Michelle Moriarty Journal Article Summary Title: Factors associated with adherence to the Mediterranean diet in the adult

population Authors: Patino-Alonso MC, Recio-Rodriguez JI, Belio JFM et al. Journal: Journal of the Academy of Nutrition and Dietetics Volume: 114 number 4 Pages: 583-589 Year: 2014

Introduction:
Review of Literature: The purpose of this study was to determine which variables such as individual characteristics, physical activity frequency and other lifestyle factors are associated with Mediterranean diet adherence in Spanish adults. Adherence was measured using a 14 question survey and the Mediterranean Diet Adherence Screener (MEDAS). Rationale: Previous research has shown that adherence to the Mediterranean diet reduces global mortality, mortality from cardiovascular disease and cancer. The diet has also shown to reduce the incidence of Parkinsons disease and the risk of weight gain and metabolic syndrome. Among other studies analyzing Mediterranean diet adherence in Spanish populations, they have not considered how physical activity frequency and other lifestyle factors correlate to adherence in Spanish adults. Hypotheses or Objectives: The objective of this study was to determine if frequency of physical activity, alcohol consumption, anthropometric measurements, age and sex have an influence in Mediterranean diet adherence.

Study Design and Methods:

Design: General Approach: Descriptive testing Specific Design: Cross-sectional study Population at Risk: The population from which the study sample was selected was Spanish adults ranging in age from 20 to 80 years old. The mean age of the participants was 55 +/- 13.7 years with 937 participants being women. Sampling Method and Sample Size: Participants were randomly selected from 6 Spanish health centers. The resulting sample size was 1,588 participants. Selection and Exclusion Criteria for Study Groups: Exclusion criteria included: Known coronary or cerebrovascular atherosclerotic disease Heart failure Moderate or severe COPD Walking-limiting musculoskeletal disease Advanced respiratory, renal or hepatic disease

 Severe mental diseases Treated oncological disease diagnosed in the past 5 years Terminally ill diagnosis Pregnancy Selection bias was present due to the fact that only Spanish adults were studied, not a larger international demographic. Dependent Variable: Non compliance or compliance to the Mediterranean diet was the dependent variable. This was measured using the validated 14 point Mediterranean Diet Adherence Screener (MEDAS) which includes 12 questions about food intake frequency and 2 questions about food intake habits related to the Spanish Mediterranean diet. Each question was scored as 0 or 1. One point was given for: Using olive oil as the principle source of fat for cooking Preferring white meat over red meat Consuming 4 or more tablespoons of olive oil a day Consuming 2 or more servings of vegetables per day Consuming 3 or more pieces of fruit per day Consuming fewer than 1 serving of animal fat per day Consuming fewer than 1 serving of red meat or sausage per day Consuming less than 1 cup of sugar sweetened beverages per day Consuming 7 or more servings of red wine per week Consuming 3 or more servings of pulses (beans/legumes) per week Consuming 3 or more servings of fish per week Consuming fewer than 2 commercial pastries per week Consuming 3 or more servings of nuts per week Consuming 2 or more servings/week of a dish with traditional sauce of tomatoes, garlic and onions. The final score ranged from 0 to 14; a total score of 9 or more points was indicative of Mediterranean diet adherence. Independent Variable: The independent variables were age tertiles (<49y, 49-62y, >62y), sex, metabolic equivalents (METs)/hour/week of physical activity, obesity, waist circumference, body fat percentage, alcohol, diabetes, hypertension, dyslipidemia, smoking, and cardiovascular risk. METs/hour/week was determined with a 7 day physical activity recall which consists of a 10-15 minute interview where participants identify the number of hours they have dedicated to physical activity requiring at least moderate effort. Participants were defined as engaging in at least 30 minutes of moderate activity 5 days/week or at least 20 minutes of heavy activity 3 days/week. Those who did not reach this level of activity were considered sedentary. Obesity was based on BMI of 30 or greater.

Waist circumference was measured by a tape measure above the iliac crest without compressing the skin. A measurement less than 108 cm in males and 88 cm in females was characterized as normal. Body fat percentage was measured using a body fat monitor (OMRON, model BF306). Alcohol consumption was divided into 3 categories: 1) abstemious, 2) males=1 to 16.9 gm/week, females=1 to 10.9 gm/week, 3) males= 17 gm/week, females 11 gm/week. Smoking, diabetes, hypertension and dyslipidemia were measured by the presence or absence of each. Cardiovascular risk was measured by the Framingham-DAgostino score. Information Bias Controlled by Study Design: Particopants were chosen randomly from the health centers but no other controls were considered.

Results:
Major Findings: Mediterranean diet adherence was found in 523 individuals (33.7%); 325 females (34.7%) and 198 males (32.1%). Adherence was lower in younger individuals (less than 49 years of age) with 131 participants complying compared to 176 individuals in the 49-62 age group and 216 individuals in the > 62 age group. Of participants less than 49 years old, adherence was greater in women and in non-obese individuals. The triglyceride levels were also lower in these compliers. In the second age tertile (49-62 y), the compliers to the diet exercised more and had a smaller body fat percentage. In the third age tertile (> 62 y), the compliers also had less body fat (35.83% +/- 6.43). The mean body fat percentage in the non-compliers in this age tertiles was 36.48% +/- 6.82. The following factors are associated with improved Mediterranean diet adherence: More physical activity (odds ratio OR= 1.588, P=0.0001) Older age (OR=2.162, P<0.01) Moderate alcohol consumption (OR=1.342, P=0.021) Poorer adherence was associated with males (OR=0.777, P=0.051) and obesity (OR=0.577, P=0.01) Statistical Analysis: The continuous variable were expressed as the mean +/- SD for normally distributed continuous data, as the median for asymmetrically distributed data, and as the distributed frequency for categorical data. Statistical normality was tested using the Kolmogorov-Smirnov test. The Mann-Whitney U-test was used for asymmetrically distributed data.

The data were analyzed using the SPSS version 20 statistical package. A value of P<0.05 was considered statistically significant.

Discussions and Conclusions:

Internal Validity: The study participants were randomly chosen but were of the same ethnicity. This could compromise the validity of the study. External Validity: While the large sample size lends to the validity of the study, it would be difficult to generalize these results outside of the Spanish adult population. Strengths and Limitations: The large sample size of 1,588 participants and the extensive list of factors that can affect Mediterranean diet adherence make this study strong. The authors state the limiting factor of the study being the heterogeneity of the participants; some individuals had diabetes and hypertension which the authors feel could lead to habit changes which could have skewed the results. Consistency with Other Studies: The authors incorporated results from similar Spanish studies to compare data. The comparative studies included looking at Mediterranean diet adherence in healthy volunteers, university students and participants with high cardiovascular risk. Other studies focused more on diet patterns rather than on factors that influence diet adherence such as the lifestyle factors analyzed in study being reviewed. Theoretical Importance of Results: The study shows that other healthy lifestyle factors lend themselves to a higher rate of compliance with the Mediterranean diet which has become more widely followed by those around the world. Practical Importance of Results: Based on the results, individuals should not necessarily do anything different from previously; the purpose of the study was more to highlight the fact that healthy lifestyle factors go along with a healthy diet pattern. Further Study: The authors state that since lower adherence was seen in the younger population, they could benefit m ore from a diet targeted to prevent cardiovascular disease over a long time period. The authors feel their results could be used for further investigation regarding this. In the future, studies could be done regarding Mediterranean diet adherence in other populations around the world to assess which area has the highest amount of compliers.