median follow-up of 4.8 years. The distribution of participants according to the HLS score was 95 (2 PAD cases) with 0 factors; 980 (17 cases) with 1 factor; 2593 (35 cases) with 2 factors; 2581 (29 cases) with 3 factors; 831 (4 cases) with 4 and 42 (0 cases) with 5 HLS factors. Table 1 shows the main clinical and lifestyle characteristics according to three categories of the HLS. Participants with higher

Discussion

In this cohort of high cardiovascular risk participants, an increasing HLS score was associated with a decreasing risk of PAD. Specifically, we observed that a combination of 3 HLS factors, including drinking alcohol in moderation, eating a healthy MedDiet, non-smoking, or practising regular physical activity in leisure time may decrease the risk of PAD by 70% in a high cardiovascular risk population, compared with participants with 0 or 1 healthy lifestyle factor.

To the best of our knowledge,

Conflicts of interest

The authors declared they do not have anything to disclose regarding conflict of interest with respect to this manuscript.

Financial support

Supported by the official funding agency for biomedical research of the Spanish Government, Instituto de Salud Carlos III (ISCIII), through grants provided to research networks specifically developed for the trial (RTIC G03/140, to RE; RTIC RD 06/0045, to Miguel A. Martínez-González) and through Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERobn), and by grants from Centro Nacional de Investigaciones Cardiovasculares (CNIC 06/2007), the Fondo de

Author contributions

NL-L, MR-C, MAM-G and ET: conceived the project; NB, JVS, ER, MAM, RE, JL, CM-B, MF, LS-M, XP, JIG, MF, JB, FA, and MR-C: conducted the research; NL-L and MR-C: wrote the statistical plan analysis and analyzed the data; NL-L: drafted and revised the manuscript; MR-C: drafted and revised the manuscript and he is guarantor; and all authors: read and approved the final manuscript.

Trial registration

URL: http://www.isrctn.com/SRCTN35739639

Unique identifier: SRCTN35739639.

Acknowledgments

We thank the participants in the trial for their enthusiastic and maintained collaboration. CIBERobn (Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición) and RTIC RD 06/0045 are initiatives of Instituto de Salud Carlos III, Spain. The funding sources played no role in the design, collection, analysis, or interpretation of the data or in the decision to submit the manuscript for publication.

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