Knowledge and adherence to the Mediterranean diet in individuals practicing regular amatorial physical activity: a cross-sectional study conducted in the Metropolitan Area of Palermo, Italy

Introduction: Mediterranean Diet (MD) is a universal model of nutrition that prevents several metabolic, cardiovascular, and oncological diseases. Main objective of the present study was to analyze adherence and knowledge regarding MD principles in a sample of individuals practicing amatorial sports from the Metropolitan Area of Palermo.

Methods: A cross-sectional study was conducted in 10 Sports Centers, between October 2020 and September 2021, through a previously validated anonymous questionnaire structured in five sections including 74 items.

Results: Overall, 337 subjects answered to the questionnaire. Based on the multivariable analysis conducted, a higher knowledge score (KS) on MD principles was observed among individuals daily consuming vegetables (OR: 3.32; CI95%: 1.82–6.02) and in the ones more adherent to MD principles (OR: 10.15; CI95%:5.47–18.85). More in depth, using MEDAS score to analyze the adherence to MD, a significant lower adherence was observed among overweight/obese (OR: 0.57; CI95%:0.33–0.99) and among employed subjects (OR: 0.52; IC95%: 0.28–0.98); while, a higher adherence was highlighted among daily consumers of vegetables (OR: 2.52; CI95%:1.52–4.17), daily consumers of fruit (OR: 1.77; CI95%:1.08–2.90), and in individuals that have daily breakfast (OR: 4.29; CI95%:1.15–15.96).

Discussion: In accordance with the WHO Europe Gaining Health Campaign, Public Health Authorities should simplify accessibility to healthy food among general population, promoting principles and accessibility to MD.

1. Introduction

The Mediterranean diet (MD) represents a valid and certified model of nutrition for a proper lifestyle (1). Although the term “diet” is often associated to the lower amount of food intake with a weight loss goal, it is a correct amount and balance of nutrients that can really benefit health (1). In 2010, MD officially became a UNESCO World Intangible transnational Heritage, having recognized its importance: it is a lifestyle that emphasizes the values of hospitality and dialog and respects diversity, bringing together people of all ages, conditions and social classes, and unifying values that bring with them physical, psy-chological, and nutritional well-being for the individual (2).

Physical activity and active lifestyle are considered key components of the MD because they help in preventing many sedentary related diseases, such as obesity, hypertension, and atherosclerosis (3–5). Regular exercise reduces mortality from various non-communicable diseases (cardiovascular events, hypertension, stroke, metabolic diseases, type 2 diabetes, colon and breast cancer, depression, and falls associated with aging), improves endothelial function, and it can also ease autonomic dysfunction associated with aging (6–9). The amount of energy consumed depends on the intensity of the activity and the frequency of training, and varies according to the individuals’ age, gender, and body mass. Balance in the quantity and quality of food is essential for physical and mental development, while imbalance can cause illness and even death (10).

Mediterranean Diet has been identified as an important prevention factor for obesity and related disorders (11). MD prevents many diseases because it is associated with better cardio-vascular health outcomes, including clinically meaningful reductions in rates of coronary heart disease, ischemic stroke, and total cardiovascular disease: several studies have shown a high correlation between the average percentage of dietary energy from saturated fatty acids and the 10-year incidence and death rate from coronary heart disease 15-year follow-up confirmed these general relationships between coronary mortality rates and cohort mean characteristics of serum cholesterol, blood pressure, and the percentage of total energy from saturated fatty acids (12–15).

The PREDIMED study demonstrated a consistent reduction in major cardiovascular events, with a down-regulation of cellular and humoral inflammatory pathways linked to atherosclerosis, in subjects who adhered to the MD supplemented with extra virgin olive oil or walnuts compared to the control group following a low-fat diet (with a relative difference of 30% and an absolute difference of 1.7–2.1%). The fact that these beneficial effects were observed in older adults at high cardiovascular risk suggests that it is never too late to change eating habits to improve health status and that the MD can play a key role in preventing cardiovascular disease at any time (16).

Walnut consumption has been shown to be a protective factor against diabetes, along with reducing meat and dairy intake and increasing fiber intake, as observed in the MD (17, 18). Furthermore, adherence to MD during pregnancy has been associated with a lower risk of neural tube defects (19), premature births (20, 21) and fetal growth problems (22), as well as a reduction in waist circumference in pre-school children (23).

The PASSI surveillance system, a survey that collects information about the Italian adult population on lifestyles and on the behavioral risk factors associated with the incidence of chronic non-communicable diseases, provides a framework with many contrasts (24). Trends concerning overweight and obesity, physical activity and sedentariness, fruit and vegetable consumption, diabetes, and cardiovascular risk have been worsening for years according to a North–South gradient. Oddly enough, the worst results were observed in the southern regions, which, as they face the Mediterranean Sea, are rightfully part of that area historically considered as the cradle of MD: most likely, the reduced observance of MD and the poor awareness of the benefits it can bring, of which the above-mentioned factors may be a proxy, are to be found in social, economic and cultural reasons that characterize the southern regions and distinguish them from the rest of the Italian areas (24).

The aim of this study was to analyze knowledge and adherence to MD principles in an everyday-life setting, in a sample of individuals practicing amatorial sports in the Metropolitan Area of Palermo. The choice of this target was linked to the fact that practicing regular physical activity is one of the “pillars” of the MD and was amply demonstrated and if integrated with a correct diet can lead to a general well-being (25).

2. Materials and methods

2.1. Study design and participants

A cross-sectional study was conducted, from October 2021 to February 2022, through the administration of a self-administered digital questionnaire on a sample of individuals aged between 18 and over 65 years who practiced weekly recreational / amateur sports activities on a voluntary basis. More specifically, the survey was aimed at analyzing knowledge, attitudes, and adherence to MD in individuals recruited in six of the major sports centers in the province of Palermo (fitness centers, tennis and padel centers, and swimming pools). Based on the 34.9% of Sicilian adults that regularly practice physical activity in 2020–2021 (prevalence) (24) with a 95% desired level of significance the minimum study population needed to enroll to have statistical significance of the study sample was 315 subjects.

The administration of the questionnaire took place through dedicated links or QR Code created on the Google Documents® platform (26). The questionnaire was anonymous and in Italian. Purposes of the study, methods of treatment, conservation and protection of personal data were explained, and an informed consent form was signed and collected.

The reliability and validity of the questionnaires were evaluated in a preliminary pilot testing study conducted among 65 adults. In this study, Cronbach’s alpha was calculated and corresponded to 0.854, with an adequate reliability of the test.

This study was approved in September 2021 by the Ethics Committee Palermo 1 (Session no. 7 of 2021).

2.2. Questionnaire description

The questionnaire consisted of 74 items distributed in five sections with the purpose of investigating:

1. Socio-demographic aspects: age, gender, anthropometric parameters (weight and height), residence, educational level, family members, work location, presence of chronic diseases, and type of disease.

2. Physical activity-related habits (how often and for how long physical activity is practiced, number of sports played, how COVID-19 has changed habits).

3. Eating/drinking habits (cooking routine, place where usually have a meal, knowledge and attitudes regarding MD, willingness to change eating habits, role of physicians and specialists in promoting MD).

4. Adherence to the MD, through a score obtained from the responses to 14 questions of the Mediterranean Diet Adherence Screener (MEDAS), validated and used in the PREDIMED study (15).

5. Knowledge and false beliefs about MD, through the Knowledge Score (KS) obtained from the true-false responses to the 12 included questions.

For the purposes of the present study, the MEDAS and KS scores are further described.

2.3. MEDAS score

The MEDAS Score, to which the fourth section is dedicated, is the score chosen to understand the adherence of individuals to the MD. Specifically, the MEDAS Score was previously validated and used in the PREDIMED study (15). In this section of the questionnaire, each participant was asked to answer 14 questions about daily food habits with the aim of understanding the adherence of everyone. One point was awarded for using olive oil as the main source of fat for cooking, preferring white meat over red meat, or for consuming: two or more tablespoons (1 tablespoon = 13.5 g) of olive oil/day (including that used for frying, salads, meals consumed from home, etc.); two or more servings of vegetables/day; three or more fruit/day; <2 servings of red meat or sausages/day; <1 portion of animal fat/day; <1 sweetened drink/day; three or more portions of legumes/week; three or more portions of fish/week; <3 sweets, biscuits or pastry products/week; three or more servings of dried fruit/week; seven or more portions of wine, beer of 33 cL/week; and consumption of white meats preferably over red ones, if the condition is not met, zero points have been recorded for the category. The total MEDAS score ranges from 0 to 14, with a higher score indicating better adherence to MD. MEDAS score ≥ 7 represents a modest agreement and a score ≥ 9 represents strong agreement with the healthy diet model (15).

2.4. Knowledge score

The KNOWLEDGE Score, to which the fifth section is dedicated, is the score used to understand the degree to which individuals are aware of MD, already validated and used in the PREDIMED study (15). In this section of the questionnaire, each participant was asked to answer 13 questions about daily alimentary habits, with the aim of understanding each person’s knowledge. The subjects answered True or False to the following questions:

- physical activity is a basic foundation of the food pyramid;

- red meat, according to the MD, should be consumed monthly;

- it is advisable to maintain a moderate consumption of cold cuts, with a maximum of one portion (or if possible, even less) per week;

- peanuts are legumes;

- extra virgin olive oil (EVO) contains vitamins, antioxidants and has a beneficial effect on health;

- worldwide, more than 400 million people are affected by type 2 diabetes mellitus;

- white meats can be eaten weekly;

- pork and kid are white meats;

- for fish is indicated the same consumption as white meat;

- in a diet to lose weight you need to make five well balanced meals a day (three main and two minor);

- it has been scientifically proven that a good adherence to the MD prevents the onset of chronic-degenerative diseases (cardiovascular diseases, tumors, etc.); and

- food control rules are the same in all countries.

From the answers obtained a knowledge score ≤ 9 was considered related to a low level of knowledge, while a score ≥ 9 to a high level of knowledge.

2.5. Statistical analysis

Data obtained were collected in a Microsoft® Excel database, which was automatically filled by the Google® Modules online questionnaire administration system. Data were analyzed using STATA14® software (StataCorp. 2015. College Station, TX, United States: StataCorp LP). Absolute and relative frequencies were calculated for categorical variables. Differences in qualitative variables were analyzed using chi-square tests (or Fisher’s exact test, when appropriate). In the univariate analysis, the factors were included in a multivariate backward stepwise logistic regression model. In addition, all the variables with a value of p ≤ 0.20 associated to adherence to the MD at MEDAS Score and KNOWLEDGE Score were selected in the multivariate model, to guarantee a more conservative approach. Crude odds ratios (ORs) and adjusted ORs (adj-ORs), with their 95% CIs, were calculated. The level of significance chosen was a value of p < 0.05 (two tailed).

3. Results

The total number of individuals adhering to the survey was 337, with a response rate (RR) of 87%. As reported in Table 1, respondents were predominantly male (n = 186; 55.2%) and mostly with ages under 40 (57.3%). About the educational level, 64.7% of respondents had a degree equal to or greater than a university degree, followed by 35.3% of participants with a high school license; most of the interviewed were employed (n = 279; 72.8%). Furthermore, 27% of respondents were Overweight/Obese as reported in Table 1.

TABLE 1

Table 1. Socio-demographic characteristics of the individuals practicing amatorial sports recruited in the survey (n = 337).

With regard to lifestyles, almost all the sample practiced physical activity weekly (97.3%) and had daily breakfast (93.2%); 73.6% of respondents habitually consumed alcohol, while only 42.2% of them adhered to MD. Specifically, there was evidence of daily consumption of fruits and vegetables by 36.2 and 52.2% of the sample, respectively (Table 2).

TABLE 2

Table 2. Lifestyles reported by the individuals practicing amatorial sports recruited in the survey (n = 337).

In Table 3, the univariate and multivariable analyses of factors associated with MD knowledge score was showed. In the multivariable model, factors significantly associated with better knowledge of the MD were individuals that daily consume vegetables (OR: 3.32; 95%CI: 1.82–6.02) and subjects that showed at minimum a modest adherence to MD (Medas Score ≥ 7; OR: 10.15; 95%CI: 5.47–18.85).

TABLE 3

Table 3. Factors associated with MD^* knowledge score in the sample of individuals practicing amatorial sports recruited in the survey (n = 337).

Table 4 reported the results of the univariate and multivariable analyses of factors associated with MD adherence explored by the MEDAS score. In the multivariable model, the following associations were highlighted: a lower adherence (MEDAS score) to MD among overweight/obese individuals (OR: 0.57; CI95%:0.33–0.99), and among employed subjects (OR: 0.52; IC95%: 0.28–0.98); a higher adherence to MD in individuals daily consuming vegetables (OR: 2.52; CI95%:1.52–4.17), daily consuming fruit (OR: 1.77; CI95%:1.08–2.90), and having daily breakfast (OR: 4.29; CI95%:1.15–15.96).

TABLE 4

Table 4. Factors associated with MD* adherence explored by the MEDAS score in the sample of individuals practicing amatorial sports recruited in the survey (n = 337).

4. Discussion

This cross-sectional study was focused on the importance of the MD, included by UNESCO in the list of intangible cultural heritage in 2010 (2). We have tried to investigate the level of knowledge and adherence to this diet, in an everyday-life setting, through a questionnaire administered to a sample of individuals practicing amatorial sports in the Metropolitan Area of Palermo. The results of our study showed that even in such a selected population there are still few individuals who adhere to the cornerstones of MD (42.2%), probably because in modern and industrialized populations there is a tendency to eat unhealthy and faster meals (27).

Mediterranean Diet is a nutrition model based on the balanced intake of micro and macronutrients which, in synergy with regular physical activity, can positively influence the well-being of everyone by preventing metabolic, cardiovascular, and cancer diseases, and it promotes longevity as well.

In a study conducted on a sample of school-age individuals, it was seen that lessons aimed at raising awareness of MD principles lead to increased consumption of fruits and vegetables, resulting in increased adherence to the MD itself (28). Indeed, a diet rich in fruits, vegetables and a regular breakfast affect the nutritional status of people and their health, thus increasing the degree of adherence to the MD with consequent reduction in the incidence of cardiovascular disease, cancer, and other serious diseases (29).

The Mediterranean Diet is not only a great dietary guideline for healthy individuals engaging in sports (30–40) but is also particularly beneficial for those with health conditions, taking into account necessary adjustments and precautions. The rise of chronic degenerative diseases can be attributed to poor diet and decreased physical activity, which are consequences of technological advancements, impacting not just industrialized countries but also in emerging ones (30).

A study on Cypriot children having regular breakfast showed greater adherence to the MD (41). Also, who consumes vegetables and fruit daily obtained a higher MEDAS score, and this was in line with a study conducted on Spanish university students, stating that high level of adherence to the MD is associated with consumptions of more than two servings of vegetables/day and three or more fruits/day (42). Weight overload was associated with body dissatisfaction and a low score on the Mediterranean diet adherence test (43); in other studies, it has been seen that even in pediatric age being overweight-obese involves a reduction in the degree of adherence to MD (44).

As highlighted in the results, unemployed individuals showed a higher adherence to the MD, probably because those who do not have a job, having more time available than those who have stable jobs, are able of choosing the best foods calmly and, therefore, preparing healthier meals to eat. The time factor emerges also from studies that have evaluated adherence to the MD during the various lockdowns caused by the COVID-19 pandemic (45, 46), highlighting how having more spare time, due to the confinement at home, allowed people to prepare healthier meals and thus follow a healthier dietary regimen.

A study conducted by Pfeifer et al. (46), reported an increase in cooking frequency during confinement associated with increased consumption of vegetables, legumes, fish, and seafood. The increased adherence to MD by those who know it best can most likely be attributed to the fact that by informing themselves about this dietary regimen, even independently, they can appreciate its health benefits and thus consider it as a viable alternative to any other diet.

These results are confirmed by other researches that investigated the association between the level of adherence and the level of knowledge on the MD, such as the one conducted by Aureli et al. (47), who observed a close correlation between adherence and knowledge of MD in a sample of 2,869 adults, with adherence increasing as knowledge increased and vice versa, in a context where, with the passage of time due to globalization and ever faster rhythms, adherence to the MD progressively decreases. This should encourage health workers to commit to ensure more knowledge and appreciation by the general population to promote its positive effect on health.

Projects involving schools, for example, could give good results because students might end up involving parents by bringing home useful information to make it clear that eating well makes people feel good, thus creating a synergy that can lead to a clear improvement of the quality of the diet. The work conducted by Philippou et al. (48), for example, has highlighted how much the involvement of families can be useful to multiply the effects of an interactive educational intervention that involves not only adolescents but also those who are part of their life, thus creating a virtuous context. In accordance with the WHO Europe Gaining Health Campaign, Public Health Authorities should simplify accessibility of general population to foods that are healthy and that promote principles of MD (49).

Therefore, the fundamental objective of public health is to work as a team to reach all those subjects who for various reasons (work, education, age, etc.…) do not have the time or are unable to get information correctly; this could be realized by starting a whole series of initiatives involving various actors such as the local Food and Nutrition Hygiene Services, which have among their objectives the spreading of healthy lifestyles, with targeted projects in the workplace, schools, and universities (37, 50, 51); general practitioners, pediatricians, and other health professionals should be addressed as well, since, according to what emerged from the “PASSI Survey” (52), they could do much more to sensitize their patients to follow a healthier diet and to carry out regular physical activity.

This study has some limitations that need to be considered. The limited sample size might lead to a reduction in the study power. Secondly, the individuals of which the sample is formed practice recreational sport activities in sport centers and, therefore, might be keener than those who do not practice any sporting activity to learn about other diets, including the MD, and this could be a selection bias; this could suggest to perform future studies to examine the comparison with a group of sedentary people and another group of elite/professional athletes. Lastly, another limitation could be the methodological approach based on the use of a self-administered questionnaire; although the instrument was previously validated, respondents may overestimate or underestimate some of the requested parameters, thus affecting the accuracy of the answers.

5. Conclusion

In an increasingly frantic world where people tend to eat quickly and without paying too much attention to what they ingest, an extra effort should be made to ensure MD principles becoming the preferred eating lifestyle by an ever-larger portion of the population.

It is essential that public health operators take charge of the situation by involving health professionals at every level, while designing and implementing at the same time initiatives targeted to schools and families, that allow to explain in a simple and clear way how a healthy diet, accompanied by regular physical activity, represents a good viaticum for an ever-higher quality of life.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, ensuring the anonymity of the respondents to the questionnaire, without undue reservation.

Ethics statement

The studies involving human participants were reviewed and approved by Palermo 1, Via del Vespro 129, 90,127, Palermo, Italy. The patients/participants provided their written informed consent to participate in this study.

Author contributions

CC, LG, NB, FB, and MB: conceptualization. ACas, FB, GT, LG, and MS: methodology. TV, ACar, and LD’A: software. ACas, ACar, FB, NB, LG, GT, ML, LD’A, and MS: validation. ACas, TV, LG, ML, and FB: formal analysis. ACar, ML, TV, and LD’A: investigation. ACar, LD’A, MS, and GT: resources. ACas, NB, MS, TV, and ML: data curation. MB, CC, and WM: writing—original draft preparation. MB: writing, review, and editing. CC, MB, and FV: visualization. FV, WM, and CC: supervision. FV and WM: project administration. WM, GT, NB, and FV: funding acquisition. All authors contributed to the article and approved the submitted version.

Acknowledgments

The authors are fully indebted with managers and owners of the six sports centers in the province of Palermo where enrollment was conducted by the AA.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

1. Cena, H, and Calder, PC. Defining a healthy diet: evidence for the role of contemporary dietary patterns in health and disease. Nutrients. (2020) 12:334. doi: 10.3390/nu12020334

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Dieta Mediterranea (2023). Unesco Italia. Available at: https://www.unesco.it/it/PatrimonioImmateriale/Detail/384 (Accessed February 2, 2023)

Google Scholar

3. Oppert, JM, Bellicha, A, and Ciangura, C. Physical activity in management of persons with obesity. Eur J Intern Med. (2021) 93:8–12. doi: 10.1016/j.ejim.2021.04.028

PubMed Abstract | CrossRef Full Text | Google Scholar

4. Ciumărnean, L, Milaciu, MV, Negrean, V, Orășan, OH, Vesa, SC, Sălăgean, O, et al. Cardiovascular risk factors and physical activity for the prevention of cardiovascular diseases in the elderly. IJERPH. (2021) 19:207. doi: 10.3390/ijerph19010207

PubMed Abstract | CrossRef Full Text | Google Scholar

5. Kanaley, JA, Colberg, SR, Corcoran, MH, Malin, SK, Rodriguez, NR, Crespo, CJ, et al. Exercise/physical activity in individuals with type 2 diabetes: a consensus statement from the American College of Sports Medicine. Med Sci Sports Exerc. (2022) 54:353–68. doi: 10.1249/MSS.0000000000002800

PubMed Abstract | CrossRef Full Text | Google Scholar

6. Mctiernan, A, Friedenreich, CM, Katzmarzyk, PT, Powell, KE, Macko, R, Buchner, D, et al. Physical activity in Cancer prevention and survival: a systematic review. Med Sci Sports Exerc. (2019) 51:1252–61. doi: 10.1249/MSS.0000000000001937

PubMed Abstract | CrossRef Full Text | Google Scholar

7. de Boer, MC, Wörner, EA, Verlaan, D, and van Leeuwen, PAM. The mechanisms and effects of physical activity on breast Cancer. Clin Breast Cancer. (2017) 17:272–8. doi: 10.1016/j.clbc.2017.01.006

PubMed Abstract | CrossRef Full Text | Google Scholar

8. Kandola, A, Ashdown-Franks, G, Hendrikse, J, Sabiston, CM, and Stubbs, B. Physical activity and depression: towards understanding the antidepressant mechanisms of physical activity. Neurosci Biobehav Rev. (2019) 107:525–39. doi: 10.1016/j.neubiorev.2019.09.040

PubMed Abstract | CrossRef Full Text | Google Scholar

9. Shin, CN, Lee, YS, and Belyea, M. Physical activity, benefits, and barriers across the aging continuum. Appl Nurs Res. (2018) 44:107–12. doi: 10.1016/j.apnr.2018.10.003

CrossRef Full Text | Google Scholar

10. Nutrizione ISS. (2023) Available at: https://www.iss.it/nutrizione (Accessed February 2, 2023).

Google Scholar

11. Donovan, MG, Selmin, OI, Doetschman, TC, and Romagnolo, DF. Mediterranean diet: prevention of colorectal Cancer. Front Nutr. (2017) 4:59.

Google Scholar

12. The Seven Countries Study The first epidemiological nutrition study, since 1958. Seven countries study | the first study to relate diet with cardiovascular disease. (Accesse 2023 Feb 2]. Available from: https://www.sevencountriesstudy.com/

Google Scholar

13. Jimenez-Torres, J, Alcalá-Diaz, JF, Torres-Peña, JD, Gutierrez-Mariscal, FM, Leon-Acuña, A, Gómez-Luna, P, et al. Mediterranean diet reduces atherosclerosis progression in coronary heart disease: an analysis of the CORDIOPREV randomized controlled trial. Stroke. (2021) 52:3440–9. doi: 10.1161/STROKEAHA.120.033214

PubMed Abstract | CrossRef Full Text | Google Scholar

14. Delgado-Lista, J, Alcala-Diaz, JF, Torres-Peña, JD, Quintana-Navarro, GM, Fuentes, F, Garcia-Rios, A, et al. Long-term secondary prevention of cardiovascular disease with a Mediterranean diet and a low-fat diet (CORDIOPREV): a randomised controlled trial. Lancet. (2022) 399:1876–85. doi: 10.1016/S0140-6736(22)00122-2

CrossRef Full Text | Google Scholar

15. Sánchez-Taínta, A, Estruch, R, Bulló, M, Corella, D, Gómez-Gracia, E, Fiol, M, et al. Adherence to a Mediterranean-type diet and reduced prevalence of clustered cardiovascular risk factors in a cohort of 3204 high-risk patients. Eur J Cardiovasc Prev Rehabil. (2008) 15:589–93. doi: 10.1097/HJR.0b013e328308ba61

CrossRef Full Text | Google Scholar

16. Jiang, R, Manson, JE, Stampfer, MJ, Liu, S, Willett, WC, and Hu, FB. Nut and Peanut butter consumption and risk of type 2 diabetes in women. JAMA. (2002) 288:2554–60. doi: 10.1001/jama.288.20.2554

PubMed Abstract | CrossRef Full Text | Google Scholar

17. Tuomilehto, J, Lindström, J, Eriksson, JG, Valle, TT, Hämäläinen, H, Ilanne-Parikka, P, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. (2001) 344:1343–50. doi: 10.1056/NEJM200105033441801

PubMed Abstract | CrossRef Full Text | Google Scholar

18. Knowler, WC, Barrett-Connor, E, Fowler, SE, Hamman, RF, Lachin, JM, Walker, EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. (2002) 346:393–403. doi: 10.1056/NEJMoa012512

PubMed Abstract | CrossRef Full Text | Google Scholar

19. Fischer, M, Stronati, M, and Lanari, M. Mediterranean diet, folic acid, and neural tube defects. Ital J Pediatr. (2017) 43:74.

Google Scholar

20. Mikkelsen, TB, Louise Østerdal, M, Knudsen, VK, Haugen, M, Meltzer, HM, Bakketeig, L, et al. Association between a Mediterranean-type diet and risk of preterm birth among Danish women: a prospective cohort study. Acta Obstet Gynecol Scand. (2008) 87:325–30. doi: 10.1080/00016340801899347

PubMed Abstract | CrossRef Full Text | Google Scholar

21. Smith, LK, Draper, ES, Evans, TA, Field, DJ, Johnson, SJ, Manktelow, BN, et al. Associations between late and moderately preterm birth and smoking, alcohol, drug use and diet: a population-based case–cohort study. Arch Dis Child Fetal Neonatal Ed. (2015) 100:F486–91.

Google Scholar

22. Martínez-Galiano, J, Olmedo-Requena, R, Barrios-Rodríguez, R, Amezcua-Prieto, C, Bueno-Cavanillas, A, Salcedo-Bellido, I, et al. Effect of adherence to a Mediterranean diet and olive oil intake during pregnancy on risk of small for gestational age infants. Nutrients. (2018) 10:1234. doi: 10.3390/nu10091234

PubMed Abstract | CrossRef Full Text | Google Scholar

23. Fernández-Barrés, S, Romaguera, D, Valvi, D, Martínez, D, Vioque, J, Navarrete-Muñoz, EM, et al. Mediterranean dietary pattern in pregnant women and offspring risk of overweight and abdominal obesity in early childhood: the INMA birth cohort study: maternal diet and childhood obesity. Pediatr Obes. (2016) 11:491–9. doi: 10.1111/ijpo.12092

PubMed Abstract | CrossRef Full Text | Google Scholar

24. EpiCentro (2023). Sorveglianza Passi. Available at: https://www.epicentro.iss.it/passi/ (Accessed February 2, 2023).

Google Scholar

25. Hershey, MS, Martínez-González, MÁ, Álvarez-Álvarez, I, Martínez Hernández, JA, and Ruiz-Canela, M. The Mediterranean diet and physical activity: better together than apart for the prevention of premature mortality. Br J Nutr. (2022) 128:1413–24. doi: 10.1017/S0007114521002877

PubMed Abstract | CrossRef Full Text | Google Scholar

26. Questionario Dieta Mediterranea Google docs. (2023) Available at: https://docs.google.com/forms/d/e/1FAIpQLSfWZfMjZlmqvi67ciGKr6XGtdSLeRkPA2ZrQkNuJ5QAwaGDnA/viewform?edit_requested=true&usp=embed_facebook (Accessed February 2, 2023).

Google Scholar

27. La dieta mediterranea ISS. (2023) Available at: https://www.iss.it/la-dieta-mediterranea (Accessed March 14, 2023).

Google Scholar

28. Roccaldo, R, Censi, L, D’Addezio, L, Berni Canani, S, and Gennaro, L. A teachers’ training program accompanying the “school fruit scheme” fruit distribution improves children’s adherence to the Mediterranean diet: an Italian trial. Int J Food Sci Nutr. (2017) 68:887–900. doi: 10.1080/09637486.2017.1303826

PubMed Abstract | CrossRef Full Text | Google Scholar

29. Gli Effetti Benefici della Dieta (2023). Fondazione dieta mediterranea. Available at: https://www.fondazionedietamediterranea.it/dieta/gli-effetti-benefici-della-dieta/ (Accessed March 14, 2023).

Google Scholar

30. Laganà, P, Coniglio, MA, Corso, C, Lo Turco, V, Dattilo, G, and Delia, S. Mediterranean diet, sport and health. Prog Nutr. (2020) 22:e2020045

Google Scholar

31. Calella, P, Gallè, F, Cerullo, G, Postiglione, N, Ricchiuti, R, Liguori, G, et al. Adherence to Mediterranean diet among athletes participating at the XXX summer universiade. Nutr Health (2022) doi: 10.1177/02601060221089118 (Epub ahead of print).

CrossRef Full Text | Google Scholar

32. Martínez-Rodríguez, A, Martínez-Olcina, M, Hernández-García, M, Rubio-Arias, JÁ, Sánchez-Sánchez, J, Lara-Cobos, D, et al. Mediterranean diet adherence, body composition and performance in beach handball players: a cross sectional study. Int J Environ Res Public Health. (2021) 18:2837. doi: 10.3390/ijerph18062837

PubMed Abstract | CrossRef Full Text | Google Scholar

33. D’Angelo, S, and Cusano, P. Adherence to the Mediterranean diet in athletes. Sport Sci. (2020) 13:58–63.

Google Scholar

34. Redondo Del Río, MP, De Mateo, SB, Carreño Enciso, L, Marugán de Miguelsanz, JM, Fernández McPhee, M, and Camina Martín, MA. Ingesta dietética y adherencia a la dieta mediterránea en un grupo de estudiantes universitarios en función de la práctica deportiva. Nutr Hosp. (2016) 33:583. doi: 10.20960/nh.583

CrossRef Full Text | Google Scholar

35. Chacón-Cuberos, R, Badicu, G, Zurita-Ortega, F, and Castro-Sánchez, M. Mediterranean diet and motivation in sport: a comparative study between university students from Spain and Romania. Nutrients. (2018) 11:30.

Google Scholar

36. Hołowko-Ziółek, J, Cięszczyk, P, Biliński, J, Basak, GW, and Stachowska, E. What model of nutrition can be recommended to people ending their professional sports career? An analysis of the Mediterranean diet and the CRON diet in the context of former athletes. Nutrients. (2020) 12:3604. doi: 10.3390/nu12123604

PubMed Abstract | CrossRef Full Text | Google Scholar

37. Santomauro, F, Lorini, C, Tanini, T, Indiani, L, Lastrucci, V, Comodo, N, et al. Adherence to Mediterranean diet in a sample of Tuscan adolescents. Nutrition. (2014) 30:1379–83. doi: 10.1016/j.nut.2014.04.008

PubMed Abstract | CrossRef Full Text | Google Scholar

38. Kontele, I, Grammatikopoulou, MG, and Vassilakou, T. Level of adherence to the Mediterranean diet and weight status among adolescent female gymnasts: a cross-sectional study. Children. (2021) 8:1135.

Google Scholar

39. Baker, ME, DeCesare, KN, Johnson, A, Kress, KS, Inman, CL, and Weiss, EP. Short-term Mediterranean diet improves endurance exercise performance: a randomized-sequence crossover trial. J Am Coll Nutr. (2019) 38:597–605.

Google Scholar

40. Manzano-Carrasco, S, Felipe, JL, Sanchez-Sanchez, J, Hernandez-Martin, A, Gallardo, L, and Garcia-Unanue, J. Physical fitness, body composition, and adherence to the Mediterranean diet in young football players: influence of the 20 mSRT score and maturational stage. Int J Environ Res Public Health. (2020) 17:3257. doi: 10.3390/ijerph17093257

PubMed Abstract | CrossRef Full Text | Google Scholar

41. Lazarou, C, and Matalas, AL. Breakfast intake is associated with nutritional status, Mediterranean diet adherence, serum iron and fasting glucose: the CYFamilies study. Public Health Nutr. (2015) 18:1308–16.

Google Scholar

42. Cobo-Cuenca, AI, Garrido-Miguel, M, Soriano-Cano, A, Ferri-Morales, A, Martínez-Vizcaíno, V, and Martín-Espinosa, NM. Adherence to the Mediterranean diet and its association with body composition and physical fitness in Spanish university students. Nutrients. (2019) 11:2830. doi: 10.3390/nu11112830

PubMed Abstract | CrossRef Full Text | Google Scholar

43. Guillén Alcolea, F, López-Gil, JF, and Tárraga López, PJ. Adherencia a la dieta mediterránea, nivel de actividad física e insatisfacción corporal en sujetos de 16 a 50 años de la Región de Murcia. Clín Investig Arterioscler. (2021) 33:10–8. doi: 10.1016/j.arteri.2020.06.005

PubMed Abstract | CrossRef Full Text | Google Scholar

44. Katsagoni, CN, Psarra, G, Georgoulis, M, Tambalis, K, Panagiotakos, DB, and Sidossis, LS. High and moderate adherence to Mediterranean lifestyle is inversely associated with overweight, general and abdominal obesity in children and adolescents: the MediLIFE-index. Nutr Res. (2020) 73:38–47.

Google Scholar

45. Mieziene, B, Burkaite, G, Emeljanovas, A, Tilindiene, I, Novak, D, and Kawachi, I. Adherence to Mediterranean diet among Lithuanian and Croatian students during COVID-19 pandemic and its health behavior correlates. Frontiers. Public Health. (2022) 10:1000161. doi: 10.3389/fpubh.2022.1000161

CrossRef Full Text | Google Scholar

46. Pfeifer, D, Rešetar, J, Gajdoš Kljusurić, J, Panjkota Krbavčić, I, Vranešić Bender, D, Rodríguez-Pérez, C, et al. Cooking at home and adherence to the Mediterranean diet during the COVID-19 confinement: the experience from the Croatian COVIDiet study. Front Nutr. (2021) 8:617721. doi: 10.3389/fnut.2021.617721

PubMed Abstract | CrossRef Full Text | Google Scholar

47. Aureli, V, and Rossi, L. Nutrition knowledge as a driver of adherence to the Mediterranean diet in Italy. Front Nutr. (2022) 9:804865. doi: 10.3389/fnut.2022.804865

PubMed Abstract | CrossRef Full Text | Google Scholar

48. Philippou, E, Middleton, N, Pistos, C, Andreou, E, and Petrou, M. The impact of nutrition education on nutrition knowledge and adherence to the Mediterranean diet in adolescent competitive swimmers. J Sci Med Sport. (2017) 20:328–32. doi: 10.1016/j.jsams.2016.08.023

PubMed Abstract | CrossRef Full Text | Google Scholar

49. World Health Organization Regional Office for Europe. Gaining health: the European strategy for the prevention and control of noncommunicable diseases. World Health Organization. Regional Office for Europe, 46 p. (2006) Available at: Available from: https://apps.who.int/iris/handle/10665/107787 (Accessed Feb 23, 2023)

Google Scholar

50. Cerame, G, Meli, V, Vitale, F, Firenze, A, Viviano, E, Mazzucco, W, et al. A study to evaluate the lifestyle of medical students in Palermo (Italy). Ig Sanita Pubbl. (2008) 64:469–84.

PubMed Abstract | Google Scholar

51. Matranga, D, Restivo, V, Maniscalco, L, Bono, F, Pizzo, G, Lanza, G, et al. Lifestyle medicine and psychological well-being toward health promotion: a cross-sectional study on Palermo (southern Italy) undergraduates. Int J Environ Res Public Health. (2020) 17:5444. doi: 10.3390/ijerph17155444

PubMed Abstract | CrossRef Full Text | Google Scholar

52. EpiCentro (2023). Sovrappeso e obesità dati sorveglianza Passi. Available at: https://www.epicentro.iss.it/passi/dati/sovrappeso?tab-container-1=tab1#dati (Accessed February 2, 2023).

Google Scholar