Dear Editors,

We have read with great interest the article Adherence to the Mediterranean Diet and Depression, Anxiety, and Stress Symptoms in Chilean University Students: A Cross-Sectional Study by Morales et al. ¹1. Morales G, Balboa-Castillo T, Fernández-Rodríguez R, Garrido-Miguel M, Guidoni CM, Sirtoli R, et al. Adherence to the Mediterranean diet and depression, anxiety, and stress symptoms in Chilean university students: a cross-sectional study. Cad Saúde Pública 2023; 39:e00206722., and consider it significant in the field of early cardiovascular prevention.

The authors found that adherence to the Mediterranean diet and consumption of fruit, vegetables, nuts, avocado, fish, and seafood are associated with a lower likelihood of depression in Chilean university students.

Regarding the findings reported in the paper, we would like to make the following contribution to the discussion. Atherosclerosis - which is the basis of cardiovascular diseases - is a long process that begins in the childhood and is the main cause of cardiovascular events in adulthood and old age ²2. D'Ascenzi F, Sciaccaluga C, Cameli M, Cecere A, Ciccone MM, Di Francesco S, et al. When should cardiovascular prevention begin? The importance of antenatal, perinatal and primordial prevention. Eur J Prev Cardiol 2021; 28:361-9.^,33. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's Strategic Impact Goal through 2020 and beyond. Circulation 2010; 121:586-613.. Unfortunately, it is known that there is a lack of awareness on the relevance of early intervention, especially among young people and women ⁴4. Vogel B, Acevedo M, Appelman Y, Merz CNB, Chieffo A, Figtree GA, et al. The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030. Lancet 2021; 397:2385-438.^,55. Mattioli AV, Moscucci F, Sciomer S, Maffei S, Nasi M, Pinti M, et al. Cardiovascular prevention in women: un update by the Italian Society of Cardiology working group on "Prevention, hypertension and peripheral disease". J Cardiovasc Med (Hagerstown) 2023; 24 Suppl 2:e147-55.. Stress and depression exert a notable influence on dietary behaviors, manifesting in various ways that differ among individuals. The relation between stress and diet is complex, and its effects can be both immediate or long-lasting. Common patterns are emotional eating and cravings ⁶6. Rodríguez-Martín BC, Meule A. Food craving: new contributions on its assessment, moderators, and consequences. Front Psychol 2015; 6:21.^,77. Mattioli AV, Coppi F, Nasi M, Gallina S. Stress and cardiovascular risk burden after the pandemic: current status and future prospects. Expert Rev Cardiovasc Ther 2022; 20:507-13.^,88. Ha OR, Lim SL. The role of emotion in eating behavior and decisions. Front Psychol 2023; 14:1265074.. Emotional eating is a coping mechanism that often involves consuming foods that provide comfort, with high content of calories, sugar, or unhealthy fats. Furthermore, stress can induce specific cravings, typically for sugar-, fat-, and salt-rich foods ⁶6. Rodríguez-Martín BC, Meule A. Food craving: new contributions on its assessment, moderators, and consequences. Front Psychol 2015; 6:21.^,77. Mattioli AV, Coppi F, Nasi M, Gallina S. Stress and cardiovascular risk burden after the pandemic: current status and future prospects. Expert Rev Cardiovasc Ther 2022; 20:507-13.^,88. Ha OR, Lim SL. The role of emotion in eating behavior and decisions. Front Psychol 2023; 14:1265074.. Under stress, individuals may opt for convenience foods that are quick to obtain but often lack nutritional value, contributing to unhealthy eating habits. Stress can also disrupt normal eating habits, leading to either overeating or undereating. Both patterns can hold implications for overall health ^7,8. Obesity induces an inflammatory state characterized by an increase in leptin levels, a pro-inflammatory adipokine, and decreased levels of adiponectin, an anti-inflammatory adipokine, have been reported ⁷7. Mattioli AV, Coppi F, Nasi M, Gallina S. Stress and cardiovascular risk burden after the pandemic: current status and future prospects. Expert Rev Cardiovasc Ther 2022; 20:507-13.^,88. Ha OR, Lim SL. The role of emotion in eating behavior and decisions. Front Psychol 2023; 14:1265074.^,99. Barrea L, Verde L, Suárez R, Frias-Toral E, Vásquez CA, Colao A, et al. Sex-differences in Mediterranean diet: a key piece to explain sex-related cardiovascular risk in obesity? A cross-sectional study. J Transl Med 2024; 22:44.^,1010. Li DL, Hodge AM, Cribb L, Southey MC, Giles GG, Milne RL, et al. Body size, diet quality, and epigenetic ageing: cross-sectional and longitudinal analyses. J Gerontol A Biol Sci Med Sci 2024; (Online ahead of print).. Inflammation has been strongly associated with the development of atherosclerosis. Regular physical activity helps in the fight against obesity and inflammation. An additional beneficial effect of regular physical activity in managing stress has been suggested ¹¹11. Bucciarelli V, Mattioli AV, Sciomer S, Moscucci F, Renda G, Gallina S. The impact of physical activity and inactivity on cardiovascular risk across women's lifespan: an updated review. J Clin Med 2023; 12:4347.. The Mediterranean diet offers many benefits for health ¹²12. Zupo R, Castellana F, Piscitelli P, Crupi P, Desantis A, Greco E, et al. Scientific evidence supporting the newly developed one-health labeling tool "Med-Index": an umbrella systematic review on health benefits of Mediterranean diet principles and adherence in a planeterranean perspective. J Transl Med 2023; 21:755.^,1313. Truzzi ML, Ballerini Puviani M, Tripodi A, Toni S, Farinetti A, Nasi M, et al. Mediterranean diet as a model of sustainable, resilient and healthy diet. Progress in Nutrition 2020; 22:388-94.. Undoubtedly, fruit and vegetable intake is a good index for assessing a good diet and, as is known, it is extremely variable in young people and also shows differences between sexes ¹⁴14. Chukwuma CI. Antioxidative, metabolic and vascular medicinal potentials of natural products in the non-edible wastes of fruits belonging to the Citrus and Prunus genera: a review. Plants (Basel) 2024; 13:191.^,1515. Mattioli AV, Coppi F, Migaldi M, Farinetti A. Fruit and vegetables in hypertensive women with asymptomatic peripheral arterial disease. Clin Nutr ESPEN 2018; 27:110-2.^,1616. Aziz T, Hussain N, Hameed Z, Lin L. Elucidating the role of diet in maintaining gut health to reduce the risk of obesity, cardiovascular and other age-related inflammatory diseases: recent challenges and future recommendations. Gut Microbes 2024; 16:2297864.. Ensuring an adequate intake of vitamins and incorporating a variety of fruit and vegetables into the diet is crucial for the overall health of young individuals and can contribute to the prevention of cardiovascular disease by various mechanisms ¹⁷17. Spyksma EE, Alexandridou A, Mai K, Volmer DA, Stokes CS. An overview of different vitamin D compounds in the setting of adiposity. Nutrients 2024; 16:231..

Young subjects are less likely to adopt a healthy lifestyle ¹⁸18. Aljadani HM, Patterson A, Sibbritt D, Taylor RM, Collins CE. Frequency and variety of usual intakes of healthy foods, fruit, and vegetables predicts lower 6-year weight gain in young women. Eur J Clin Nutr 2020; 74:945-52.^,1919. Dumbrell S, Mathai D. Getting young men to eat more fruit and vegetables: a qualitative investigation. Health Promot J Austr 2008; 19:216-21.. Ünal & Özenoğlu ²⁰20. Ünal G, Özenoglu A. Association of Mediterranean diet with sleep quality, depression, anxiety, stress, and body mass index in university students: a cross-sectional study. Nutr Health 2024; (Online ahead of print). reported that adherence to the Mediterranean diet was decreasing among university students. Most students (59.2%) had poor Mediterranean diet adherence. Compared to poor adherers, subjects with good adherence to the Mediterranean diet had significantly lower depression scores and stress levels in both males and females. These results confirmed what was reported by Morales et al. ¹1. Morales G, Balboa-Castillo T, Fernández-Rodríguez R, Garrido-Miguel M, Guidoni CM, Sirtoli R, et al. Adherence to the Mediterranean diet and depression, anxiety, and stress symptoms in Chilean university students: a cross-sectional study. Cad Saúde Pública 2023; 39:e00206722..

To prevent the early development of atherosclerosis with a notable benefit in the onset of cardiovascular disease with age, it is important to raise young people’s awareness of the importance of a proper lifestyle. The recent decline in lifestyle in the Life’s Essential 8 and the inherent connection with stress and depression facilitate the identification of areas in which action should be taken ²¹21. Augé-Bailac F, Rosselló X. Value of the Life's Essential 8 score in cardiovascular health and mortality. Rev Esp Cardiol (Engl Ed) 2024; (Online ahead of print).^,2222. Fan C, Zhu W, He Y, Da M. The association between Life's Essential 8 and all-cause, cancer and non-cancer mortality in US cancer survivors: a retrospective cohort study of NHANES. Prev Med 2024; 179:107853.^,2323. Ruan YX, Wu MX, Gao JW, Guo DC, Cai JW, Huang ZG, et al. AHA Life's Essential 8 and new-onset CKD: a prospective cohort study from the UK Biobank. Clin Exp Nephrol 2023; (Online ahead of print).. Tailored interventions for young people are needed.

How to intercept young people is the key question: for young women, pregnancy seems to be an optimal time to assess cardiovascular health and promote the adoption of virtuous behaviors ²⁴24. Mattioli AV, Coppi F, Bucciarelli V, Gallina S. Cardiovascular risk stratification in young women: the pivotal role of pregnancy. J Cardiovasc Med 2023; 24:793-7.^,2525. Khan SS, Brewer LC, Canobbio MM, Cipolla MJ, Grobman WA, Lewey J, et al. Optimizing prepregnancy cardiovascular health to improve outcomes in pregnant and postpartum individuals and offspring: a scientific statement from the American Heart Association. Circulation 2023; 147:e76-91..

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