Mediterranean diet and overall mortality differences in the European Union

Association of Diet, Physical Activity Guidelines and Cardiometabolic Risk Markers in Children

The aim was to identify different dietary and physical activity (PA) patterns in 5- to 14-year-old children with a high prevalence of overweight and obesity using cluster analysis based on their adherence to the Spanish Society of Community Nutrition dietary guidelines and levels of PA, and to determine their associations with age, sex, body composition, and cardiometabolic risk markers. In 549 children, hierarchical cluster analysis was used to identify subgroups with similar adherence to dietary recommendations and level of PA. Three clusters were identified: Cluster 1, with the lowest level of vigorous PA and adherence to dietary recommendations; Cluster 2, with the lowest levels of moderate and vigorous PA and the highest adherence to dietary recommendations; and Cluster 3, with the highest level of PA, especially vigorous PA and a medium level adherence to dietary recommendations. Cluster 3 had lower total body fat and higher lean body mass percentages than Cluster 2. Cluster 2 had lower high-density lipoprotein cholesterol and higher low-density lipoprotein cholesterol levels than Cluster 1. The results from our study suggest that it is important to consider adherence to PA recommendations together with adherence to dietary guidelines to understand patterns of obesogenic habits in pediatric populations with high prevalence of overweight and obesity.

Improving Adherence to Mediterranean-Style Diet With a Community Culinary Coaching Program: Methodology Development and Process Evaluation

The Community Culinary Coaching Program is a community-based participatory program aimed at improving communal settlement residents' nutrition. The residents, central kitchens, preschools, and communal dining rooms were identified as areas for intervention. Evaluation included goals accomplishment assessed by food purchases by the central kitchens, and residents' feedback through focus groups. Purchasing included more vegetables (mean (standard error) percent change), (+7% (4); P = .32), fish (+115% (11); P < .001), whole grains, and legumes (+77% (9); P < .001); and less soup powders (-40% (9); P < .05), processed beef (-55% (8); P < .001), and margarine (-100% (4); P < .001). Residents recommended continuing the program beyond the project duration. This model might be useful in organizations with communal dining facilities.

Improving the quality of foods available in a rural kibbutz cafeteria in Israel to align with a freshly prepared Mediterranean-style diet through a community culinary coaching programme

OBJECTIVE

To examine the impact of a community culinary coaching programme (CCCP) on cafeteria food alignment with a freshly prepared Mediterranean-style diet, and diners' consumption habits and satisfaction.

DESIGN

A non-randomized, controlled, community-based participatory research programme. CCCP included eight 90 min coaching sessions with a community steering committee, 22 h of kitchen staff training, 12 h of pre-school staff training and 30 h of education for diners; control communities received no intervention. Outcomes, measured before and 12 months after programme initiation, included cafeteria food alignment with a freshly prepared Mediterranean-style diet through a food items list derived from the cafeteria food purchasing software, and adult diners' consumption habits and satisfaction through questionnaires.

SETTING

Communal cafeterias of rural kibbutzim.

PARTICIPANTS

Intervention: kibbutz with 493 adults and 214 children. Control: Two kibbutzim with a total of 487 adults and 206 children.

RESULTS

Intervention cafeteria food improved significantly in all Mediterranean index categories except nuts (legumes, wholegrain products, fish, MUFA/SFA P < 0·0001; fruits, vegetables P < 0·001; processed meats P = 0·004), and in the proportion of ultra-processed and unprocessed or minimally processed foods categories of the NOVA classification (-22 %, P < 0·001 and +7 %, P < 0·001, respectively), compared with the control community. The intervention group's satisfaction was significantly improved in twenty-five (83 %) out of the thirty satisfaction items, compared with twelve (40 %) in the control group. No changes were identified in diners' consumption habits in either intervention or control communities.

CONCLUSIONS

CCCP might be useful in improving alignment of cafeteria food with a freshly prepared Mediterranean-style diet.

Evaluation of Mediterranean diet adherence scores: a systematic review

OBJECTIVE

The aim of this review was to evaluate the conceptual suitability, applicability and psychometric properties of scores used internationally to measure adherence to the Mediterranean diet (MD).

DESIGN

This was a systematic review to identify original articles that examined some aspects of the conceptual suitability, applicability or psychometric properties of the MD adherence score. Electronic searches were carried out on the international databases MEDLINE, Scopus, Web of Science and EMBASE (from January 1980 to 31 December 2015).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

The study included original articles that examined some aspects of the conceptual suitability, applicability or psychometric properties of the MD adherence score. The studies where MD adherence scores were administered but did not bring forward any evidence about their performance related to conceptual suitability, applicability or psychometric properties were excluded.

DATA EXTRACTION

Information relating to the scales was extracted in accordance with the quality criteria defined by the Scientific Advisory Committee of the Medical Outcomes Trust for measurement of health results and the quality criteria recommended by Terwee: (1) conceptual, (2) applicability and (3) psychometric properties. Three authors independently extracted information from eligible studies.

RESULTS

Twenty-seven studies were identified as meeting the inclusion criteria, yielding 28 MD adherence scores. The results showed that evidence is scarce and that very few scores fulfilled the applicability parameters and psychometric quality. The scores developed by Panagiotakos et al, Buckland et al and Sotos-Prieto et al showed the highest levels of evidence.

CONCLUSIONS

Scores measuring adherence to MD are useful tools for identifying the dietary patterns of a given population. However, further information is required regarding existing scores. In addition, new instruments with greater conceptual and methodological rigour should be developed and evaluated for their psychometric properties.

Adherence to Mediterranean and low-fat diets among heart and lung transplant recipients: a randomized feasibility study

BACKGROUND

Heart and lung transplant recipients are at a substantially increased risk of cardiovascular disease (CVD). Since both low-fat and Mediterranean diets can reduce CVD in immunocompetent people at high risk, we assessed adherence among thoracic transplant recipients allocated to one or other of these diets for 12 months.

METHODS

Forty-one transplant recipients (20 heart; 21 lung) randomized to a Mediterranean or a low-fat diet for 12 months received diet-specific education at baseline. Adherence was primarily assessed by questionnaire: 14-point Mediterranean diet (score 0-14) and 9-point low-fat diet (score 0-16) respectively, high scores indicating greater adherence. Median scores at baseline, 6 months, 12 months, and 6-weeks post-intervention were compared by dietary group. We further assessed changes in weight, body mass index (BMI) and serum triglycerides from baseline to 12 months as an additional indicator of adherence.

RESULTS

In those randomized to a Mediterranean diet, median scores increased from 4 (range 1-9) at baseline, to 10 (range 6-14) at 6-months and were maintained at 12 months, and also at 6-weeks post-intervention (median 10, range 6-14). Body weight, BMI and serum triglycerides decreased over the 12-month intervention period (mean weight - 1.8 kg, BMI -0.5 kg/m2, triglycerides - 0.17 mmol/L). In the low-fat diet group, median scores were 11 (range 9-14) at baseline; slightly increased to 12 (range 9-16) at 6 months, and maintained at 12 months and 6 weeks post-intervention (median 12, range 8-15). Mean changes in weight, BMI and triglycerides were - 0.2 kg, 0.0 kg/m2 and - 0.44 mmol/L, respectively.

CONCLUSIONS

Thoracic transplant recipients adhered to Mediterranean and low-fat dietary interventions. The change from baseline eating habits was notable at 6 months; and this change was maintained at 12 months and 6 weeks post-intervention in both Mediterranean diet and low-fat diet groups. Dietary interventions based on comprehensive, well-supported education sessions targeted to both patients and their family members are crucial to success. Such nutritional strategies can help in the management of their substantial CVD risk.

TRIAL REGISTRATION

The IRAS trial registry ( ISRCTN63500150 ). Date of registration 27 July 2016. Retrospectively registered.

Mediterranean Diet and Its Correlates among Adolescents in Non-Mediterranean European Countries: A Population-Based Study

Little is known about the factors which might influence the adherence to a Mediterranean diet in non-Mediterranean European countries. Thus, the main purpose of this study was to determine the associations between socioeconomic, psychological, and physical factors on a Mediterranean diet. In this cross-sectional study, participants were 14–18-year-old adolescents (N = 3071) from two non-Mediterranean countries: Lithuania (N = 1863) and Serbia (N = 1208). The dependent variable was Mediterranean diet, and was assessed with the Mediterranean Diet Quality Index for children and adolescents questionnaire. Independent variables were gender, body-mass index, self-rated health, socioeconomic status, psychological distress, physical activity, and sedentary behavior. The associations between dependent and independent variables were analyzed by using logistic regression. Results showed that higher adherence to a Mediterranean diet was associated with higher self-rated health, socioeconomic status, and physical activity, yet low adherence to a Mediterranean diet was associated with being female, having higher body-mass index, psychological distress, and sedentary behavior. Our findings suggest that future studies need to explore associations between lifestyle habits—especially in target populations, such as primary and secondary school students.

Short-term prognosis of patients with acute coronary syndromes through the evaluation of physical activity status, the adoption of Mediterranean diet and smoking habits: the Greek Acute Coronary Syndromes (GREECS) study

PURPOSE

Our aim was to evaluate whether healthy dietary habits, physical activity and non-smoking are associated with less severe acute coronary syndromes and better short-term prognosis.

SUBJECTS AND METHODS

From October 2003 to September 2004, 2172 patients (1649 males), hospitalized for severe acute coronary syndromes in six major hospitals in Greece were included in the study. The severity of severe acute coronary syndromes was assessed through troponin-I and maximum creatinine kinase MB levels, while 30-day recurrent event rate (death or rehospitalization for cardiovascular disease, angioplasty or coronary artery bypass surgery) was used to evaluate the prognosis of the patients. A 'healthy index' that assessed adherence to the Mediterranean diet, moderate alcohol intake, physical activity and abstinence from smoking was developed (range 0-4).

RESULTS

One unit increment in the healthy index was associated with -12.4+/-2.4 ng/ml decrease in troponin I levels (P=0.001) and -9.7+/-2.5 ng/ml decrease in maximum creatinine kinase MB levels (P=0.001). The in-hospital mortality rate was 3.2% in males and 5.7% in females (i.e. overall 82 deaths, P=0.009); during the first 30 days following hospitalization the event rate was 15.7% in males and 16.3% in females (P=0.001). Values of the healthy index above one (i.e. presence of two or more protective factors) seemed to be associated with 44-84% lower risk of having recurrent events (P<0.001), even after various adjustments were made.

CONCLUSION

Among patients who had had severe acute coronary syndromes, a healthy lifestyle seemed to be associated with less severe cardiac events and lower risk of death or rehospitalization 30 days after the event.

A Comparison of Food Supply from 1984 to 2009 and Degree of Dietary Westernization in Taiwan with Asian Countries and World Continents

OBJECTIVE

To compare quality, quantity, and trends of food supply from 1984 to 2009 and degree of food westernization in Taiwan with Asian countries and world continents by using food balance data.

METHODS

We compiled data from food balance sheets of Taiwan and Food and Agriculture Organization, including five continents and three most populated countries each in Eastern, Southern, and Southeastern Asia over the period 1984-2009. Quantity of food supply per capita was referenced to Taiwan food guides. The population-weighted means of food supply from Europe, North America, South America, and Australia and New Zealand continents in terms of energy and nutrient distributions, animal/plant sources, and sugar/alcohol contribution were used as indicators of westernization. Trends of food supply per capita of six food groups were plotted, and linear regression was applied to evaluate food changes.

FINDINGS

Taiwan's food supply provided sufficient quantity in food energy, with the lowest cereals/roots supply and rice to wheat ratio, but the highest meat and oil supplies per capita among the 10 studied Asian countries. Taiwan food supply showed the most westernization among these countries.

CONCLUSION

Food supply of Taiwan, although currently sufficient, indicated some security problems and high tendency of diet westernization.

Micronutrient intakes among children and adults in Greece: the role of age, sex and socio-economic status

The aim of the present study was to report the usual nutrient intakes of sixteen micronutrients by schoolchildren, adults and the elderly in Greece and to further explore the role of age, sex and socio-economic status (SES) on meeting the recommended nutrient intakes. Dietary intake, demographic and SES data from three existing studies conducted in Greece (in 9–13-year-old children; 40–60-year-old adults; and 50–75-year-old women) were collected. The prevalence of study participants with inadequate micronutrient intakes were assessed using the estimated average requirement (EAR) cut-point method. Regarding sex and age differences, the highest prevalences of inadequate nutrient intakes occurred in post-menopausal women. In both sexes and all age groups, the prevalence of vitamin D intake below EAR reached 100%. Furthermore, nutrient intakes of 75% or more below EAR were found for vitamin E in all age groups, folate in women and for calcium and magnesium in post-menopausal women (p < 0.05). Regarding SES differences, the prevalences of inadequate calcium and vitamin C intakes were higher for children and postmenopausal women of lower SES compared to their higher SES counterparts (p < 0.05). The current study reported the highest prevalences of inadequate intakes for both sexes and all age and SES groups for calcium, folate and vitamins D and E. These findings could provide guidance to public health policy makers in terms of updating current dietary guidelines and fortifying foods to meet the needs of all population subgroups.

How health conditions translate into self-ratings: a comparative study of older adults across Europe

Using data from the Survey of Health, Ageing and Retirement in Europe, we examine how respondents translate morbidity and disability into self-rated health (SRH), how national populations differ in SRH, and how normative and person-specific reporting styles shape SRH. We construct proxy variables that allow us to specify cultural differences in reporting styles and individual differences in relative rating behavior. Using generalized logistic regression, we find that both of these dimensions of subjectivity are related to SRH; however, their inclusion does not significantly alter the connection between SRH and the set of disease and disability indicators. Further, country differences in SRH persist after controlling for all these factors. Our findings suggest that observed country differences in SRH reflect compositional differences, cultural differences in reporting styles, and perceptions of how health restricts typical activities. SRH also seems to capture underlying but unmeasured health differences across populations.

Mediterranean diet adherence rates in Sicily, southern Italy

OBJECTIVE

To assess adherence to the Mediterranean diet and nutrient intakes in a population of Sicily, southern Italy and to evaluate possible determinants, particularly socio-cultural and lifestyle factors.

DESIGN

Cross-sectional.

SETTING

Urban and rural areas of eastern Sicily.

SUBJECTS

Between May 2009 and December 2010, 3090 adults were randomly recruited through the collaboration of fourteen general practitioners. Adherence to the Mediterranean diet was measured by the MedDietScore. Nutrient intakes were assessed through the 24 h recall of the previous day's dietary intake.

RESULTS

Rural participants were barely more adherent to the Mediterranean diet than their urban counterparts (mean scores were 27·8 and 27·2, respectively, P = 0·037). The MedDietScore was correlated with intakes of MUFA, fibre and vitamin C, as well as with consumption of non-refined cereals, vegetables, fruit, meat, dairy products, alcohol and nuts. Regression analysis revealed that older and more educated people were more likely to be in the highest tertile of MedDietScore (OR = 1.90; 95 % CI 1·39, 2·59 and OR = 1·29; 95 % CI 1·05, 1·58, respectively). A significant difference in quantity (moderate) and quality (red wine and beer) of alcohol was found according to adherence to the Mediterranean diet. Finally, more active participants were 1·5 times more likely to form part of the high-adherence group.

CONCLUSIONS

A slow but concrete moving away from traditional patterns has been observed in younger people and low educated people. Public health interventions should focus on these target populations in order to improve the quality of their diet.

In comparison with palm oil, dietary nut supplementation delays the progression of atherosclerotic lesions in female apoE-deficient mice

Epidemiological studies have demonstrated the benefits of nut consumption on cardiovascular risk factors and CHD, attributed to their fatty acid profile, rich in unsaturated fatty acids, and also to other nutrients. The effect of nuts on atherosclerotic lesions was studied in female and male apoE-knockout mice fed a diet supplemented with 3 % (w/w) mixed nuts (mix: almonds, hazelnuts and walnuts in a proportion of 0.25:0·25:0.50, respectively), and compared with mice receiving an isoenergetic diet of similar fat content provided as palm oil. After 12 weeks, plasma lipid parameters and aortic lesions were measured. Males receiving nuts had lower plasma cholesterol than the palm oil group, and both sex groups had lower plasma non-HDL-cholesterol and lower content of reactive oxygen species in LDL than mice receiving the palm oil diet, the latter decrease being more pronounced in females than in males. Females consuming the nut diet showed a smaller aortic lesion area than those consuming palm oil, whereas no differences were observed in males. In females, hepatic paraoxonase 2 (Pon2) mRNA increased, and no change was observed in prenylcysteine oxidase 1 (Pcyox1) expression after the consumption of the nut-containing diet. In addition, aortic atherosclerotic lesions correlated directly with total plasma cholesterol and inversely with hepatic Pon2 expression. The results suggest that the beneficial effect of nut intake in female apoE-deficient mice may be attributed to reduced non-HDL-cholesterol levels and enhanced PON2 antioxidant activity.

Evidence on the prevalence and geographic distribution of major cardiovascular risk factors in Italy

OBJECTIVE

To assess the prevalence and geographic distribution of major cardiovascular risk factors in a large community-wide sample of the Italian population.

DESIGN

A cross-sectional survey. Standardized methods were used to collect and measure cardiovascular risk factors. Data were adjusted for survey weightings. Qualitative and quantitative variables were compared with parametric and non-parametric tests, as appropriate.

SETTING

Towns (n 193) across different Italian regions.

SUBJECTS

Unselected adults (n 24 213; 12 626 men; 11 587 women) aged 18-98 years (mean age 56·9 (sd 15·3) years), who volunteered to participate in a community-wide screening programme over a 2 d period in 2007.

RESULTS

Overall, the prevalence of major cardiovascular risk factors was: obesity, 22·7 % (women 18·9 %, men 26·1 %); overweight, 44·7 % (women 31·6 %, men 56·7 %); hypertension, 59·6 % (women 48·3 %, men 70·0 %); dyslipidaemia, 59·1 % (women 57·7 %, men 60·3 %); diabetes, 15·3 % (women 11·2 %, men 19·0 %) and smoking, 19·8 % (women 14·0 %, men 25·2 %). We found a high prevalence of unhealthy eating habits; fruit and vegetable consumption was below the recommended range in 60 % of the study population. Ninety per cent of the study population had more than one cardiovascular risk factor and 84 % had between two and five cardiovascular risk factors. There were differences among Italian macro-areas mainly for obesity, hypertension, dyslipidaemia and diabetes.

CONCLUSIONS

The study provides alarming evidence on current prevalence data for major cardiovascular risk factors in a large sample of the Italian population. Particularly, obesity and hypertension represent a relevant public health problem. There is a pressing need for effective preventive health measures which must also take into account the differences among Italian macro-areas.

Mediterranean dietary pattern and cancer risk in the EPIC cohort

Background:

Although several studies have investigated the association of the Mediterranean diet with overall mortality or risk of specific cancers, data on overall cancer risk are sparse.

Methods:

We examined the association between adherence to Mediterranean dietary pattern and overall cancer risk using data from the European Prospective Investigation Into Cancer and nutrition, a multi-centre prospective cohort study including 142 605 men and 335 873. Adherence to Mediterranean diet was examined using a score (range: 0–9) considering the combined intake of fruits and nuts, vegetables, legumes, cereals, lipids, fish, dairy products, meat products, and alcohol. Association with cancer incidence was assessed through Cox regression modelling, controlling for potential confounders.

Results:

In all, 9669 incident cancers in men and 21 062 in women were identified. A lower overall cancer risk was found among individuals with greater adherence to Mediterranean diet (hazard ratio=0.96, 95% CI 0.95–0.98) for a two-point increment of the Mediterranean diet score. The apparent inverse association was stronger for smoking-related cancers than for cancers not known to be related to tobacco (P (heterogeneity)=0.008). In all, 4.7% of cancers among men and 2.4% in women would be avoided in this population if study subjects had a greater adherence to Mediterranean dietary pattern.

Conclusion:

Greater adherence to a Mediterranean dietary pattern could reduce overall cancer risk.

Adherence to the Mediterranean diet and albuminuria levels in Greek adolescents: data from the Leontio Lyceum ALbuminuria (3L study)

BACKGROUND/OBJECTIVES

Mediterranean diet has favorable effects on the cardiovascular system, whereas albuminuria is associated with atherosclerosis progression. The aim of the study was to assess the relationships of adherence rates to the Mediterranean diet with albumin to creatinine ratio (ACR), in a cohort of Greek adolescents who participated in the Leontio Lyceum ALbuminuria (3L) study.

SUBJECTS/METHODS

In a total of 365 adolescents 12-17 years of age included in 3L study, ACR values were determined in a morning-spot urine.

RESULTS

The Mediterranean diet Quality Index for children and adolescents (KIDMED) was estimated and accordingly subjects were divided into those with high (≥ 8), average (4-7) and low (≤ 3) score. Adolescents with low (n=153, 42%) compared with those with average (n=187, 51.2%) and high (n=25, 6.8%) KIDMED score were characterized by greater ACR values (22.4 vs 13.4 vs 12.1 mg/g, P<0.05) even after adjustment for confounders. In the total population, KIDMED score was related to body mass index (r=0.122, P=0.02), waist circumference (r=0.118, P=0.02), systolic blood pressure (BP) (r=0.119, P=0.023), whereas it was negatively associated with ACR (r=-0.111, P=0.041). Regarding ACR, it was associated with age (r=-0.11, P=0.044), male sex (r=0.16, P=0.003), body mass index (r=-0.131, P=0.016) and systolic BP (r=-0.144, P=0.008).

CONCLUSIONS

Adolescents who adhere to the Mediterranean diet exhibit lower levels of albuminuria, independently of demographic and hemodynamic confounders. The inverse relation of KIDMED index with ACR suggests a close link of accelerated vascular damage reflected by albuminuria with low adherence to this favorable diet of the Mediterranean basin.

Cardiovascular disease risk factors and dietary habits of farmers from Crete 45 years after the first description of the Mediterranean diet

BACKGROUND

Farmers from Crete as first studied within the framework of the Seven Countries Study, were historically known for holding the title of the 'gold standard' of health status globally and had a very low prevalence of both cardiovascular disease (CVD) and cancer. Taking the above into account we evaluated the changes in CVD risk factors among farmers in Crete, Greece and compared our findings with data from the 1960s.

DESIGN

Cross-sectional.

METHODS

Five hundred and two farmers (18-79 years old) from the Valley of Messara in Crete were randomly selected and examined in 2005. Complete clinical, biochemical, dietetic, anthropometrical and lifestyle CVD risk factors were assessed, matched and compared with published data from the 1960s.

RESULTS

In comparison with 45 years ago, present day male farmers from Crete were found to have a 30% higher BMI (29.8 vs. 22.9 kg/m, P<0.001) and a 16% higher total cholesterol level (239.6 vs. 206.9 mg/dl, P<0.001) and also a not so favourable daily dietary intake (increase in meat and saturated fat and decrease in fruit, P<0.001, respectively), while a significant reduction in systolic blood pressure and energy intake was noticed. In regards to changes in subcutaneous adipose tissue fatty acid composition, a decrease in monounsaturated (P<0.001) and an increase in saturated fatty acids (P<0.001) was also found elucidating the temporal change in dietary habits.

CONCLUSION

The population's lack of adherence to the Mediterranean diet, have led to the fact that currently farmers from Crete are likely to be at a higher risk for developing CVD in comparison with earlier generations.

Evaluating the food environment: application of the Healthy Eating Index-2005

BACKGROUND

The Healthy Eating Index-2005 (HEI-2005), a tool designed to evaluate concordance with the 2005 Dietary Guidelines, has been used to monitor the quality of foods consumed by Americans. Because the HEI-2005 is not tied to individual requirements and is scored on a per 1000 kcal basis, it can be used to assess the overall quality of any mix of foods.

PURPOSE

The goal of this paper is to examine whether the HEI-2005 can be applied to the food environment.

METHODS

Two examples were selected to examine the application of the HEI-2005 to the food environment: the dollar menu displayed at a fast-food restaurant (coded and linked to the MyPyramid Equivalents Database and the Food and Nutrient Database for Dietary Studies) to represent the community level and the 2005 U.S. Food Supply (measured with food availability data, loss-adjusted food availability data, nutrient availability data, and Salt Institute data) to represent the macro level.

RESULTS

The dollar menu and the 2005 U.S. Food Supply received 43.4 and 54.9 points, respectively (100 possible points). According to the HEI-2005, for the offerings at a local fast-food restaurant and the U.S. Food Supply to align with national dietary guidance, substantial shifts would be necessary: a concomitant addition of fruit, dark-green vegetables, orange vegetables, legumes, and nonfat milk; replacement of refined grains with whole grains; and reduction in foods and food products containing sodium, solid fats, and added sugars.

CONCLUSIONS

Because the HEI-2005 can be applied to both environmental- and individual-level data, it provides a useful metric for studies linking data across various levels of the socioecologic framework of dietary behavior. The present findings suggest that new dietary guidance could target not only individuals but also the architects of our food environment.

Worldwide variation of adherence to the Mediterranean diet, in 1961-1965 and 2000-2003

OBJECTIVE

The present study aimed to analyse the worldwide trends of adherence to the Mediterranean diet (MD), in 1961-1965 and 2000-2003.

DESIGN

Data were obtained from the FAO food balance sheets in two periods: 1961-1965 and 2000-2003. In order to have a sample from across the world, forty-one countries were selected. The average of available energy for different food groups was calculated for all selected countries. These values were used to evaluate the adherence to the MD through a variation of Mediterranean Adequacy Index (MAI).

RESULTS

The majority of the forty-one countries in this study have tended to drift away from a Mediterranean-like dietary pattern. Mediterranean Europe and the Other Mediterranean country groups suffered a significant decrease in their MAI values. The Mediterranean European group, especially Greece, experienced the greatest decrease in MAI value. In both periods, the Other Mediterranean countries showed the highest MAI values. In an analysis by countries, Iran had the highest increase in MAI across the time periods, and Egypt occupied the first place in the ranking in 2000-2003. The Northern European group was the only one that registered an increase in MAI, although this was not statistically significant.

CONCLUSIONS

Many countries in the Mediterranean basin are drifting away from the Mediterranean dietary pattern (MDP). However, countries in Northern Europe and some other countries around the world are taking on a Mediterranean-like dietary pattern. The Other Mediterranean countries have the closest adherence to the MDP, currently and in the 1960s. Nutrition policy actions to tackle dietary westernisation and preserve the healthy prudent MDP are required.

Availability of Mediterranean and non-Mediterranean foods during the last four decades: comparison of several geographical areas

Objective

The purpose of the present study was to evaluate the changes in the availability of the most important food components of the traditional Mediterranean diet and other food groups in five geographical areas during a 43-year period.

Design

Ecological study with food availability data obtained from FAO food balance sheets in forty-one countries for the period 1961–1965 and 2000–2004.

Setting

Mediterranean, Northern and Central Europe, Other Mediterranean countries and Other Countries of the World were the studied areas.

Results

The main changes since the 1960s, at an availability level, were found in European areas and in Other Mediterranean countries. The greatest changes were found in Mediterranean Europe, recording high availability of non-Mediterranean food groups (animal fats, vegetable oils, sugar and meat), whereas the availability of alcoholic beverages, including wine, and legumes decreased. Despite having lost some of its typical characteristics, Mediterranean Europe has more olive oil, vegetables, fruits and fish available than other areas. Although Northern Europe has a greater availability of non-Mediterranean foods, there has been a tendency towards a decrease in availability of some of these foods and to increase Mediterranean food such as olive oil and fruits.

Conclusions

The present study suggests that European countries, especially those in the Mediterranean area, have experienced a ‘westernisation’ process of food habits, and have increasingly similar patterns of food availability (mainly non-Mediterranean food groups) among them. Measures must be taken to counteract these tendencies and to avoid their possible negative consequences. It is also crucial to find ways to promote and preserve the Mediterranean diet and its lifestyle in modern societies.

Diet quality of a population sample from coastal north-east Spain evaluated by a Mediterranean adaptation of the diet quality index (DQI)

OBJECTIVE

To assess the adherence to the Mediterranean dietary pattern in the population from a coastal region from north-east Spain and its relationship to diseases, applying the Mediterranean Diet Quality Index (M-DQI) validated by the use of several biomarkers.

DESIGN

Cross-sectional nutrition survey.

SETTING

Population-based random sample derived from the Catalan Nutrition Survey.

SUBJECTS

A total of 621 healthy adults.

RESULTS

The Catalan representative sample presented a mean M-DQI score of 6.6 (sd 2.3, median 7, range 0-14). The percentage of adherence to the Mediterranean diet was 53 %; 10 % of subjects showed high adherence to the Mediterranean diet, while only 2 % were categorized as poorest adherence. The plasma fatty acid profile of the Catalan sample progressed with perfect regularity throughout the index ranges. Both EPA and DHA presented a significant correlation to the M-DQI (r = -0.410 for EPA and -0.360 for DHA). A significant increase in palmitic, oleic and alpha-linolenic acids and a significant decrease in stearic, linoleic and arachidonic acids content were also observed. The mean values for the M-DQI according to the clinical characteristics of the Catalan sample were also calculated.

CONCLUSIONS

The M-DQI has been demonstrated a suitable tool for assessment of an individual's nutritional status according to the Mediterranean dietary pattern and for clinical purposes. Although the current diet followed in Catalonia seems to agree with the main characteristics of the Mediterranean diet, the promotion of the Mediterranean pattern should be reinforced in the Catalan population, especially among young people.

Food balance sheet and household budget survey dietary data and mortality patterns in Europe

Worldwide dietary data for nutrition monitoring and surveillance are commonly derived from food balance sheets (FBS) and household budget surveys (HBS). We have compared food supply from FBS and food availability data from HBS among eighteen European countries and have estimated the extent to which they correlate, focusing on food groups which are comparably captured by FBS and HBS and for which there is epidemiological evidence that they can have a noticeable impact on population mortality. Spearman's correlation coefficient was +0·78 (P < 10− 3) for vegetables (including legumes),+0·76 (P < 10− 3) for fruits, +0·69 (P < 10− 3) for fish and seafood and +0·93 (P < 10− 3) for olive oil. With respect to meat and meat products, the coefficient was lower at +0·39 (P = 0·08). Moreover, we have examined whether the supply (FBS) or the availability (HBS) of food groups known or presumed to have beneficial effect on the occurrence of CHD and total cancer can predict overall, coronary and cancer mortality in ecological analyses. After controlling for purchasing power parity-adjusted gross domestic product and tobacco smoking we found that for vegetables, fruits, fish and seafood, as well as for olive oil, both the FBS and the HBS estimates were inversely associated with all three indicators of mortality, although the number of countries with complete information on all study variables hindered formal statistical documentation (P>0·05 in some instances). FBS and HBS have their own strengths and weaknesses, but they may complement each other in dietary assessments at the population level.

Adherence rates to the Mediterranean diet are low in a representative sample of Greek children and adolescents

Data from studies in pediatric samples exploring adherence to the Mediterranean diet are scarce. The aim of the present work was to explore adherence to a Mediterranean diet pattern in a representative sample of Greek children and adolescents. The study sample (n = 1305, 3-18 y) was representative of the Greek pediatric population in terms of sex and age. Information on participants' sociodemographic, anthropometric, and lifestyle characteristics were collected through telephone interviews. Adherence to the Mediterranean diet guidelines for adults and to the general dietary guidelines for children was evaluated using KIDMED scores: the higher the score, the more favorable the dietary pattern. The Goldberg cut-off limits for the ratio of energy intake:basal metabolic rate were used to evaluate dietary underreporting and children were accordingly classified as low energy reporters (LER) or non-LER. Only 11.3% of children and 8.3% of adolescents had an optimal KIDMED score (>/=8). In adolescents, partial correlation analysis revealed a negative weak association between KIDMED and BMI (r = -0.092; P = 0.031), which remained significant in the non-LER subgroup (r = -0.137, P = 0.011). Multiple regression analysis revealed that higher KIDMED scores were associated, in non-LER children, with less time spent on sedentary activities (P = 0.002) and higher paternal education (P = 0.050), whereas in adolescents, with younger age (P = 0.001), less time spent on sedentary activities (P = 0.015), higher maternal education (P = 0.014), and higher eating frequency (P = 0.041). In conclusion, low adherence rates to the Mediterranean diet were observed in Greek children and adolescents; this evidence needs to be further explored regarding its impact on health and disease.

Trends in food availability in Portugal in 1966–2003

BACKGROUND

Dietary intake has changed considerably in South European countries, but whether those changes were similar between countries is currently unknown.

AIM OF THE STUDY

To assess the trends in food availability in Portugal and four other Mediterranean countries from 1966 to 2003.

METHODS

Food and Agricultural Organization food balance sheets from Portugal, France, Italy, Greece and Spain. Trends were assessed by linear regression.

RESULTS

The per capita availability of calories has increased in Portugal, France, Greece, Italy and Spain in the past 40 years. Portugal presented the most rapid growth with an annual increase of 28.5 +/- 2.2 kcal (slope +/- standard error), or +1000 kcal overall. In animal products, Portugal had an annual increase of 20.7 +/- 0.9 kcal, much higher than the other four countries. Conversely, the availabilities of vegetable and fruit only showed a slight growth of 1.0 +/- 0.1 kcal/year and 2.5 +/- 0.4 kcal/year, respectively, thus increasing the ration of animal to vegetable products. Olive oil availability increased in all countries with the notable exception of Portugal, where a significant decrease was noted. Wine supply decreased in all five countries; in contrast, beer supply started to take up more alcohol share. Percentage of total calories from fat increased from nearly 25% to almost 35% in Portugal during the study period, mainly at the expenses of calories from carbohydrates, whereas the share of protein showed just a slight increase. Furthermore, fat and protein were increasingly provided by animal products.

CONCLUSIONS

Portugal is gradually moving away from the traditional Mediterranean diet to a more Westernized diet as well as France, Greece, Italy and Spain. Noticeably, the trends of diet transition were observed relatively faster in Portugal than in the other four Mediterranean countries.

Portuguese households' diet quality (adherence to Mediterranean food pattern and compliance with WHO population dietary goals): trends, regional disparities and socioeconomic determinants

OBJECTIVE

To evaluate households' diet-quality trends and regional disparities, as well as to identify the influence of its socioeconomic determinants.

METHODS/SUBJECTS

Two dietary indexes were applied: a revised Healthy Diet Indicator version (HDIr) and the Mediterranean Adequacy Index (MAI). The socioeconomic differences between households with low-diet quality (if their scoring in HDIr or MAI was below the national median) and the remaining ones were analysed by means of logistic regression. Representative samples of households among each region were analysed.

RESULTS

Adherence to a Mediterranean diet was poor in all Portuguese regions; the proportion of households adhering to it has diminished in the North, Centre, Lisbon and Tejo valley. The proportion of households with high HDIr decreased in the North, Centre, Lisbon and Tejo valley and Algarve. In multivariate analysis, households whose head had secondary or higher education, living in semi-urban or urban areas, from the Azores region, within the higher income or outside home food expenditures groups were more likely to be in low-quality diet.

CONCLUSIONS

The decreasing adherence to a Mediterranean food pattern and the diminishing compliance with World Health Organization dietary goals show that Portuguese households have reduced their diet quality. The observed influence of urbanization and region on diet quality highlights the importance of considering regional nutrition strategies.

The use of indexes evaluating the adherence to the Mediterranean diet in epidemiological studies: a review

The purpose of this paper is to review some of the methods that several epidemiological studies use to evaluate the adherence of a population to the Mediterranean diet pattern. Among these methods, diet indexes attempt to make a global evaluation of the quality of the diet based on a traditional Mediterranean reference pattern, described as a priori, general and qualitative. The Mediterranean diet indexes, hence, summarise the diet by means of a single score that results from a function of different components, such as food, food groups or a combination of foods and nutrients. The reviewed evaluation methods can be classified into three categories depending on the way they are calculated: (1) those based on a positive or negative scoring of the components, (2) those that add or substract standardised components, and (3) those that are based on a ratio between components.

Dietary scores have been used to explore the multiple associations between the Mediterranean diet, as an integral entity, and health parameters such as life expectancy or the incidence of obesity, cardiovascular diseases and some types of cancers. Moreover, these indexes are also useful tools to measure food consumption trends and to identify the involved factors, as well as to develop comprehensive public health nutrition recommendations.

A more precise and quantitative definition of the Mediterranean diet is required if the adherence to such a dietary pattern is intended to be more accurately measured. Other aspects of the Mediterranean diet indexes should also be taken into account, like the inclusion of typical Mediterranean foods such as nuts and fish and the validation of the dietary pattern approach by using biomarkers.

Effect of Olive Oil-Fried Sardine Consumption on Cholesterol Content in the Serum, Lipoproteins, Spleen and Adipose Tissue of Hypercholesterolemic Rats

BACKGROUND

The information about the effect of fried-oily fish consumption on cholesterol metabolism is rather scarce.

AIM

To test the effect of olive oil-fried sardine consumption on cholesterol content in the serum, lipoproteins, spleen and adipose tissue of hypercholesterolemic rats.

METHODS

Hypercholesterolemia was induced for 3 weeks by a casein + olive diet containing cholesterol and bovine bile (COC). Rats were later switched for 2 weeks to diets containing casein + olive oil (CO), olive oil-fried sardines (S), and olive oil-fried sardines-cholesterol-bovine bile (SC) while one rat group continued on the COC diet. Cholesterol was determined in serum, lipoproteins, adipose tissue and spleen.

RESULTS

The SC diet markedly blocked the hypercholesterolemic induction of the cholesterol-raising agents. Dietary cholesterol withdrawal decreased serum cholesterol levels, with the S diet inducing the highest decrease in serum and VLDL + LDL-cholesterol levels. Cholesterol withdrawal decreased spleen total cholesterol content and weight but the S diet was unable to reduce spleen cholesterol content (micromol/g) more than CO diet. Adipose tissue of S rats displayed the lowest cholesterol values. Cholesterol (mmol/g) of adipose tissue correlated very significantly with total serum cholesterol (r = 0.9225, p < 0.0001) and VLDL + LDL-cholesterol (r = 0.9313, p < 0.0001).

CONCLUSIONS

Cholesterol in adipose tissue was very sensitive to variations in plasma cholesterol. Consumption of fried sardines interacts with cholesterol withdrawal, accelerating serum cholesterol normalization and reduction of cholesterol levels in adipose tissue.

Dietary patterns and their socio-demographic determinants in 10 European countries: data from the DAFNE databank

OBJECTIVE

To describe the dietary patterns of 10 European countries and their socio-demographic determinants, using the comparable between-countries DAFNE data.

DESIGN

Analysis of standardized and postharmonized data collected through the national household budget surveys.

SETTING

Nationally representative surveys undertaken in 10 European countries, generally in the second half of the 1990s.

RESULTS

The differences in the fruit and vegetable consumption previously identified between Mediterranean and Northern European countries seem to be leveling out, particularly in relation to fruit consumption. Pulses, however, still characterize the diet of the Mediterraneans. Straying from their traditional food choices, Mediterraneans recorded high availability of unprocessed red meat, while Central and Northern Europeans preferably consumed meat products. The household availability of beverages (alcoholic and non-alcoholic) is generally higher among Central and Northern European populations. Principal component (PC) analysis led to the identification of two dietary patterns in each of the 10 countries. The first was similar in all countries and indicated 'wide-range' food buyers. The second was slightly more varied and described 'beverage and convenience' food buyers. PC1 was common among households of retired and elderly members, while PC2 was common among households located in urban or semi-urban areas and among adult Scandinavians living alone.

CONCLUSIONS

The dietary patterns identified point towards a progressive narrowing of dietary differences between North and South European countries. The comparable between-countries DAFNE data could prove useful in ecological studies, in the formulation of dietary guidelines and public health initiatives addressing specific population groups.

SPONSORSHIP

European Commission.