Determinants of adherence to the Mediterranean diet among adults in Mediterranean countries: a systematic literature review.

PurposeIn recent years, children in Mediterranean countries have shown low adherence to Mediterranean Diet (MD) with a shift toward a Western diet. This study aims to understand the reasons behind moving away from the MD among children, by providing an overview of the different correlates influencing MD adherence among preschool and school-age children (3–8 years old).MethodsA systematic review was conducted and reported in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines and registered in the Prospero database (CRD42023370607). Literature was searched in PubMed, Web of Science and PsycINFO databases for studies, without restrictions on publication date. Inclusion criteria were preschool and school-aged children, studies conducted in Mediterranean countries, and statistical analyses of the association between the different correlates and MD adherence quantified by a validated dietary assessment. Studies that did not provide sub-analyses for the specified age group were excluded. A quality analysis of the included studies was performed using the National Collaborating Centre for Methods and Tools (NCCMT) scale.ResultsA total of 12 studies were included, primarily from European Mediterranean countries, with fewer studies from the Middle East and North Africa. The vast majority of the included studies reported on interpersonal correlates related to the parent’s influence on MD adherence, while child’s age and sex, physical activity, and time spent on video games were classified as individual, and only the place of residence was classified as an environmental correlate. The quality assessment generally showed weak scores.ConclusionThe primary factors influencing MD were interpersonal correlates related to parents, indicating that interventions should target both children and parents to effectively reinforce MD adherence.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00394-025-03769-9.

Background and aimWhile the Mediterranean diet (MD) is promoted in non-Mediterranean countries, inhabitants of Mediterranean countries seem to be shifting away from this healthy diet. The aim of this study is to provide an overview of MD adherence in the general adult population of Mediterranean countries.MethodsA systematic review was conducted following the PRISMA 2020 (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines and registered in the Prospero database (CRD42020189337). Literature was searched in PubMed, Web of Science and PsycINFO databases for studies published from 2010 up to and including 2021. The following inclusion criteria were used: age 18 years and older, sample size > 1000 participants, and using a validated MD adherence score. Studies that only included participants with nutrition-related or other severe chronic disorders, as well as studies that only included specific subpopulations (e.g., pregnant women), were excluded in order to focus on the general adult population. A quality analysis of the included studies was done using the NCCMT scale.ResultsA total of 50 studies were included. The number of participants in the included studies ranged between 1013 and 94,113. Most of the included studies pertained to the European Mediterranean countries, with fewer studies from the Middle Eastern and North African Mediterranean countries. The vast majority of the included studies reported low or moderate MD adherence, both based on the mean adherence as well as the low or moderate adherence category often being the most prevalent. There were no clear differences noted between sex and age groups. The quality assessment generally showed weak or moderate scores.ConclusionsMediterranean populations have been showing moderate adherence to MD in the past 10 years, indicating room for improving adherence to the MD in countries of its origin.

Background In literature, few studies evaluated Mediterranean diet (MD) adherence in pregnant women, so we decided to conduct a survey to analyze MD and healthy habits in pregnant women living in North East of Italy, in 2018. Methods In our monocentric observational study, we enrolled >18 years pregnant women (2nd-3rd trimester) to evaluate MD adherence through “PREDIMED” validated questionnaire. Based on previous studies on MD score, women were classified into High-MD adherence (score >8; range 0-14) and low-MD adherence group (score ≤ 8). Comparisons between groups were performed using a t-test, Wilcoxon-Mann-Whitney test, chi square test and regression models as appropriate. We also investigated BMI (body mass index) and healthy habits before and during pregnancy. Results We analyzed 113 questionnaires and MD score, ranging from 3 to 13, had a mean value of 8.04 (SD 1.95), with low MD adherence in 63% (71) of our sample. Women (mean age 32 years; min 22- max 43; SD 1.95) were mostly employed (95; 84%) and alcohol consumers before pregnancy 79 (70%), especially wine 53 (47%). 5 (4%) didn't quit smoking while pregnant. Comparing BMI data before and during pregnancy to international recommendations, we found inadequate weight gain for each BMI category (100% in underweight, 70.7% in normal weight, 35% in overweight, 50% in obese range). Age was associated with MD adherence (β 0.11; 95%CI 0.04-0.17). Employment was also positively associated with higher MD values (p 0.002). Wine assumption before pregnancy was statistically significant associated with high MD group (p 0.0334). Conclusions In our study we found MD adherence levels lower than expected and an inadequate weight gain during pregnancy. MD seems also to be age and employment-related. Wine consumption before pregnancy and its positive association with MD need to be further analyzed. Key messages Mediterranean Diet adherence among pregnant women studied is not high and weight gain is frequently inadequate. Age and employment status might influence MD adherence in pregnancy.

Association between Mediterranean diet adherence and colorectal cancer: a dose-response meta-analysis

The current study aims to describe the Mediterranean diet (MD) adherence across the US regions, and explore the predictive factors of MD adherence among US adults. Cross-sectional secondary data analysis. MD adherence score (0-9) was calculated using the Block 98 FFQ. Hot spot analysis was conducted to describe the geospatial distribution of MD adherence across the US regions. Logistic regression explored predictors of MD adherence. Nationwide community-dwelling residency in the USA. Adults aged ≥45 years (n 20 897) who participated in the REasons for Geographic and Racial Differences in Stroke study and completed baseline assessment during January 2003 and October 2007. The mean of MD adherence score was 4·36 (sd 1·70), and 46·5 % of the sample had high MD adherence (score 5-9). Higher MD adherence clusters were primarily located in the western and northeastern coastal areas of the USA, whereas lower MD adherence clusters were majorly observed in south and east-north-central regions. Being older, black, not a current smoker, having a college degree or above, an annual household income ≥ $US 75K, exercising ≥4 times/week and watching TV/video <4 h/d were each associated with higher odds of high MD adherence. There were significant geospatial and population disparities in MD adherence across the US regions. Future studies are needed to explore the causes of MD adherence disparities and develop effective interventions for MD promotion in the USA.

An abandonment of traditional dietary patterns is growingly observed in Mediterranean countries, especially among younger generations. This study aimed to explore determinants of Mediterranean diet (MD) adherence in 5 Mediterranean countries (Italy, Spain, Portugal, Egypt, and Lebanon) within the context of the EU funded project DELICIOUS (UnDErstanding consumer food choices &amp; promotion of healthy and sustainable Mediterranean diet and LIfestyle in Children and adolescents through behavIOUral change actionS). The sample consisted of 2011 parents of children and adolescents aged 6-17 years old. The main background characteristics, including age, sex, education, family situation, weight status, physical activity levels, sleep and screen time duration, were collected. The level of adherence to the MD was assessed using the KIDMED index. Eating habits (i.e., breakfast, place of eating, etc.) were also investigated. Logistic regression analyses were performed to test for likelihood of higher adherence to the MD. The mean KIDMED score in the study sample was 6.1 [standard deviation (SD) 2.0] with significant differences across countries [Lebanon 5.7 (SD 2.0), Italy 5.8 (SD 2.1), Spain 6.3 (SD 2.1), Egypt 6.5 (SD 1.9), and Portugal 6.5 (SD 2.0)]. A total of 865 participants were deemed as highly adherent to the MD [highest tertile, mean KIDMED score = 8.0 (SD 0.9)]. Major determinants of higher adherence to the MD were the following: among background characteristics, younger age group, higher physical activity level and adequate sleep duration; regarding dietary habits, having breakfast, out-of-home eating, eating with family members and at school, and home-cooked meals were associated with higher MD adherence. Parents’ younger age and higher education were also determinants of higher adherence. In conclusion, a cluster of healthy lifestyle behaviors can be observed among Mediterranean children and adolescents as determinant of higher adherence to the MD. Key messages • Lifestyle habits tend to cluster into healthy behaviors. • Differences in Mediterranean diet adherence may occur across countries.

Nutrition knowledge and Mediterranean diet adherence in the southeast United States: Validation of a field-based survey instrument

3w?>Studies investigating the association of Mediterranean diet (MD) adherence with pancreatic cancer risk are limited and had inconsistent results. We examined the association between MD adherence and pancreatic cancer incidence by pooling data from the Netherlands Cohort Study (NLCS, 120,852 subjects) and the Dutch cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC‐NL, 40,011 subjects). MD adherence was assessed using alternate and modified Mediterranean diet scores (aMED and mMED, respectively), including and excluding alcohol. After median follow‐ups of 20.3 (NLCS) and 19.2 (EPIC‐NL) years, 449 microscopically confirmed pancreatic cancer (MCPC) cases were included in study‐specific multivariable Cox models. Study‐specific estimates were pooled using a random‐effects model. MD adherence was not significantly associated with MCPC risk in pooled and study‐specific analyses, regardless of sex and MD score. Pooled hazard ratios (95% confidence interval) for high (6–8) compared to low (0–3) values of mMED excluding alcohol were 0.66 (0.40–1.10) in men and 0.94 (0.63–1.40) in women. In never smokers, mMED excluding alcohol seemed to be inversely associated with MCPC risk (nonsignificant). However, no association was observed in ever smokers (pheterogeneity = 0.03). Hazard ratios were consistent across strata of other potential effect modifiers. Considering MD scores excluding alcohol, mMED‐containing models generally fitted better than aMED‐containing models, particularly in men. Although associations somewhat differed when all pancreatic cancers were considered instead of MCPC, the overall conclusion was similar. In conclusion, MD adherence was not associated with pancreatic cancer risk in a pooled analysis of two Dutch cohorts.

The present study examined the association of BMI, fat mass, physical activity engagement (PA), maximal oxygen consumption (VO2max), screen time and academic performance (AP) with Mediterranean diet (MD) adherence in a sample of high socio-economic status (SES) children. A non-randomised design was used. A multilinear regression model was developed using backward elimination. Analysis included variables pertaining to age, BMI, VO2max, fat percentage, AP, PA engagement and screen time. All participants had a high SES and so this variable was not included as a predictor. Data met the assumptions required for multiple regressions in terms of linearity, homoscedasticity, normality, independence and non-multicollinearity. Two state and three mixed funding schools in Granada, Spain. Data were collected from 244 children aged between 10 and 12 years. Better AP, higher PA engagement and lower screen time were found to be predictive of MD adherence. These variables explained 22·9 % of the variance in data measuring adolescent MD adherence. The present study suggests that, in addition to SES, PA, AP and screen time are important components to consider when targeting improvements in MD adherence in children. It is, therefore, concluded that interventions targeting improvements in PA, AP and screen time are needed to promote MD adherence in children, regardless of SES.

(1) Background: The present study aimed to examine the relationship between physical activity (PA), screen time (ST), maximal oxygen uptake (VO2max), Mediterranean diet (MD) adherence, self-esteem (SE) and academic performance (AP) in primary education students. In order to address this aim, an explanatory model was developed to examine the existing relationships between PA, ST, VO2max, MD adherence, SE and AP. Further, the proposed structural model was examined via multi-group analysis as a function of sex and school type. (2) Methods: A non-experimental, descriptive, comparative and cross-sectional study was designed with a total sample of 269 Spanish students (11.29 ± 0.62). Validated questionnaires were administered to collect data on study variables. (3) Results: Relative to boys, girls reported better academic grades and showed a stronger positive relationship between MD adherence and AP, MD adherence and PA, and VO2max and SE. Likewise, girls showed a stronger negative relationship between ST and VO2max, and ST and MD adherence. At the same time, mixed funding school (MFS) students reported higher PA engagement than state school (SS) students. However, SS students reported better MD adherence, ST and AP than MFS students. Further, a stronger positive relationship was found in SS students between MD adherence or VO2max and SE than in MFS students. Also, within the former group, ST was more negatively related to MD adherence and VO2max. (4) Conclusions: Scientific and educational communities must develop future strategies that consider potential determinants in order to target more desirable outcomes.

Mediterranean diet (MD) adherence has been associated with a large variety of health benefits. However, prospective studies investigating the relation between MD adherence and colorectal cancer risk had inconsistent results. In this analysis of the Netherlands Cohort Study (NLCS), we evaluated sex- and subsite-specific associations of MD adherence with colorectal cancer risk. In 1986, 120,852 subjects filled out the NLCS baseline questionnaire, which incorporated a 150-item food frequency questionnaire. MD adherence was estimated through alternate Mediterranean diet scores including and excluding alcohol (aMED and aMEDr, respectively). Using 20.3 year follow-up data, 1993 male and 1574 female colorectal cancer cases could be included in multivariable case-cohort analyses. aMEDr was not significantly associated with colorectal cancer risk, regardless of sex. Hazard ratios (95% confidence intervals) per two-point increment were 1.04 (0.95–1.13) for men and 0.97 (0.88–1.07) for women. Additionally, there was no evidence of an inverse association with any of the colorectal cancer subsites (colon, proximal colon, distal colon, and rectum). In women, the association between aMEDr and colorectal cancer risk was significantly modified by smoking status (Pinteraction = 0.015). Comparable results were obtained for the original aMED including alcohol. In conclusion, higher MD adherence was not associated with a reduced risk of colorectal cancer or anatomical subsites in the context of a Dutch population.

This study examines whether adherence to the Mediterranean diet (MD), alone and combined with physical activity (MedEx), is associated with cognitive decline and dementia incidence, with socioeconomic status (SES) as a potential modifier. We included 8,568 subjects (mean age 72.3 ± 9.6years, 52.4% female) from three pooled Italian population-based studies. MD adherence was assessed using the Panagiotakos algorithm. We analyzed the association of MD and MedEx adherence, both continuously and categorized in tertiles, with cognitive decline and incident dementia using Cox regression. SES modification was examined through interaction analysis and SES-stratified models. Cognitive decline occurred in 38.1% of participants but was not associated with MD adherence. In SES-stratified analysis, among high SES individuals, each 2-point increase in MD adherence reduced cognitive decline risk by 14%, and high MD adherence was associated with a 48% reduction (HR 0.52, 95%CI 0.31-0.90). In this group, medium MedEx adherence reduced cognitive decline risk by 77% (HR 0.23, 95%CI 0.07-0.83). No significant association was found between MD/MedEx adherence and incident dementia (4.2%), regardless of SES. SES may modify the relationship between MD and cognitive decline, with greater benefits observed in higher SES groups. Further studies, particularly in vulnerable populations, are needed to inform tailored preventive strategies for cognitive decline.

Background and aim: The Mediterranean Diet (MD) is valued for its health benefits, yet adherence is declining, especially in its regions of origin. In Middle Eastern Mediterranean countries like Lebanon, this decline is exacerbated by ongoing economic challenges, which have disrupted dietary habits and access to MD components. Revitalizing adherence to the MD requires a clear understanding of its determinants, which remain poorly understood in these contexts. This study aims to address this gap by examining the socio-cognitive and environmental factors influencing MD adherence among Lebanese adults, using the Socio-Ecological Model (SEM). Methods: A cross-sectional study was conducted in Lebanon between November 2023 and January 2024 using an online questionnaire, available in Arabic and English. Adults aged 18 and above were recruited via convenience and snowball sampling. The questionnaire assessed socio-demographics, socio-cognitive and environmental factors, and adherence to the MD using the validated MEDAS questionnaire. Data were analyzed using univariate tests and multiple regression to examine associations between MD adherence and socio-demographic, socio-cognitive, and environmental factors. Results: A total of 304 participants completed the survey. The majority were women (74.7%). The research population had a mean age of 33.3 years and a relatively high education (92.7% bachelor's degree and above). Adherence to the MD was generally low to moderate (mean score: 5.97 ± 2.0 on a scale from 0 to 14), with only 4.3% showing high adherence. While several socio-cognitive and environmental factors were correlated with MD adherence in bivariate analysis, only perceived ease of following the MD, a component of perceived behavioral control, was significantly associated with MD adherence in the multiple regression analysis (β = 0.23; p = 0.002). Conclusions : These findings highlight the importance of addressing perceived behavioral control by implementing practical, context-specific interventions that make adherence to the MD easier, especially in times of crisis.

The present study aimed to examine the relationship between screen time (ST), sleep time (SLT), physical fitness (PF), Mediterranean diet (MD) adherence, eating behaviours, and body mass index (BMI) in a sample of pre-schoolers from Granada (Spain). In order to address this aim, an explanatory model was developed to examine existing relationships between ST, SLT, PF, MD, pro-intake (PRO-I) and anti-intake (ANT-I) behaviours, and BMI. Further, the proposed structural model was examined via multi-group analysis as a function of sex and BMI. A cross-sectional study was conducted with 653 three- to six-year-old pre-schoolers attending 18 different schools invited to take part in the present study. Structural equation modelling (SEM) was employed to analyse relationships between study variables as a function of sex and BMI. SEM analysis revealed negative associations between ST and PF (p < 0.005), ST and MD adherence (p < 0.005), ST and SLT (p < 0.005), MD adherence and ANT-I behaviours (p < 0.005), and MD adherence and BMI (p = 0.033). In contrast, positive associations emerged between SLT and MD adherence (p < 0.005), and PRO-I behaviours and BMI (p < 0.005). SEM revealed differences according to sex and BMI. The study highlights significant relationships between lifestyle behaviours and physical and dietary outcomes in pre-schoolers from southern Spain, with variations based on sex and BMI. These findings suggest the need for interventions aimed at reducing ST and promoting better sleep, PF, and dietary habits in order to limit weight-related and general health risks in pre-schoolers from southern Spain.

Food insecurity and Mediterranean diet adherence among Greek university students