OBJECTIVE:This study aimed to identify metabolomic profiles associated with type 2 diabetes and insulin resistance (HOMA-IR) and relate them to the risk of total mortality. METHODS:A longitudinal study was conducted in a subset of participants from a diabetes case-cohort study (mean age, 66.5 years; 62% women; 176/699 with incident T2D) within the PREDIMED trial. Plasma metabolites were analyzed using LC-MS/MS methods at baseline (discovery sample) and 1-year follow-up (validation sample). Multi-metabolite profile scores for type 2 diabetes and HOMA-IR, respectively, were derived using elastic net regression. Cox proportional hazards were fitted to assess the association between metabolomic profiles and total mortality, adjusting for potential confounders. External validation was performed in the NHS/HPFS cohorts. RESULTS:A total of 31 metabolites were associated with type 2 diabetes and 105 with HOMA-IR. Both metabolomic profiles were significantly associated with a higher risk of total mortality (type 2 diabetes HR = 1.52, 95%CI: 1.04-2.25; HOMA-IR HR = 1.33, 95%CI: 1.00-1.75) in the PREDIMED cohort. Shared metabolites between both metabolomic signatures, including glycine, SDMA, DMGV, and phosphocreatine, were associated with mortality. These associations were replicated in a pooled analysis of three independent American cohorts (type 2 diabetes HR = 1.09, 95%CI: 1.05-1.13; HOMA-IR HR = 1.04, 95%CI: 1.00-1.09). CONCLUSIONS:In an older population at high cardiometabolic risk, metabolomic scores of type 2 diabetes and insulin resistance were associated with total mortality risk, potentially explaining some mechanisms behind the increased risk of mortality observed in epidemiological studies for individuals with glycemic dysregulations.

Background:Cardiovascular disease (CVD) is a leading cause of morbidity and mortality among individuals with diabetes, where risk remains elevated even with good glycemic control. Cardiac biomarkers such as N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hsTnT), high sensitivity C Reactive Protein (hsCRP), Procollagen Type I Carboxy-Terminal Propeptide (PICP), and 3-Nytrotirosine (3-NT) may capture subclinical cardiac stress and injury beyond traditional risk measures. Methods:We analyzed 562 participants from the PREDIMED-Plus trial with data on diabetes status, glycosylated hemoglobin (HbA1c), and cardiovascular biomarkers. At baseline, participants were categorized as having normoglycemia (HbA1c <5.7%; n=50), prediabetes (HbA1c ≥5.7 to <6.5%; n=353), diabetes with well-controlled glycemia (HbA1c <7%; n=127), or diabetes with poorly controlled glycemia (HbA1c ≥7%; n=32). Cardiac biomarkers assessed at baseline, 3 years, and 5 years included NT-proBNP, hsTnT, hsCRP, PICP, and 3-NT. Mixed models, adjusted for demographic, clinical, and lifestyle covariates, were used to examine cross-sectional and longitudinal associations. Results:Cross-sectionally, higher HbA1c was inversely associated with NT-proBNP (β = -0.16, 95% CI: -0.29, -0.04) and directly associated with hsTnT (β = 0.08, 95% CI: 0.02, 0.14), particularly among those with poorly controlled diabetes. No consistent associations were observed for hsCRP, PICP, or 3-NT. Longitudinally, baseline differences in diabetes status were not significantly related to biomarker changes. However, compared to normoglycemic participants, those with well-controlled diabetes showed higher increases in hsTnT (β = 0.10, 95% CI: 0.02, 0.19) and PICP (β = 0.14, 95% CI: 0.01, 0.28). Conclusion:Even with adequate glycemic control, individuals with diabetes may experience progression of subclinical cardiac damage and fibrosis. Incorporating cardiac biomarkers into risk assessment may improve early identification of CVD risk in high-risk populations.

AIM:Despite growing evidence linking better oxidative balance to improved cardiometabolic health, metabolite signatures reflecting oxidative status remain still poorly characterized. We aimed to identify a plasma metabolite signature of the oxidative balance score (OBS) and to examine its association with incident cardiovascular disease (CVD) and type 2 diabetes (T2D). METHODS:The discovery population included 1732 participants at high cardiovascular risk from the PREDIMED study with available plasma metabolomics using LC-MS and OBS data at baseline. The OBS was calculated at baseline and after 1-year of follow-up based on 12 a priori selected pro- and antioxidant dietary and non-dietary lifestyle factors, with higher scores indicating a more favorable antioxidant balance. A set of metabolites predicting OBS was selected from 388 candidate metabolites using elastic net regression. Multivariable Cox models were used to examine the associations between the OBS metabolite signature and incident CVD and T2D. RESULTS:A subset of 21 metabolites was consistently selected (amino acids, vitamins, nucleotides, lipid species, xenobiotics, and others). The metabolite signature was inversely associated with incident CVD in the baseline sample (HR per SD 0.70; 95% CI 0.61-0.81), but not in the 1-year sample (HR 0.94; 95% CI 0.81-1.09). In addition, baseline (HR 0.70; 95% CI 0.60-0.80) and 1-year (HR 0.84; 95% CI 0.72-0.97) OBS metabolite signatures were inversely associated with T2D risk. CONCLUSIONS:A plasma metabolite signature reflecting oxidative balance-related exposures was inversely associated with CVD and T2D risk at baseline. The association with T2D was also observed when the signature was applied to 1-year measurements and in an independent external cohort, whereas the association with CVD was not replicated at 1 year. Most metabolites showed biologically plausible patterns, correlating with specific pro- and antioxidant exposures and including metabolites previously implicated in oxidative stress-related processes. CLINICAL TRIAL REGISTRATION:This trial was registered at controlled-trials.com as ISRCTN35739639.

Objective This study aimed to identify metabolomic profiles associated with type 2 diabetes and insulin resistance (HOMA-IR) and relate them to the risk of total mortality. Methods A longitudinal study was conducted in a subset of participants from a diabetes case-cohort study (mean age, 66.5 years; 62% women; 176/699 with incident T2D) within the PREDIMED trial. Plasma metabolites were analyzed using LC-MS/MS methods at baseline (discovery sample) and 1-year follow-up (validation sample). Multi-metabolite profile scores for type 2 diabetes and HOMA-IR, respectively, were derived using elastic net regression. Cox proportional hazards were fitted to assess the association between metabolomic profiles and total mortality, adjusting for potential confounders. External validation was performed in the NHS/HPFS cohorts. Results A total of 31 metabolites were associated with type 2 diabetes and 105 with HOMA-IR. Both metabolomic profiles were significantly associated with a higher risk of total mortality (type 2 diabetes HR = 1.52, 95%CI: 1.04–2.25; HOMA-IR HR = 1.33, 95%CI: 1.00–1.75) in the PREDIMED cohort. Shared metabolites between both metabolomic signatures, including glycine, SDMA, DMGV, and phosphocreatine, were associated with mortality. These associations were replicated in a pooled analysis of three independent American cohorts (type 2 diabetes HR = 1.09, 95%CI: 1.05–1.13; HOMA-IR HR = 1.04, 95%CI: 1.00–1.09). Conclusions In an older population at high cardiometabolic risk, metabolomic scores of type 2 diabetes and insulin resistance were associated with total mortality risk, potentially explaining some mechanisms behind the increased risk of mortality observed in epidemiological studies for individuals with glycemic dysregulations.

Background/Objectives: Whether habitual dietary omega-3 fatty acid intake is reflected in circulating biomarkers of atrial fibrillation (AF)-related pathways is unclear. We assessed whether usual dietary intake of n-3 fatty acids-considered as total, marine-derived, or non-marine-derived-was associated with the trajectories of five serum markers that reflect AF-related mechanistic pathways [N-terminal pro-B-type natriuretic peptide (NT-pro-BNP), high-sensitivity troponin T (hs-TnT), high-sensitivity C-reactive protein (CRP), the C-terminal propeptide of type-I procollagen (PICP), and 3-nitrotyrosine (3-NT)] over 5 years of follow-up. Methods: In 510 participants of the PREDIMED-Plus trial (older Spanish adults with metabolic syndrome), we measured plasma NT-pro-BNP, hs-TnT, CRP, PICP, and 3-NT at baseline and after 3 and 5 years. Energy-adjusted omega-3 intake was assessed with a validated 143-item food-frequency questionnaire. Cross-sectional and 5-year longitudinal associations according to tertiles of omega-3 fatty acid intake were estimated with linear regression and mixed-effects models. Results: Median total omega-3 intake was 2.0 g/day. Total omega-3 intake was not associated with any biomarker, neither cross-sectionally nor longitudinally. Marine omega-3 was directly associated cross-sectionally with 3-NT (highest vs. lowest tertile +28.4%, 95% CI 5.5 to 56.2; p-trend = 0.014) but not longitudinally. Moderate baseline non-marine omega-3 fatty acid intake was associated with a decrease in PICP after 5 years of follow-up. Conclusions: Overall, habitual total omega-3 fatty acid intake was not associated with circulating AF-related pathways. The sporadic association between marine omega-3 fatty acid intake and 3-NT in the cross-sectional assessment and the isolated non-linear association between baseline non-marine omega-3 fatty acid intake and PICP after 5 years warrant further investigation.

Blood biomarkers can characterize the atrial substrate and help elucidate mechanisms of atrial fibrillation (AF) development. Understanding whether sedentary behavior affects AF-related biomarkers may inform prevention strategies. We studied 252 participants in PREDIMED-Plus, a multicenter randomized trial in Spain for the primary prevention of cardiovascular disease. Participants wore wrist accelerometers for one week at baseline and at least once during follow-up (years 3 or 5). Blood samples were collected at each time point to measure selected biomarkers: propeptide of procollagen type I, high-sensitivity (hs) troponin T (hsTnT), hs C-reactive protein, 3-nitrotyrosine, and N-terminal propeptide of B-type natriuretic peptide (NT-proBNP). Using isotemporal substitution, we estimated the effect of replacing 30 min/day of sedentary time (< 1.5 METs in waking time) with low-intensity physical activity (LPA, 1.5–3 METs), moderate-to-vigorous PA (MVPA, > 3 METs), or time in bed (bedtime to wake-up) on log-transformed biomarker levels, cross-sectionally and longitudinally, via linear regression and mixed models. At baseline, participants (mean age 65 ± 4.9 years, BMI 32.2 ± 3.3 kg/m², 40

The effect of alcohol consumption on atrial fibrillation risk remains controversial. Evaluating the association of alcohol consumption with atrial fibrillation-related biomarkers may help better understand the relevant mechanistic underpinnings. We studied participants from the PREDIMED-Plus study, a weight-loss randomised trial in metabolically unhealthy adults. N-terminal pro-B-type natriuretic protein, high-sensitivity troponin-T (hsTnT), high-sensitivity C-reactive protein (hsCRP), 3-nitrotyrosine and procollagen type 1 carboxy-terminal propeptide were measured in serum at baseline and years 3 and 5 of follow-up. We calculated average alcohol consumption in drinks/d (1 drink = 14 grams alcohol) with validated FFQ. Using multivariable models, we estimated cross-sectional and longitudinal associations of alcohol consumption with log-transformed biomarkers. Among 523 participants (mean age (sd): 65·1 (4·9) years, 40 % female), mean alcohol consumption was 1 drink/d. Cross-sectionally, alcohol consumption was not associated with cardiac biomarkers. Longitudinally, compared with non-consumers, heavy drinkers at baseline (≥ 4 drinks/d) had smaller increases in hsTnT (β: -0·10, 95 % CI: -0·20, 0·00) over 5 years. In contrast, those who increased alcohol consumption over follow-up experienced greater increases in hsCRP (β: 0·31, 95 % CI: 0·00, 0·63) compared with those whose drinking behaviour stayed the same. In this high-risk population, higher baseline alcohol intake was associated with smaller increases in hsTnT over follow-up while increases in alcohol intake over time were associated with higher levels of systemic inflammation. These findings highlight the importance of considering longitudinal changes in average alcohol exposure when evaluating its relationship with cardiometabolic biomarkers.

BACKGROUND AND AIMS:Moderate wine consumption has been associated with lower cardiovascular disease (CVD) risk in older populations. However, wine consumption information through self-reports is prone to measurement errors inherent to subjective assessments. The aim of this study was to evaluate the association between urinary tartaric acid, an objective biomarker of wine consumption, and the rate of a composite clinical CVD event. METHODS:A case-cohort nested study was designed within the PREDIMED trial with 1232 participants: 685 incident cases of CVD and a random subcohort of 625 participants (including 78 overlapping cases). Wine consumption was registered using validated food frequency questionnaires. Liquid chromatography-tandem mass spectrometry was used to measure urinary tartaric acid at baseline and after one year of intervention. Weighted Cox regression models were used to estimate hazard ratios (HRs) of CVD. RESULTS:Tartaric acid was correlated with self-reported wine consumption at baseline [r = 0.46 (95% CI 0.41; 0.50)]. Five categories of post hoc urinary tartaric acid excretion were used for better representation of risk patterns. Concentrations of 3-12 and 12-35 μg/mL, which reflect ∼3-12 and 12-35 glasses/month of wine, were associated with lower CVD risk [HR 0.62 (95% CI 0.38; 1.00), P = .050 and HR 0.50 (95% CI 0.27; 0.95), P = .035, respectively]. Less significant associations between self-reported wine consumption and CVD risk were observed. CONCLUSIONS:Light-to-moderate wine consumption, measured through an objective biomarker (tartaric acid), was prospectively associated with lower CVD rate in a Mediterranean population at high cardiovascular risk.

Breastfeeding is inversely associated with cardiometabolic disease incidence in prospective studies; however, the metabolic pathways underlying these associations remain largely unknown. Here, we derive a plasma metabolomic score of lifetime total duration of breastfeeding using elastic net regularized regression in Nurses’ Health Studies (n = 4349) and replicate in the Women’s Health Initiative (n = 2088). Data include 181 untargeted plasma metabolites profiled by liquid chromatography mass spectrometry using blood samples collected in mid-life, and self-reported lifetime total duration of breastfeeding. We then examine the associations between the metabolite-based breastfeeding score and risk of T2D and CVD using multivariable Cox regression models and replicated in two external cohorts. The metabolite-based breastfeeding score comprised of 5 metabolites (i.e., C54:2 triglyceride, C56:2 triglyceride, C56:3 triglyceride, cotinine, indole-3-propionate), which show a modest but statistically significant correlation with lifetime total duration of breastfeeding. The metabolite-based breastfeeding score significantly inversely associate with T2D incidence (HR = 0.76, 95

Dietary guidelines recommend replacing saturated fatty acid with unsaturated fats, particularly polyunsaturated fatty acids. Cohort studies do not suggest a clear benefit of higher intake of polyunsaturated fatty acids but, in contrast, higher circulating linoleic acid (LA) levels—reflective of dietary LA intake, are associated with a reduced risk of type 2 diabetes. However, genetic variants in the fatty acid desaturase 1 gene (FADS1) may influence individual responses to plant-based fats. We explored whether FADS1 variants influence the relationships of LA and α-linolenic acid (ALA) intakes and nut consumption with plasma phospholipid fatty acid profiles and type 2 diabetes risk in a large-scale cohort study and a randomized controlled trial. In the EPIC-InterAct case-cohort (7,498 type 2 diabetes cases, 10,087 subcohort participants), we investigated interactions of dietary and plasma phospholipid fatty acids and nut consumption with FADS1 rs174547 in relation to incident type 2 diabetes using weighted Cox regression. In PREDIMED (492 participants in the Mediterranean Diet + Nuts intervention group, 436 participants in the control group), we compared changes in plasma phospholipid FAs from baseline to year 1. In EPIC-InterAct and PREDIMED, nut consumption was positively associated with LA plasma levels and inversely with arachidonic acid, the latter becoming stronger with increasing number of the minor rs174547 C allele (p interaction EPIC-InterAct: 0.030, PREDIMED: 0.003). Although the inverse association of nut consumption with diabetes seemed stronger in participants with rs174547 CC-genotype (HR: 0.73, 95

The Mediterranean diet (MedDiet) is strongly associated with lower cardiovascular disease (CVD) risk and is particularly rich in polyphenols, bioactive compounds with potential cardioprotective effects. However, the specific phenolic compounds underlying these benefits remain unclear. The objective of this study was to develop a urinary multi-metabolite signature of phenolic compounds reflecting MedDiet adherence and to evaluate its prospective association with CVD risk. In a case–cohort nested study within the PREDIMED trial, we measured 62 phenolic metabolites in spot urine by liquid chromatography–high‐resolution mass spectrometry at baseline and after 1 year in 1180 individuals: 653 incident CVD cases (stroke, myocardial infarction, CVD death, or heart failure) and a random subcohort of 603 participants (76 overlapping cases). We applied elastic net regression to derive a urinary multi-metabolite signature prospectively associated with MedDiet adherence, measured by the validated 14-item Mediterranean Diet Adherence Screener (MEDAS). Multivariable Cox models were used to estimate hazard ratios (HRs) of CVD by levels of the multi-metabolite signature. The urinary multi-metabolite signature, comprising eight phenolic compounds selected by elastic net regression, was inversely associated with CVD risk in a dose–response pattern (HR per SD = 0.80 (0.68–0.94); HR Q4 vs Q1 = 0.48 (0.30–0.78); p-trend = 0.002). The metabolites included in the signature were derived from foods typical of the MedDiet, particularly virgin olive oil, wine, nuts, fruits, and vegetables. After 1 year, MedDiet interventions significantly increased urolithin A metabolites (derived from walnuts) compared to the control group. We identified a urinary multi-metabolite signature of MedDiet adherence that is prospectively associated with lower CVD incidence. These findings support that polyphenols derived from the MedDiet showed inverse associations with cardiovascular outcomes. The study was registered with the International Standard Randomized Controlled Trial Number (ISRCTN) 35739639.

Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide. Although catheter ablation is the most efficacious therapy, relapses occur frequently (30%) in the first year after ablation. Novel biomarkers of recurrence are needed for a better prediction of recurrence and management of AF. In this pilot study, we aimed to analyze the baseline proteome of subjects included in a case-control study to find differential proteins associated with AF recurrence. Methods: Baseline serum proteomics (354 proteins) data from 16 cases (recurrent AF) and 17 controls (non-recurrent) were obtained using MS/MS analysis. A false discovery rate was performed using a nonlinear fitting method for the selection of proteins. Logistic regression models were used to further analyze the association between differentially expressed proteins and AF recurrence. Results: Ten proteins were differentially represented in cases vs. controls. Two were upregulated in the cases compared to the controls: keratin type I cytoskeletal 17 (Fold-change [FC] = 2.14; p = 0.017) and endoplasmic bifunctional protein (FC = 1.65; p = 0.032). Eight were downregulated in the cases compared to the controls: C4bpA (FC = 0.64; p = 0.006), coagulation factor XI (FC = 0.83; p = 0.011), CLIC1 (FC = 0.62; p = 0.017), haptoglobin (FC = 0.37; p = 0.021), Ig alpha-2 chain C region (FC = 0.49; p = 0.022), C4bpB (FC = 0.73; p = 0.028), N-acetylglucosamine-1-phosphotransferase subunit gamma (FC = 0.61; p = 0.033), and platelet glycoprotein Ib alpha chain (FC = 0.84; p = 0.038). Conclusion: This pilot study identifies ten differentially expressed serum proteins associated with AF recurrence, offering potential biomarkers for improved prediction and management.

Background:Blood biomarkers can characterize the atrial substrate, helping to elucidate mechanisms of atrial fibrillation (AF) development. Understanding whether sedentary behavior affects AF-related biomarkers is key for future prevention strategies. Methods:We studied 252 participants in PREDIMED-Plus, a multicenter randomized trial in Spain for the primary prevention of cardiovascular disease. A wrist-worn accelerometer was used to measure physical activity (PA) in a week at baseline and at least once during follow-up at years 3 and 5. Blood samples were collected at each time point to measure selected cardiovascular biomarkers: propeptide of procollagen type I, high-sensitivity (hs) troponin T (hsTnT), hs C-reactive protein, 3-nitrotyrosine, and N-terminal propeptide of B-type natriuretic peptide (NT-proBNP). Sedentary time was assessed as inactive time (< 1.5 METs in waking time). Using isotemporal substitution, we analyzed the impact of replacing 30-min sedentary time per day with low-intensity PA (LPA, 1.5-3 METs), moderate to vigorous PA (MVPA, > 3 METs) and time in bed (time difference between going to bed and getting up) on log-transformed biomarkers cross-sectionally and longitudinally, using linear regression and mixed models. Results:At baseline, 252 eligible participants averaged 65 years of age (SD 4.9), and BMI 32.2 kg/m2 (SD 3.3), and 40% were female. Cross-sectionally, replacing 30-min sedentary time with LPA, MVPA, or time in bed had no significant association with biomarkers. After 5 years, replacing baseline 30-min of sedentary time per day with LPA or MVPA was associated with lower hs-TnT concentrations compared to baseline (-4%, 95% CI -8%, -1%; -2%, 95% CI -7%, 4%, respectively). Substituting 30-min sedentary time with LPA or MVPA showed nonsignificant reductions in NT-proBNP (-3%, 95% CI -11%, 5%; -8%, 95% CI -20%, 5%, respectively), but not a consistent association with other biomarkers. Conclusion:In overweight/obese individuals, prolonged sedentary time, when compared to engaging in PA, was associated with unfavorable changes of hs-TnT over 5 years, but no significant impact on other AF-related biomarkers.

Background Exploring longitudinal associations of blood biomarkers with left atrial (LA) structure and function can enhance our understanding of atrial fibrillation (AF) etiopathogenesis. Methods We studied 532 participants of the PREDIMED-Plus trial, a multicenter randomized trial in overweight and obese adults with metabolic syndrome. At baseline, 3 and 5 years after randomization, participants underwent transthoracic echocardiography and provided blood for serum biomarker measurements (propeptide of procollagen type I (PICP), high-sensitivity (hs) troponin T (hsTnT), hs C-reactive protein (hsCRP), 3-nitrotyrosine (3-NT), and N-terminal propeptide of B-type natriuretic peptide (NT-proBNP)). Outcomes of interest included LA peak systolic longitudinal strain (LA PSLS), LA volume index (LAVi), LA function index (LAFi), and LA stiffness index (LASi). We performed cross-sectional and longitudinal analyses to evaluate relationships between log-transformed biomarkers and echocardiographic measurements using multiple linear regression and mixed models. Results The participants in this analysis had a mean age of 65.0 (SD 4.8) years, and 40% were females. At baseline, increased NT-proBNP and hsTnT were associated with larger LAVi and worse LA function as measured by the LAFi, LASi, and LA PSLS. Longitudinally, higher NT-proBNP, but not higher hsTnT, was associated with increased LAVi and worsening LA function. Over 5 years, 1 unit increase in log(NT-proBNP) was associated with steeper decline in LA PSLS (-0.19%, 95% confidence intervals (CI) -0.35%, -0.02%) and greater increase in LAVi (0.28 mL/m2, 95% CI 0.10, 0.45) each year. PICP, hsCRP, and 3-NT did not show consistently significant associations with LA outcomes at baseline and through 5 years. Conclusion In an overweight and obese population, higher NT-proBNP was associated with LA volume enlargement and worsening LA function over 5 years. The implications of these findings for the prevention and prediction of AF warrant further investigation.

Metabolome-based biomarkers contribute to identify mechanisms of disease and to a better understanding of overall mortality. In a long-term follow-up subsample (n = 1878) of the PREDIMED trial, among 337 candidate baseline plasma metabolites repeatedly assessed at baseline and after 1 year, 38 plasma metabolites were identified as predictors of all-cause mortality. Gamma-amino-butyric acid (GABA), homoarginine, serine, creatine, 1-methylnicotinamide and a set of sphingomyelins, plasmalogens, phosphatidylethanolamines and cholesterol esters were inversely associated with all-cause mortality, whereas plasma dimethylguanidino valeric acid (DMGV), choline, short and long-chain acylcarnitines, 4-acetamidobutanoate, pseudouridine, 7-methylguanine, N6-acetyllysine, phenylacetylglutamine and creatinine were associated with higher mortality. The multi-metabolite signature created as a linear combination of these selected metabolites, also showed a strong association with all-cause mortality using plasma samples collected at 1-year follow-up in PREDIMED. This association was subsequently confirmed in 4 independent American cohorts, validating the signature as a consistent predictor of all-cause mortality across diverse populations.

Background: Evidence from observational studies and randomized trials suggest a favorable role of omega-3 fatty acids on cardiovascular outcomes. However, whether omega-3 fatty acids may reduce the incidence of peripheral artery disease (PAD) is not known. Aims: We prospectively evaluated blood and adipose tissue levels of alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), docosahexaenoic acid (DHA), and the sum of EPA and DHA, with respect to incident PAD. Methods: We included 11 prospective studies from a global consortium up to May 2023 with measurements of ALA, EPA, DPA, or DHA (as a % of total fatty acids) in blood or adipose tissue among adults (age≥18), who were free of coronary artery disease, stroke, and PAD at baseline, and assessed incident PAD events. Each cohort conducted de novo individual-level analyses with a prespecified analytical plan and harmonized definitions for exposures, outcomes, covariates (including demographics, cardiovascular risk factors, medication use, and omega-6 fatty acid levels), and subgroups. Pooled hazard ratios (HRs) were calculated using inverse-variance weighted meta-analysis. Results: Among 142,316 participants from North America, Europe, and Australia followed for a weighted median of 13.7 years (range of median follow-up: 9.8 to 26.2 years), 1,842 incident cases of PAD were ascertained. In multivariable-adjusted pooled analysis, very long-chain EPA, DPA, DHA, and EPA+DHA each associated with lower PAD incidence, with HRs (95% CI) per interquintile range of 0.79 (0.69, 0.91), 0.80 (0.68, 0.95), 0.74 (0.64, 0.85), and 0.79 (0.69, 0.90), respectively ( P <0.01 for each) ( Figure 1 ). Long-chain ALA was not associated with PAD, 1.14 (0.98, 1.33). Heterogeneity between studies was low to moderate ( I 2\ ranging from 0% to 57%). Results were broadly consistent in prespecified subgroups by age, sex, smoking status, prevalent diabetes, and biomarker lipid fraction. Conclusion: In this large international consortium, objective levels of very long-chain, but not long-chain, omega-3 fatty acids inversely associated with incident PAD. Our data suggest a protective role for very long-chain omega-3 fatty acids in the development of PAD, supporting the need for further mechanistic studies and appropriately powered randomized controlled trials.

Objectives Frailty has emerged as a key indicator of biological aging. This study aimed to assess the relationship between MedDiet adherence and frailty prevalence in the context of metabolic syndrome (MetS). Design Cross-sectional study. Baseline data from PREDIMED-Plus trial Setting Primary care health, 23 recruitment sites (2013–2016). Participants A total of 6874 participants with overweight/obesity and ≥3 MetS components. Measurements Adherence to the MedDiet: 17-item MedDiet score. Frailty and prefrailty (3 or 1–2 criteria): modified Fried Frailty Index (FFI), considering exhaustion, physical activity and functional capacity. Main independent variable was analysed: as a continuous variable (range: 0–17); in quartiles of adherence using univariate and multivariate logistic regression models adjusted for potential confounders. Results Prefrailty and frailty prevalence were 49.7% and 2.9%, respectively. Compared to those with the lowest MedDiet adherence (0–6), participants with the highest adherence (11–17) had significantly lower odds of meeting frailty criteria. Fully adjusted models showed ORs of 0.479 (p = 0.097) for frailty, 0.705 (p = 0.001) for prefrailty, and 0.694 (p = 0.001) for frailty or prefrailty in participants with higher/greater MedDiet adherence. Each 1-point increase in the 17-item score was associated with an OR ranging from 0.878 to 0.977 (p < 0.05 for all comparisons, except functional capacity: p = 0.100). When adherence was dichotomized, the adjusted ORs ranged from 0.406 to 0.834 (p < 0.05 for all comparisons). Conclusions Higher adherence to MedDiet was associated with a lower prevalence of frailty and prefrailty in older adults with overweight/obesity and MetS, reinforcing its potential role in promoting healthy aging despite cardiometabolic comorbidities.