- Email: [email protected]
Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study
Nutrition, Metabolism & Cardiovascular Diseases (xxxx) xxx, xxx
Available online at www.sciencedirect.com
Nutrition, Metabolism & Cardiovascular Diseases journal homepage: www.elsevier.com/locate/nmcd
Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study Nicola Veronese a,b,*, Maria Notarnicola a, Anna M. Cisternino b, Rosa Inguaggiato b, Vito Guerra c, Rosa Reddavide b, Rossella Donghia c, Ornella Rotolo b, Iris Zinzi b, Gioacchino Leandro b,d, Valeria Tutino a, Giovanni Misciagna e, Maria G. Caruso a,b, the MICOL study group1 a
Laboratory of Nutritional Biochemistry, Castellana Grotte, Bari, Italy Ambulatory of Clinical Nutrition, Castellana Grotte, Bari, Italy Clinical Trial Unit, Castellana Grotte, Bari, Italy d Unit of Gastroenterology, Castellana Grotte, Bari, Italy e Scientific and Ethical Committee-National Institute of Gastroenterology-Research Hospital, IRCCS “S. de Bellis”, Castellana Grotte, Bari, Italy b c
Received 1 May 2019; received in revised form 2 November 2019; accepted 4 November 2019 Handling Editor: P. Strazzullo Available online - - -
KEYWORDS Mediterranean diet; Olive oil; Trend; Epidemiology
Abstract Background and aims: Increasing literature data show that adherence to the Mediterranean diet is undergoing profound changes in recent years, albeit with marked differences across nations. In Italy, one of the cradles of the Mediterranean diet, the literature regarding the trend for Mediterranean diet adherence is conflicting. Thus, we aimed to explore the trends of adherence to the Mediterranean diet in a large cohort of participants living in South Italy, over 20 years from 1985e86 to 2005e06. Methods and results: Cross-sectional study with two evaluations, one made in 1985e86 and another in 2005e06; all participants were adults aged 30e70 years of age. The adherence to the Mediterranean diet was evaluated using the score proposed by Panagiotakos et al. This score features values ranging from 0 to 55, higher scores reflecting a greater adherence. The data are reported by age (30e49 vs. 50e69 years). Overall, 2451 subjects were included in 1985e86 and 2375 in 2005e06. A significant reduction was observed in the adherence to the Mediterranean diet (age 30e49 years: 31.82 4.18 in 1985e86 vs. 29.20 4.48 in 2005e06, reduction by 8.2%, p < 0.0001; age 50e69: 32.20 4.09 in 1985e86 vs.30.15 4.27 in 2005e06, reduction by 6.3%, p < 0.0001). Among all these items, the most dramatic change was observed for olive oil consumption, that decreased by 2.35 points in younger and 0.89 in older people. Conclusion: The adherence to the Mediterranean diet decreased from 1985e86 to 2005e06 in South Italy, particularly in younger people, above all due to a decreased olive oil consumption. ª 2019 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.
Introduction * Corresponding author. National Institute of GastroenterologyResearch Hospital, IRCCS “Saverio de Bellis”, Via Turi 27, 70013 Castellana, Bari, Italy, E-mail address: [email protected] (N. Veronese). 1 Members of MICOL study group investigators are listed in Appendix A section.
The Mediterranean diet is included in UNESCO heritage [1]. This kind of diet is characterized by a high consumption of plant foods (e.g. legumes, cereals, fruits and vegetables, nuts and seeds), fish and olive oil, a moderate
https://doi.org/10.1016/j.numecd.2019.11.003 0939-4753/ª 2019 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
2
consumption of (red) wine and a low consumption of meat and dairy products [2]. Overall, the Mediterranean dietary pattern is considered healthy, and increasing reports in literature conclude that good adherence to this pattern is associated with a protective effect against various chronic diseases, including metabolic [3] and cardiovascular diseases [4], fractures [5], osteoarthritis [6e8] and, finally, mortality [9]. Even if there is abundant literature supporting the importance of following a Mediterranean diet regimen in order to prevent chronic diseases, it has been noted that several Mediterranean countries (including Spain [10,11] and Greece [12]) are drifting away from the Mediterranean dietary pattern, whereas countries in Northern Europe are tending to show a more strict observance of a Mediterranean-like dietary pattern [2]. In Italy, the studies available have reported conflicting results. In Milan, a big city in North Italy, some authors observed no significant differences over 15 years of follow-up (between 1991 and 2005) [13] in the adherence to the Mediterranean diet, whilst another study reported a significantly decreased adherence to the Mediterranean diet over 5 years [14]. To the best of our knowledge, only one study has been made of people living in South Italy, even if South Italy is one of the birthplaces of the Mediterranean diet [15]. In the Molisani study, the authors reported a significant decrease in the adherence to Mediterranean diet, over 5 years [16]. Given this background, we aimed to explore the trends of adherence to Mediterranean diet, comparing a large cohort of participants living in South Italy in 1985e86 vs. 2005e06. Methods Study design, setting and participants This study included participants randomly sampled from the electoral rolls of the population of Castellana Grotte, a town in Southern Italy (Apulia region). Between 1985 and 1986, 3500 persons were contacted and 2472 (Z70.6%) were enrolled within the context of the MICOL (Multicentrica Italiana Colelitiasi) 1. Between 2005 and 2006, among 1942 subjects initially contacted, 1708 (Z87.9%) participated in the baseline survey (MICOL III). Additionally, in the same years, 1900 young participants (between 30 and 49 years) were contacted (panel study). Among them, 1265 (Z66.6%) decided to participate in the study. For the aims of this study, we included only people aged 30e70 years. The MICOL study design is reported in Supplementary Fig. 1. The proposal of this research was approved by the Institutional Review Board (Ethical Committee) of IRCCS De Bellis and written informed consent was obtained from each participant before entering the study. Mediterranean diet score: outcome of interest Dietary intake was assessed using a validated tool, the Block Brief 2000 Food Frequency Questionnaire (FFQ)
N. Veronese et al.
during the baseline visit [17]. Seventy items were assessed to determine an individual’s typical food and beverage consumption over the past year. The frequency of consumption was reported at nine levels of intake from “never” to “every day”. This questionnaire had already been validated (in Italian) in this specific population [18] and the data for the adherence to the Mediterranean diet were extracted using the Food Composition Database for Epidemiological Studies in Italy [19]. In this study, adherence to a Mediterranean diet was evaluated using the Mediterranean diet score proposed by Panagiotakos et al. (aMED) [20] The aMED takes into consideration foods commonly consumed by Mediterranean populations. Respondents were asked to rate their consumption of each single food item using a score ranging from 0 (no adherence) to 5 (best adherence); the total possible score ranges from 0 to 55, with higher values indicating a greater adherence to a Mediterranean diet. The calculation of the Mediterranean diet score in our study is shown in Supplementary Table 1. Cereals (e.g. bread, pasta, rice), whole grain bread, fruits, vegetables, legumes (e.g. peas, beans), fish were categorized on the basis of servings/month and specifically as: 0 Z never; 1 Z 1 to 2 servings per month (rare); 2 Z 3 to 6 (frequent); 3 Z 7 to 10 (very frequent); 4 Z 11 to 24 (weekly); 5 Z daily. Consumption of red meat, poultry, and full fat dairy products (e.g. milk) was categorized as: 0 Z daily; 1 Z weekly; 2 Z very frequent; 3 Z frequent; 4 Z rare; 5 Z never). Consumption of olive oil was categorized as how many times it was used over one week, and based on the type of cooking, where raw olive oil increases the adherence to the Mediterranean diet and cooked oil decreases it. Alcoholic beverages were categorized as: 0 700 ml/day or 0; 1 Z 600e699 ml/day; 2 Z 500e599 ml/day; 3 Z 400e499 ml/day; 4 Z 300e399 ml/day; 5Z< 300 ml/day. In the original paper by Panagiotakos et al. [20], the authors considered only non-refined cereals, whilst we also included refined cereals in this item; moreover, no information regarding potatoes intake was present in the MICOL study and instead of this food, we used whole grain bread; meat included both white and red meats. In order to make stronger our results, we did run a similar analysis using another score, i.e. the Italian Mediterranean Index as developed by Agnoli et al. [21]. This score is based on intake of 11 items: high intakes of 6 typical Mediterranean foods; low intakes of 4 nonMediterranean foods; and also alcohol. Possible scores ranged from 0 to 11, higher scores reflecting more adherence to Mediterranean diet. For the aims of our paper we included all the foods mentioned, except soft-drinks, an information not available in our cohort. Statistical analysis Means and standard deviations were used as index of centrality and dispersion of the distributions. Proportion test for continuous parameters and the Wilcoxon ranksum (ManneWhitney) test were used to test statistical
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
Trends in adherence to the Mediterranean diet
3
hypotheses, with the level of statistical significance of rejection of the null hypothesis set at p < 0.05. The data are presented by age (30e49 vs. 50e69 years). Moreover, we ran a linear regression analysis, taking as independent variables age, gender and population study years and as dependent outcome the adherence to the Mediterranean diet. All the analyses were performed using STATA 13.0. Results Study size In the MICOL 1 (1985e86) 2472 participants were initially included, and 2451 of them were included in the present research. Among the 2973 participants examined in 2005e06, 2375 were included; subjects under 30 or over 70 years at the time of the interview were excluded. Descriptive data Table 1 reports the general features of the population examined. In both evaluations younger people (i.e. those aged between 30 and 49 years) were more numerous than older people (aged between 50 and 69 years). Overall, there were more males than females. As shown in Table 1, in both groups, over 20 years of observation we observed a significant reduction in the adherence to the Mediterranean diet, by a mean of 8.2% in
younger and of 6.3% in older people (age 30e49 years: 31.82 4.18 in 1985e86 vs. 29.20 4.48 in 2005e06, p < 0.0001; age 50e69: 32.20 4.09 in 1985e86 vs.30.15 4.27 in 2005e06, p < 0.0001). The distribution of adherence to the Mediterranean diet, by age, is graphically reported in Fig. 1 and by gender in Fig. 2. Outcome data Considering the single items in the Mediterranean diet score, we observed, in both younger and older people, that the consumption of cereals (including pasta, bread and similar), whole grain bread, vegetables, legumes, fish significantly increased between 1985e86 and 2005e06, whilst the consumption of fruits, meat, poultry, dairy, olive oil and alcohol significantly decreased (Table 1). Among all these items, the most dramatic decrease was observed for olive oil, that declined by 2.35 points in younger and by 0.89 in older people. This finding was furthermore confirmed using the Italian Mediterranean Index (Supplementary Table 2). Finally, as shown in Table 2, the adherence to Mediterranean diet over time was not affected by age or gender, reinforcing the concept that this trend is probably due to other causes. On the contrary, in both models, younger people showed a more significant decrease in the adherence to the Mediterranean diet compared to the older population. The same was observed using the Italian Mediterranean Index (Supplementary Table 2).
Period 1985-1986 Age 50-69yrs
Density
0.05 0.0
0.05 0.0
Density
0.1
0.1
0.15
0.15
Period 1985-1986 Age 30-49yrs
10
20
30
40
50
10
20
Dietary score
40
50
40
50
Period 2005-2006 Age 50-69yrs
Density
0.05
0.0
0.0
0.05
0.1
0.1
0.15
0.15
Period 2005-2006 Age 30-49yrs
Density
30
Dietary score
10
20
30
Dietary score Figure 1
40
50
10
20
30
Dietary score
Mediterranean diet adherence (by age) in 1985e86 and in 2005e06.
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
4
N. Veronese et al.
0.15
0.1 0.15
Females
0.1 0.0
20
30
40
10
50
40
50
0.15
30
0.1
Period 1985-1986 Age 50-69yrs
0.0 20
30
40
10
50
20
30
40
50
0.1
Period 2005-2006 Age 30-49yrs
0.05 0.0
0.0
0.05
Density
0.1
0.15
0.15
10
Density
20
0.05
Density
0.1 0.05 0.0
Density
0.15
10
20
30
40
10
50
20
30
40
50
0.1
Period 2005-2006 Age 50-69yrs
0.05
0.0
0.0
0.05
Density
0.1
0.15
0.15
10
Density
Period 1985-1986 Age 30-49yrs
0.05
Density
0.05 0.0
Density
Males
10
20
30
40
50
10
20
Dietary score
30
40
50
Dietary score
Figure 1
(continued).
Table 1 Comparison between metabolic characteristics and Mediterranean diet items, by age. Age 30e49 years 1985e86
General characteristics Gender (F) (%) Age (years) (MSD) BMI (kg/m2) (MSD) Mediterranean diet score items Cereals (MSD) Whole grain bread (MSD) Fruits (MSD) Vegetables (MSD) Legumesc (MSD) Fish (MSD) Meat (MSD) Poultry (MSD) Dairyd (MSD) Olive oil (MSD) Alcohol (ml/die) (MSD) Mediterranean Diet Score (MSD)
a
Age 50e69 years 2005e06
b
f
p
1985e86a
2005e06b
(n Z 1112)
(n Z 1102)
pf
(n Z 1339)
(n Z 1273)
541 (40.40) 39.68 5.48 26.86 4.50
537 (42.18) 39.77 5.38 27.24 4.76
0.35e 0.63 0.09
493 (44.33) 57.81 5.39 28.23 4.87
464 (42.11) 59.63 5.42 29.84 5.41
0.29e <0.0001 <0.0001
2.97 0.84 0.26 0.94 4.69 0.91 2.54 0.91 2.30 0.73 1.86 0.89 3.83 0.93 3.07 0.89 3.90 1.73 3.54 1.92 2.84 2.11 31.82 4.18
3.46 0.85 0.52 1.03 4.22 1.12 3.35 1.02 2.38 0.68 2.09 0.83 3.38 1.00 2.96 0.89 2.99 1.89 2.19 1.74 1.66 2.26 29.20 4.48
<0.0001 <0.0001 <0.0001 <0.0001 0.004 <0.0001 <0.0001 0.001 <0.0001 <0.0001 <0.0001 <0.0001
2.97 0.84 0.46 1.30 4.78 0.74 2.62 0.86 2.26 0.79 1.71 0.91 4.10 0.89 3.15 0.92 3.74 1.84 3.65 1.89 2.76 2.15 32.20 4.09
3.20 0.91 0.61 1.27 4.50 0.79 3.58 0.93 2.44 0.67 2.14 0.79 3.22 1.02 2.84 0.85 2.92 1.92 2.76 1.93 1.93 2.26 30.15 4.27
<0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
Notes: a Micol 1. b Micol 3 & Panel-Study. c Peas, Beans, Lentils, Broad Beans, Chickpeas. d Skimmed milk, Partially Skimmed. e Proportion test. f Wilcoxon rank-sum (ManneWhitney) test.
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
Trends in adherence to the Mediterranean diet
36
5
Males
Mediterranean Diet Score (mean)
35 34 33
32.1
32 30.9
31
31.53
30 29.93
29
30-49
28
50-69
27 26 MICOL I (1985-86) 36
MICOL III (2005-06)
Females
Mediterranean Diet Score (mean)
35 34 33
32.32
32
32.23
31
30
29.11
29 30-49
28
28.21
50-69
27 26 MICOL I (1985-86) Figure 2
MICOL III (2005-06)
Mean change of adherence to Mediterranean diet over follow-up time.
Discussion Key results In this study, evaluating two cohorts in 1985e86 and in 2005e06, we observed a significant decrease in the adherence to Mediterranean diet, as shown by two different indexes. This figure seems to be more evident in younger than older people, as supported by the linear regression analysis. Among all the foods examined, the greatest decrease was observed for olive oil. Interpretation Our findings agree with those present in literature. In the Moli-sani study conducted in Molise, South Italy, the authors reported a dramatic decrease in the adherence to the
Mediterranean diet among 21,000 participants [16]. Of particular interest is that this study was conducted between 2005e06 and 2007e10. Therefore, the authors justified their findings by pointing out that 2007 was the year of the global economic crisis and this could account for the observed decrease, particularly in older people [16]. A similar figure was observed in two other Mediterranean countries, i.e. Spain and Greece [12]. In a systematic review made of this topic, for example, in 18 articles the adherence to the Mediterranean diet was only moderate in Greece and in Cyprus, indicating a continuing transition from dietary patterns in the 1950s-60 s towards a more Westernized diet [12]. However, in another study made in Milan, the authors failed to observe any significant change in the adherence to the Mediterranean diet, therefore suggesting that further research is needed in this field [13].
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
6
N. Veronese et al.
Table 2 Multiple linear regression model of Mediterranean diet score on sex, BMI and two populations period (1985-86a) and (2005-06b), subdivided by age class (A), and on sex, BMI, education, job, and two populations period (1985-86a) and (2005-06b), subdivided by age class (B). Age 30e49 years
bc A) Gender Male (Ref. category) Female BMI (kg/m2) Populations study 1985-86a (Ref. category) 2005-06b B) Gender Male (Ref. category) Female Education None (Ref. category) Elementary Middle Hight Degree Job No/Loss Job (Ref. category) Housewife Retired Low income Middle income Hight income BMI (kg/m2) Populations study 1985-86a (Ref. category) 2005-06b a b c
Age 50e69 years
se(b)
p
95% C.I.
bc
0.17 0.02
0.009 0.004
0.78 to 0.11 0.02 to 0.09
2.62
0.17
<0.001
2.95 to
2.28
0.50
0.20
0.01
0.89 to
0.11
0.24 0.05 0.31 0.88
0.40 0.43 0.46 0.57
0.56 0.90 0.50 0.12
1.03 0.89 1.22 2.00
0.49 0.40 0.90 0.76 0.17 0.05
0.66 1.09 0.63 0.62 0.70 0.02
0.46 0.72 0.15 0.22 0.81 0.01
0.20
<0.001
e
se(b)
p
0.80 0.01
0.18 0.02
<0.001 0.58
1.16 to 0.44 0.02 to 0.04
2.08
0.18
<0.001
2.44 to
1.73
0.66
0.21
0.002
1.08 to
0.24
0.07 0.06 0.65 1.40
0.27 0.35 0.40 0.61
0.80 0.85 0.11 0.02
e 0.74 1.20 0.87 0.94 1.15 0.01
1.41 1.40 1.40 1.41 1.50 0.02
0.60 0.39 0.54 0.50 0.44 0.45
2.03 1.54 1.88 1.81 1.79 0.02
0.20
<0.001
2.67 to
e
0.45 0.05 e
e
95% C.I.
e
e
e to to to to
0.56 0.78 0.59 0.23
e
e 2.68
1.79 to 0.81 2.54 to 1.74 2.13 to 0.33 1.99 to 0.46 1.21 to 1.56 0.01 to 0.08
e 3.07 to
2.28
2.28
0.60 to 0.46 0.62 to 0.75 0.14 to 1.45 0.20 to 2.60
to to to to to to
3.52 3.95 3.61 3.70 4.10 0.05
1.89
Micol 1. Micol 3 & Panel-Study. b: coefficient; se(b): standard error of coefficient.
We may justify these findings on the basis of some hypotheses. Firstly, Italy; like other Mediterranean countries, South Italy is undergoing a Westernisation process, whereby societies are tending to adopt Western culture and dietary habits, shifting away from the healthy diet pattern typical of Mediterranean countries [22]. This is particularly true for the use of olive oil that practically lead to the decrease in the adherence to Mediterranean diet that we observed. In general, an increased contribution of sugars to overall dietary intake is being observed, that can explain the lower adherence to the Mediterranean diet [23]. Our results substantially confirmed this hypothesis since the consumption of cereals (including pasta, bread and similar) and whole grain bread significantly increased over time. Another justification can be the difficulty in following a Mediterranean diet regimen due to economic constraints. In the Moli-sani study, for example, the authors reported that major socioeconomic indicators were not associated with a higher adherence to the Mediterranean diet during the first evaluation (in 2005e06), but had become one of the most important determinants of low adherence to the Mediterranean diet in 2007e10. The foods used to assess the adherence to the Mediterranean diet were, in fact, among the most expensive [24]. In this
sense, our study suggests that among all the components, it is the consumption of olive oil that is dramatically decreasing. It is widely known that Italy is one of the major consumers of olive oil worldwide, while data suggest that the consumption of this food is decreasing overall, probably due to its cost [25]. Generalisability Some recent literature reported strategies to try to improve the adherence to the Mediterranean diet, based on the assumption that this diet is beneficial for several health outcomes. A first theory is based on the fact that the Mediterranean diet is a sustainable dietary pattern, i.e. a diet having a “low environmental impact and respectful of biodiversity while optimizing natural and human resources” [26]. Thus, if it is true that this dietary regimen could be expensive at personal level, it may be more affordable at the population level. Secondly, since, as shown in our work, the reduction in the adherence to the Mediterranean diet is more pronounced in younger than older people, efforts are being made to improve dietary habits in the workplace, by modifying food selection, eating patterns, meal frequency, and the sourcing of meals taken during work [27]. This can be an important project for the future,
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
Trends in adherence to the Mediterranean diet
in order to make significant changes in workplaces and optimize diet in the population. Limitations The findings of our work should be interpreted within some limitations. Firstly, we modified the original score proposed by Panagiotakos et al. [20] and in Agnoli et al. [21], replacing some foods with others or without considering some food, such as soft-drinks. Even if we tried to conserve the original meaning of the score, we cannot judge a possible bias in any direction as compared to the original score. Secondly, we assessed Mediterranean diet adherence in two different populations. Again, this could introduce a selection bias since the attitudes of people could have changed owing to the availability of different foods during the follow-up period. Thirdly, data were obtained in a selected population so caution is needed when extending results to other population settings. Fourthly, non-Mediterranean foods (such as sugarsweetened beverages, fast foods, etc.) were not included in our FFQ, but these foods might help to explain our findings. Finally, the information regarding dietary habits are self-reported and this could introduce another bias. Conclusions In conclusion, our study showed that the adherence to Mediterranean diet decreased overall from 1985e86 to 2005e06, particularly in younger people, above all due to a decreased olive oil consumption. These findings indicate that public health interventions (e.g. to lower the cost of some foods) are urgently needed in order to promote Mediterranean diet adherence, since this kind of dietary pattern is associated with several beneficial effects [28]. Financial support This work was supported by the Italian Ministry of Health: N ICS -160.2/RF03.111; current research 25. The funder had no role in the design, analysis or writing of this article. Authors’ contribution MGC, and NV designed the study and wrote the paper; MN and VT interpreted the data; AMC,RR,RI,OR, IZ enrolled the subjects; VG, RD and GL analysed the data; GM conceived the study. Declaration of Competing Interest None. Appendix A The MICOL study group also includes: Mario Correale, De Michele Giampiero, Mastrosimini Anna, Iacovazzi Palma, Laboratory of Clinic Pathology, IRCCS Saverio de Bellis,
7
Castellana Grotte, Bari, Italy; Noviello Marisa, Unit of Radiology, IRCCS Saverio de Bellis, Castellana Grotte, Bari, Italy; Marisa Chiloiro, Unit of Radiology, Hospital San Giacomo, Monopoli, Bari; Burattini Osvaldo, Pugliese Vittorio, Laboratory of Biostatistic and Epidemiology, IRCCS Saverio de Bellis, Castellana Grotte, Bari, Italy. Benedetta D’Attoma Laboratory of Experimental Biochemistry, IRCCS Saverio de Bellis, Castellana Grotte, Bari, Italy. Appendix B. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.numecd.2019.11.003. References [1] Davis C, Bryan J, Hodgson J, Murphy K. Definition of the mediterranean diet: a literature review. 2015. p. 9139e53. [2] da Silva R, Bach-Faig A, Quintana BR, Buckland G, de Almeida MDV, Serra-Majem L. Worldwide variation of adherence to the Mediterranean diet. In: 1961e1965 and 2000e2003. Public health nutrition. vol. 12; 2009. p. 1676e84. [3] Babio N, Bulló M, Salas-Salvadó J. Mediterranean diet and metabolic syndrome: the evidence. Public Health Nutr 2009;12:1607e17. [4] Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279e90. [5] Malmir H, Saneei P, Larijani B, Esmaillzadeh A. Adherence to Mediterranean diet in relation to bone mineral density and risk of fracture: a systematic review and meta-analysis of observational studies. Eur J Nutr 2017;57(6):2147e60. [6] Veronese N, La Tegola L, Crepaldi G, Maggi S, Rogoli D, Guglielmi G. The association between the Mediterranean diet and magnetic resonance parameters for knee osteoarthritis: data from the Osteoarthritis Initiative. Clin Rheumatol 2018;37(8):2187e93. [7] Veronese N, Stubbs B, Noale M, Solmi M, Luchini C, Maggi S. Adherence to the Mediterranean diet is associated with better quality of life: data from the Osteoarthritis Initiative. Am J Clin Nutr 2016;104:1403e9. [8] Veronese N, Stubbs B, Noale M, Solmi M, Luchini C, Smith TO, et al. Adherence to a Mediterranean diet is associated with lower prevalence of osteoarthritis: data from the osteoarthritis initiative. Clin Nutr (Edinb) 2017;36:1609e14. [9] Bonaccio M, Di Castelnuovo A, Costanzo S, Gialluisi A, Persichillo M, Cerletti C, et al. Mediterranean diet and mortality in the elderly: a prospective cohort study and a meta-analysis. Br J Nutr 2018;120: 841e54. [10] Bach-Faig A, Fuentes-Bol C, Ramos D, Carrasco JL, Roman B, Bertomeu IF, et al. The Mediterranean diet in Spain: adherence trends during the past two decades using the Mediterranean Adequacy Index. Public Health Nutr 2011;14:622e8. [11] León-Munoz LM, Guallar-Castillón P, Graciani A, López-García E, Mesas AE, Aguilera MT, et al. Adherence to the mediterranean diet pattern has declined in Spanish adultse3. J Nutr 2012;142: 1843e50. [12] Kyriacou A, Evans JM, Economides N, Kyriacou A. Adherence to the Mediterranean diet by the Greek and Cypriot population: a systematic review. Eur J Public Health 2015;25:1012e8. [13] Pelucchi C, Galeone C, Negri E, La Vecchia C. Trends in adherence to the Mediterranean diet in an Italian population between 1991 and 2006. Eur J Clin Nutr 2010;64:1052e6. [14] Leone A, Battezzati A, De Amicis R, De Carlo G, Bertoli S. Trends of adherence to the mediterranean dietary pattern in northern Italy from 2010 to 2016. Nutrients 2017;9. [15] Keys A. Mediterranean diet and public health: personal reflections. Am J Clin Nutr 1995;61:1321Se3S. [16] Bonaccio M, Di Castelnuovo A, Bonanni A, Costanzo S, De Lucia F, Persichillo M, et al. Decline of the Mediterranean diet at a time of economic crisis. Results from the Moli-sani study. Nutr Metab Cardiovasc Dis : Nutr Metab Cardiovasc Dis 2014;24:853e60.
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
8 [17] Block G, Hartman AM, Naughton D. A reduced dietary questionnaire: development and validation. Epidemiology 1990;1:58e64. [18] Leoci C, Centonze S, Guerra V, Cisternino A, Misciagna G. Validazione e riproducibilità di un questionario di frequenza alimentare semi-quantitativo autosomministrato. Giorn Ital Nutr Clin Prev 1993;1:58e9. [19] Gnagnarella PS S, Parpinel M. Food composition Database for epidemiological studies in Italy. 2015. http://www.bda-ieo.it. [Accessed 20 June 2018]. [20] Panagiotakos DB, Pitsavos C, Stefanadis C. Dietary patterns: a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk. Nutr Metab Cardiovasc Dis : Nutr Metab Cardiovasc Dis 2006;16:559e68. [21] Agnoli C, Krogh V, Grioni S, Sieri S, Palli D, Masala G, et al. A prioridefined dietary patterns are associated with reduced risk of stroke in a large Italian cohort. J Nutr 2011;141:1552e8. [22] Trichopoulou A. Traditional Mediterranean diet and longevity in the elderly: a review. Public Health Nutr 2004;7:943e7.
N. Veronese et al. [23] Popkin BM, Gordon-Larsen P. The nutrition transition: worldwide obesity dynamics and their determinants. Int J Obes 2004;28:S2. [24] Tong TY, Imamura F, Monsivais P, Brage S, Griffin SJ, Wareham NJ, et al. Dietary cost associated with adherence to the Mediterranean diet, and its variation by socio-economic factors in the UK Fenland Study. Br J Nutr 2018;119:685e94. [25] Luchetti F. Importance and future of olive oil in the world market d an introduction to olive oil. Eur J Lipid Sci Technol 2002; 104:559e63. [26] Dernini S, Berry EM. Mediterranean diet: from a healthy diet to a sustainable dietary pattern. Frontiers in Nutrition 2015;2. [27] Korre M, Tsoukas MA, Frantzeskou E, Yang J, Kales SN. Mediterranean diet and workplace health promotion. Current cardiovascular risk reports 2014;8:416. [28] Dinu M, Pagliai G, Casini A, Sofi F. Mediterranean diet and multiple health outcomes: an umbrella review of meta-analyses of observational studies and randomized trials. Nutr Metab Cardiovasc Dis 2017;27:e21.
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
Available online at www.sciencedirect.com
Nutrition, Metabolism & Cardiovascular Diseases journal homepage: www.elsevier.com/locate/nmcd
Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study Nicola Veronese a,b,*, Maria Notarnicola a, Anna M. Cisternino b, Rosa Inguaggiato b, Vito Guerra c, Rosa Reddavide b, Rossella Donghia c, Ornella Rotolo b, Iris Zinzi b, Gioacchino Leandro b,d, Valeria Tutino a, Giovanni Misciagna e, Maria G. Caruso a,b, the MICOL study group1 a
Laboratory of Nutritional Biochemistry, Castellana Grotte, Bari, Italy Ambulatory of Clinical Nutrition, Castellana Grotte, Bari, Italy Clinical Trial Unit, Castellana Grotte, Bari, Italy d Unit of Gastroenterology, Castellana Grotte, Bari, Italy e Scientific and Ethical Committee-National Institute of Gastroenterology-Research Hospital, IRCCS “S. de Bellis”, Castellana Grotte, Bari, Italy b c
Received 1 May 2019; received in revised form 2 November 2019; accepted 4 November 2019 Handling Editor: P. Strazzullo Available online - - -
KEYWORDS Mediterranean diet; Olive oil; Trend; Epidemiology
Abstract Background and aims: Increasing literature data show that adherence to the Mediterranean diet is undergoing profound changes in recent years, albeit with marked differences across nations. In Italy, one of the cradles of the Mediterranean diet, the literature regarding the trend for Mediterranean diet adherence is conflicting. Thus, we aimed to explore the trends of adherence to the Mediterranean diet in a large cohort of participants living in South Italy, over 20 years from 1985e86 to 2005e06. Methods and results: Cross-sectional study with two evaluations, one made in 1985e86 and another in 2005e06; all participants were adults aged 30e70 years of age. The adherence to the Mediterranean diet was evaluated using the score proposed by Panagiotakos et al. This score features values ranging from 0 to 55, higher scores reflecting a greater adherence. The data are reported by age (30e49 vs. 50e69 years). Overall, 2451 subjects were included in 1985e86 and 2375 in 2005e06. A significant reduction was observed in the adherence to the Mediterranean diet (age 30e49 years: 31.82 4.18 in 1985e86 vs. 29.20 4.48 in 2005e06, reduction by 8.2%, p < 0.0001; age 50e69: 32.20 4.09 in 1985e86 vs.30.15 4.27 in 2005e06, reduction by 6.3%, p < 0.0001). Among all these items, the most dramatic change was observed for olive oil consumption, that decreased by 2.35 points in younger and 0.89 in older people. Conclusion: The adherence to the Mediterranean diet decreased from 1985e86 to 2005e06 in South Italy, particularly in younger people, above all due to a decreased olive oil consumption. ª 2019 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.
Introduction * Corresponding author. National Institute of GastroenterologyResearch Hospital, IRCCS “Saverio de Bellis”, Via Turi 27, 70013 Castellana, Bari, Italy, E-mail address: [email protected] (N. Veronese). 1 Members of MICOL study group investigators are listed in Appendix A section.
The Mediterranean diet is included in UNESCO heritage [1]. This kind of diet is characterized by a high consumption of plant foods (e.g. legumes, cereals, fruits and vegetables, nuts and seeds), fish and olive oil, a moderate
https://doi.org/10.1016/j.numecd.2019.11.003 0939-4753/ª 2019 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
2
consumption of (red) wine and a low consumption of meat and dairy products [2]. Overall, the Mediterranean dietary pattern is considered healthy, and increasing reports in literature conclude that good adherence to this pattern is associated with a protective effect against various chronic diseases, including metabolic [3] and cardiovascular diseases [4], fractures [5], osteoarthritis [6e8] and, finally, mortality [9]. Even if there is abundant literature supporting the importance of following a Mediterranean diet regimen in order to prevent chronic diseases, it has been noted that several Mediterranean countries (including Spain [10,11] and Greece [12]) are drifting away from the Mediterranean dietary pattern, whereas countries in Northern Europe are tending to show a more strict observance of a Mediterranean-like dietary pattern [2]. In Italy, the studies available have reported conflicting results. In Milan, a big city in North Italy, some authors observed no significant differences over 15 years of follow-up (between 1991 and 2005) [13] in the adherence to the Mediterranean diet, whilst another study reported a significantly decreased adherence to the Mediterranean diet over 5 years [14]. To the best of our knowledge, only one study has been made of people living in South Italy, even if South Italy is one of the birthplaces of the Mediterranean diet [15]. In the Molisani study, the authors reported a significant decrease in the adherence to Mediterranean diet, over 5 years [16]. Given this background, we aimed to explore the trends of adherence to Mediterranean diet, comparing a large cohort of participants living in South Italy in 1985e86 vs. 2005e06. Methods Study design, setting and participants This study included participants randomly sampled from the electoral rolls of the population of Castellana Grotte, a town in Southern Italy (Apulia region). Between 1985 and 1986, 3500 persons were contacted and 2472 (Z70.6%) were enrolled within the context of the MICOL (Multicentrica Italiana Colelitiasi) 1. Between 2005 and 2006, among 1942 subjects initially contacted, 1708 (Z87.9%) participated in the baseline survey (MICOL III). Additionally, in the same years, 1900 young participants (between 30 and 49 years) were contacted (panel study). Among them, 1265 (Z66.6%) decided to participate in the study. For the aims of this study, we included only people aged 30e70 years. The MICOL study design is reported in Supplementary Fig. 1. The proposal of this research was approved by the Institutional Review Board (Ethical Committee) of IRCCS De Bellis and written informed consent was obtained from each participant before entering the study. Mediterranean diet score: outcome of interest Dietary intake was assessed using a validated tool, the Block Brief 2000 Food Frequency Questionnaire (FFQ)
N. Veronese et al.
during the baseline visit [17]. Seventy items were assessed to determine an individual’s typical food and beverage consumption over the past year. The frequency of consumption was reported at nine levels of intake from “never” to “every day”. This questionnaire had already been validated (in Italian) in this specific population [18] and the data for the adherence to the Mediterranean diet were extracted using the Food Composition Database for Epidemiological Studies in Italy [19]. In this study, adherence to a Mediterranean diet was evaluated using the Mediterranean diet score proposed by Panagiotakos et al. (aMED) [20] The aMED takes into consideration foods commonly consumed by Mediterranean populations. Respondents were asked to rate their consumption of each single food item using a score ranging from 0 (no adherence) to 5 (best adherence); the total possible score ranges from 0 to 55, with higher values indicating a greater adherence to a Mediterranean diet. The calculation of the Mediterranean diet score in our study is shown in Supplementary Table 1. Cereals (e.g. bread, pasta, rice), whole grain bread, fruits, vegetables, legumes (e.g. peas, beans), fish were categorized on the basis of servings/month and specifically as: 0 Z never; 1 Z 1 to 2 servings per month (rare); 2 Z 3 to 6 (frequent); 3 Z 7 to 10 (very frequent); 4 Z 11 to 24 (weekly); 5 Z daily. Consumption of red meat, poultry, and full fat dairy products (e.g. milk) was categorized as: 0 Z daily; 1 Z weekly; 2 Z very frequent; 3 Z frequent; 4 Z rare; 5 Z never). Consumption of olive oil was categorized as how many times it was used over one week, and based on the type of cooking, where raw olive oil increases the adherence to the Mediterranean diet and cooked oil decreases it. Alcoholic beverages were categorized as: 0 700 ml/day or 0; 1 Z 600e699 ml/day; 2 Z 500e599 ml/day; 3 Z 400e499 ml/day; 4 Z 300e399 ml/day; 5Z< 300 ml/day. In the original paper by Panagiotakos et al. [20], the authors considered only non-refined cereals, whilst we also included refined cereals in this item; moreover, no information regarding potatoes intake was present in the MICOL study and instead of this food, we used whole grain bread; meat included both white and red meats. In order to make stronger our results, we did run a similar analysis using another score, i.e. the Italian Mediterranean Index as developed by Agnoli et al. [21]. This score is based on intake of 11 items: high intakes of 6 typical Mediterranean foods; low intakes of 4 nonMediterranean foods; and also alcohol. Possible scores ranged from 0 to 11, higher scores reflecting more adherence to Mediterranean diet. For the aims of our paper we included all the foods mentioned, except soft-drinks, an information not available in our cohort. Statistical analysis Means and standard deviations were used as index of centrality and dispersion of the distributions. Proportion test for continuous parameters and the Wilcoxon ranksum (ManneWhitney) test were used to test statistical
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
Trends in adherence to the Mediterranean diet
3
hypotheses, with the level of statistical significance of rejection of the null hypothesis set at p < 0.05. The data are presented by age (30e49 vs. 50e69 years). Moreover, we ran a linear regression analysis, taking as independent variables age, gender and population study years and as dependent outcome the adherence to the Mediterranean diet. All the analyses were performed using STATA 13.0. Results Study size In the MICOL 1 (1985e86) 2472 participants were initially included, and 2451 of them were included in the present research. Among the 2973 participants examined in 2005e06, 2375 were included; subjects under 30 or over 70 years at the time of the interview were excluded. Descriptive data Table 1 reports the general features of the population examined. In both evaluations younger people (i.e. those aged between 30 and 49 years) were more numerous than older people (aged between 50 and 69 years). Overall, there were more males than females. As shown in Table 1, in both groups, over 20 years of observation we observed a significant reduction in the adherence to the Mediterranean diet, by a mean of 8.2% in
younger and of 6.3% in older people (age 30e49 years: 31.82 4.18 in 1985e86 vs. 29.20 4.48 in 2005e06, p < 0.0001; age 50e69: 32.20 4.09 in 1985e86 vs.30.15 4.27 in 2005e06, p < 0.0001). The distribution of adherence to the Mediterranean diet, by age, is graphically reported in Fig. 1 and by gender in Fig. 2. Outcome data Considering the single items in the Mediterranean diet score, we observed, in both younger and older people, that the consumption of cereals (including pasta, bread and similar), whole grain bread, vegetables, legumes, fish significantly increased between 1985e86 and 2005e06, whilst the consumption of fruits, meat, poultry, dairy, olive oil and alcohol significantly decreased (Table 1). Among all these items, the most dramatic decrease was observed for olive oil, that declined by 2.35 points in younger and by 0.89 in older people. This finding was furthermore confirmed using the Italian Mediterranean Index (Supplementary Table 2). Finally, as shown in Table 2, the adherence to Mediterranean diet over time was not affected by age or gender, reinforcing the concept that this trend is probably due to other causes. On the contrary, in both models, younger people showed a more significant decrease in the adherence to the Mediterranean diet compared to the older population. The same was observed using the Italian Mediterranean Index (Supplementary Table 2).
Period 1985-1986 Age 50-69yrs
Density
0.05 0.0
0.05 0.0
Density
0.1
0.1
0.15
0.15
Period 1985-1986 Age 30-49yrs
10
20
30
40
50
10
20
Dietary score
40
50
40
50
Period 2005-2006 Age 50-69yrs
Density
0.05
0.0
0.0
0.05
0.1
0.1
0.15
0.15
Period 2005-2006 Age 30-49yrs
Density
30
Dietary score
10
20
30
Dietary score Figure 1
40
50
10
20
30
Dietary score
Mediterranean diet adherence (by age) in 1985e86 and in 2005e06.
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
4
N. Veronese et al.
0.15
0.1 0.15
Females
0.1 0.0
20
30
40
10
50
40
50
0.15
30
0.1
Period 1985-1986 Age 50-69yrs
0.0 20
30
40
10
50
20
30
40
50
0.1
Period 2005-2006 Age 30-49yrs
0.05 0.0
0.0
0.05
Density
0.1
0.15
0.15
10
Density
20
0.05
Density
0.1 0.05 0.0
Density
0.15
10
20
30
40
10
50
20
30
40
50
0.1
Period 2005-2006 Age 50-69yrs
0.05
0.0
0.0
0.05
Density
0.1
0.15
0.15
10
Density
Period 1985-1986 Age 30-49yrs
0.05
Density
0.05 0.0
Density
Males
10
20
30
40
50
10
20
Dietary score
30
40
50
Dietary score
Figure 1
(continued).
Table 1 Comparison between metabolic characteristics and Mediterranean diet items, by age. Age 30e49 years 1985e86
General characteristics Gender (F) (%) Age (years) (MSD) BMI (kg/m2) (MSD) Mediterranean diet score items Cereals (MSD) Whole grain bread (MSD) Fruits (MSD) Vegetables (MSD) Legumesc (MSD) Fish (MSD) Meat (MSD) Poultry (MSD) Dairyd (MSD) Olive oil (MSD) Alcohol (ml/die) (MSD) Mediterranean Diet Score (MSD)
a
Age 50e69 years 2005e06
b
f
p
1985e86a
2005e06b
(n Z 1112)
(n Z 1102)
pf
(n Z 1339)
(n Z 1273)
541 (40.40) 39.68 5.48 26.86 4.50
537 (42.18) 39.77 5.38 27.24 4.76
0.35e 0.63 0.09
493 (44.33) 57.81 5.39 28.23 4.87
464 (42.11) 59.63 5.42 29.84 5.41
0.29e <0.0001 <0.0001
2.97 0.84 0.26 0.94 4.69 0.91 2.54 0.91 2.30 0.73 1.86 0.89 3.83 0.93 3.07 0.89 3.90 1.73 3.54 1.92 2.84 2.11 31.82 4.18
3.46 0.85 0.52 1.03 4.22 1.12 3.35 1.02 2.38 0.68 2.09 0.83 3.38 1.00 2.96 0.89 2.99 1.89 2.19 1.74 1.66 2.26 29.20 4.48
<0.0001 <0.0001 <0.0001 <0.0001 0.004 <0.0001 <0.0001 0.001 <0.0001 <0.0001 <0.0001 <0.0001
2.97 0.84 0.46 1.30 4.78 0.74 2.62 0.86 2.26 0.79 1.71 0.91 4.10 0.89 3.15 0.92 3.74 1.84 3.65 1.89 2.76 2.15 32.20 4.09
3.20 0.91 0.61 1.27 4.50 0.79 3.58 0.93 2.44 0.67 2.14 0.79 3.22 1.02 2.84 0.85 2.92 1.92 2.76 1.93 1.93 2.26 30.15 4.27
<0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
Notes: a Micol 1. b Micol 3 & Panel-Study. c Peas, Beans, Lentils, Broad Beans, Chickpeas. d Skimmed milk, Partially Skimmed. e Proportion test. f Wilcoxon rank-sum (ManneWhitney) test.
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
Trends in adherence to the Mediterranean diet
36
5
Males
Mediterranean Diet Score (mean)
35 34 33
32.1
32 30.9
31
31.53
30 29.93
29
30-49
28
50-69
27 26 MICOL I (1985-86) 36
MICOL III (2005-06)
Females
Mediterranean Diet Score (mean)
35 34 33
32.32
32
32.23
31
30
29.11
29 30-49
28
28.21
50-69
27 26 MICOL I (1985-86) Figure 2
MICOL III (2005-06)
Mean change of adherence to Mediterranean diet over follow-up time.
Discussion Key results In this study, evaluating two cohorts in 1985e86 and in 2005e06, we observed a significant decrease in the adherence to Mediterranean diet, as shown by two different indexes. This figure seems to be more evident in younger than older people, as supported by the linear regression analysis. Among all the foods examined, the greatest decrease was observed for olive oil. Interpretation Our findings agree with those present in literature. In the Moli-sani study conducted in Molise, South Italy, the authors reported a dramatic decrease in the adherence to the
Mediterranean diet among 21,000 participants [16]. Of particular interest is that this study was conducted between 2005e06 and 2007e10. Therefore, the authors justified their findings by pointing out that 2007 was the year of the global economic crisis and this could account for the observed decrease, particularly in older people [16]. A similar figure was observed in two other Mediterranean countries, i.e. Spain and Greece [12]. In a systematic review made of this topic, for example, in 18 articles the adherence to the Mediterranean diet was only moderate in Greece and in Cyprus, indicating a continuing transition from dietary patterns in the 1950s-60 s towards a more Westernized diet [12]. However, in another study made in Milan, the authors failed to observe any significant change in the adherence to the Mediterranean diet, therefore suggesting that further research is needed in this field [13].
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
6
N. Veronese et al.
Table 2 Multiple linear regression model of Mediterranean diet score on sex, BMI and two populations period (1985-86a) and (2005-06b), subdivided by age class (A), and on sex, BMI, education, job, and two populations period (1985-86a) and (2005-06b), subdivided by age class (B). Age 30e49 years
bc A) Gender Male (Ref. category) Female BMI (kg/m2) Populations study 1985-86a (Ref. category) 2005-06b B) Gender Male (Ref. category) Female Education None (Ref. category) Elementary Middle Hight Degree Job No/Loss Job (Ref. category) Housewife Retired Low income Middle income Hight income BMI (kg/m2) Populations study 1985-86a (Ref. category) 2005-06b a b c
Age 50e69 years
se(b)
p
95% C.I.
bc
0.17 0.02
0.009 0.004
0.78 to 0.11 0.02 to 0.09
2.62
0.17
<0.001
2.95 to
2.28
0.50
0.20
0.01
0.89 to
0.11
0.24 0.05 0.31 0.88
0.40 0.43 0.46 0.57
0.56 0.90 0.50 0.12
1.03 0.89 1.22 2.00
0.49 0.40 0.90 0.76 0.17 0.05
0.66 1.09 0.63 0.62 0.70 0.02
0.46 0.72 0.15 0.22 0.81 0.01
0.20
<0.001
e
se(b)
p
0.80 0.01
0.18 0.02
<0.001 0.58
1.16 to 0.44 0.02 to 0.04
2.08
0.18
<0.001
2.44 to
1.73
0.66
0.21
0.002
1.08 to
0.24
0.07 0.06 0.65 1.40
0.27 0.35 0.40 0.61
0.80 0.85 0.11 0.02
e 0.74 1.20 0.87 0.94 1.15 0.01
1.41 1.40 1.40 1.41 1.50 0.02
0.60 0.39 0.54 0.50 0.44 0.45
2.03 1.54 1.88 1.81 1.79 0.02
0.20
<0.001
2.67 to
e
0.45 0.05 e
e
95% C.I.
e
e
e to to to to
0.56 0.78 0.59 0.23
e
e 2.68
1.79 to 0.81 2.54 to 1.74 2.13 to 0.33 1.99 to 0.46 1.21 to 1.56 0.01 to 0.08
e 3.07 to
2.28
2.28
0.60 to 0.46 0.62 to 0.75 0.14 to 1.45 0.20 to 2.60
to to to to to to
3.52 3.95 3.61 3.70 4.10 0.05
1.89
Micol 1. Micol 3 & Panel-Study. b: coefficient; se(b): standard error of coefficient.
We may justify these findings on the basis of some hypotheses. Firstly, Italy; like other Mediterranean countries, South Italy is undergoing a Westernisation process, whereby societies are tending to adopt Western culture and dietary habits, shifting away from the healthy diet pattern typical of Mediterranean countries [22]. This is particularly true for the use of olive oil that practically lead to the decrease in the adherence to Mediterranean diet that we observed. In general, an increased contribution of sugars to overall dietary intake is being observed, that can explain the lower adherence to the Mediterranean diet [23]. Our results substantially confirmed this hypothesis since the consumption of cereals (including pasta, bread and similar) and whole grain bread significantly increased over time. Another justification can be the difficulty in following a Mediterranean diet regimen due to economic constraints. In the Moli-sani study, for example, the authors reported that major socioeconomic indicators were not associated with a higher adherence to the Mediterranean diet during the first evaluation (in 2005e06), but had become one of the most important determinants of low adherence to the Mediterranean diet in 2007e10. The foods used to assess the adherence to the Mediterranean diet were, in fact, among the most expensive [24]. In this
sense, our study suggests that among all the components, it is the consumption of olive oil that is dramatically decreasing. It is widely known that Italy is one of the major consumers of olive oil worldwide, while data suggest that the consumption of this food is decreasing overall, probably due to its cost [25]. Generalisability Some recent literature reported strategies to try to improve the adherence to the Mediterranean diet, based on the assumption that this diet is beneficial for several health outcomes. A first theory is based on the fact that the Mediterranean diet is a sustainable dietary pattern, i.e. a diet having a “low environmental impact and respectful of biodiversity while optimizing natural and human resources” [26]. Thus, if it is true that this dietary regimen could be expensive at personal level, it may be more affordable at the population level. Secondly, since, as shown in our work, the reduction in the adherence to the Mediterranean diet is more pronounced in younger than older people, efforts are being made to improve dietary habits in the workplace, by modifying food selection, eating patterns, meal frequency, and the sourcing of meals taken during work [27]. This can be an important project for the future,
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
Trends in adherence to the Mediterranean diet
in order to make significant changes in workplaces and optimize diet in the population. Limitations The findings of our work should be interpreted within some limitations. Firstly, we modified the original score proposed by Panagiotakos et al. [20] and in Agnoli et al. [21], replacing some foods with others or without considering some food, such as soft-drinks. Even if we tried to conserve the original meaning of the score, we cannot judge a possible bias in any direction as compared to the original score. Secondly, we assessed Mediterranean diet adherence in two different populations. Again, this could introduce a selection bias since the attitudes of people could have changed owing to the availability of different foods during the follow-up period. Thirdly, data were obtained in a selected population so caution is needed when extending results to other population settings. Fourthly, non-Mediterranean foods (such as sugarsweetened beverages, fast foods, etc.) were not included in our FFQ, but these foods might help to explain our findings. Finally, the information regarding dietary habits are self-reported and this could introduce another bias. Conclusions In conclusion, our study showed that the adherence to Mediterranean diet decreased overall from 1985e86 to 2005e06, particularly in younger people, above all due to a decreased olive oil consumption. These findings indicate that public health interventions (e.g. to lower the cost of some foods) are urgently needed in order to promote Mediterranean diet adherence, since this kind of dietary pattern is associated with several beneficial effects [28]. Financial support This work was supported by the Italian Ministry of Health: N ICS -160.2/RF03.111; current research 25. The funder had no role in the design, analysis or writing of this article. Authors’ contribution MGC, and NV designed the study and wrote the paper; MN and VT interpreted the data; AMC,RR,RI,OR, IZ enrolled the subjects; VG, RD and GL analysed the data; GM conceived the study. Declaration of Competing Interest None. Appendix A The MICOL study group also includes: Mario Correale, De Michele Giampiero, Mastrosimini Anna, Iacovazzi Palma, Laboratory of Clinic Pathology, IRCCS Saverio de Bellis,
7
Castellana Grotte, Bari, Italy; Noviello Marisa, Unit of Radiology, IRCCS Saverio de Bellis, Castellana Grotte, Bari, Italy; Marisa Chiloiro, Unit of Radiology, Hospital San Giacomo, Monopoli, Bari; Burattini Osvaldo, Pugliese Vittorio, Laboratory of Biostatistic and Epidemiology, IRCCS Saverio de Bellis, Castellana Grotte, Bari, Italy. Benedetta D’Attoma Laboratory of Experimental Biochemistry, IRCCS Saverio de Bellis, Castellana Grotte, Bari, Italy. Appendix B. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.numecd.2019.11.003. References [1] Davis C, Bryan J, Hodgson J, Murphy K. Definition of the mediterranean diet: a literature review. 2015. p. 9139e53. [2] da Silva R, Bach-Faig A, Quintana BR, Buckland G, de Almeida MDV, Serra-Majem L. Worldwide variation of adherence to the Mediterranean diet. In: 1961e1965 and 2000e2003. Public health nutrition. vol. 12; 2009. p. 1676e84. [3] Babio N, Bulló M, Salas-Salvadó J. Mediterranean diet and metabolic syndrome: the evidence. Public Health Nutr 2009;12:1607e17. [4] Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279e90. [5] Malmir H, Saneei P, Larijani B, Esmaillzadeh A. Adherence to Mediterranean diet in relation to bone mineral density and risk of fracture: a systematic review and meta-analysis of observational studies. Eur J Nutr 2017;57(6):2147e60. [6] Veronese N, La Tegola L, Crepaldi G, Maggi S, Rogoli D, Guglielmi G. The association between the Mediterranean diet and magnetic resonance parameters for knee osteoarthritis: data from the Osteoarthritis Initiative. Clin Rheumatol 2018;37(8):2187e93. [7] Veronese N, Stubbs B, Noale M, Solmi M, Luchini C, Maggi S. Adherence to the Mediterranean diet is associated with better quality of life: data from the Osteoarthritis Initiative. Am J Clin Nutr 2016;104:1403e9. [8] Veronese N, Stubbs B, Noale M, Solmi M, Luchini C, Smith TO, et al. Adherence to a Mediterranean diet is associated with lower prevalence of osteoarthritis: data from the osteoarthritis initiative. Clin Nutr (Edinb) 2017;36:1609e14. [9] Bonaccio M, Di Castelnuovo A, Costanzo S, Gialluisi A, Persichillo M, Cerletti C, et al. Mediterranean diet and mortality in the elderly: a prospective cohort study and a meta-analysis. Br J Nutr 2018;120: 841e54. [10] Bach-Faig A, Fuentes-Bol C, Ramos D, Carrasco JL, Roman B, Bertomeu IF, et al. The Mediterranean diet in Spain: adherence trends during the past two decades using the Mediterranean Adequacy Index. Public Health Nutr 2011;14:622e8. [11] León-Munoz LM, Guallar-Castillón P, Graciani A, López-García E, Mesas AE, Aguilera MT, et al. Adherence to the mediterranean diet pattern has declined in Spanish adultse3. J Nutr 2012;142: 1843e50. [12] Kyriacou A, Evans JM, Economides N, Kyriacou A. Adherence to the Mediterranean diet by the Greek and Cypriot population: a systematic review. Eur J Public Health 2015;25:1012e8. [13] Pelucchi C, Galeone C, Negri E, La Vecchia C. Trends in adherence to the Mediterranean diet in an Italian population between 1991 and 2006. Eur J Clin Nutr 2010;64:1052e6. [14] Leone A, Battezzati A, De Amicis R, De Carlo G, Bertoli S. Trends of adherence to the mediterranean dietary pattern in northern Italy from 2010 to 2016. Nutrients 2017;9. [15] Keys A. Mediterranean diet and public health: personal reflections. Am J Clin Nutr 1995;61:1321Se3S. [16] Bonaccio M, Di Castelnuovo A, Bonanni A, Costanzo S, De Lucia F, Persichillo M, et al. Decline of the Mediterranean diet at a time of economic crisis. Results from the Moli-sani study. Nutr Metab Cardiovasc Dis : Nutr Metab Cardiovasc Dis 2014;24:853e60.
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003
8 [17] Block G, Hartman AM, Naughton D. A reduced dietary questionnaire: development and validation. Epidemiology 1990;1:58e64. [18] Leoci C, Centonze S, Guerra V, Cisternino A, Misciagna G. Validazione e riproducibilità di un questionario di frequenza alimentare semi-quantitativo autosomministrato. Giorn Ital Nutr Clin Prev 1993;1:58e9. [19] Gnagnarella PS S, Parpinel M. Food composition Database for epidemiological studies in Italy. 2015. http://www.bda-ieo.it. [Accessed 20 June 2018]. [20] Panagiotakos DB, Pitsavos C, Stefanadis C. Dietary patterns: a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk. Nutr Metab Cardiovasc Dis : Nutr Metab Cardiovasc Dis 2006;16:559e68. [21] Agnoli C, Krogh V, Grioni S, Sieri S, Palli D, Masala G, et al. A prioridefined dietary patterns are associated with reduced risk of stroke in a large Italian cohort. J Nutr 2011;141:1552e8. [22] Trichopoulou A. Traditional Mediterranean diet and longevity in the elderly: a review. Public Health Nutr 2004;7:943e7.
N. Veronese et al. [23] Popkin BM, Gordon-Larsen P. The nutrition transition: worldwide obesity dynamics and their determinants. Int J Obes 2004;28:S2. [24] Tong TY, Imamura F, Monsivais P, Brage S, Griffin SJ, Wareham NJ, et al. Dietary cost associated with adherence to the Mediterranean diet, and its variation by socio-economic factors in the UK Fenland Study. Br J Nutr 2018;119:685e94. [25] Luchetti F. Importance and future of olive oil in the world market d an introduction to olive oil. Eur J Lipid Sci Technol 2002; 104:559e63. [26] Dernini S, Berry EM. Mediterranean diet: from a healthy diet to a sustainable dietary pattern. Frontiers in Nutrition 2015;2. [27] Korre M, Tsoukas MA, Frantzeskou E, Yang J, Kales SN. Mediterranean diet and workplace health promotion. Current cardiovascular risk reports 2014;8:416. [28] Dinu M, Pagliai G, Casini A, Sofi F. Mediterranean diet and multiple health outcomes: an umbrella review of meta-analyses of observational studies and randomized trials. Nutr Metab Cardiovasc Dis 2017;27:e21.
Please cite this article as: Veronese N et al., Trends in adherence to the Mediterranean diet in South Italy: A cross sectional study, Nutrition, Metabolism & Cardiovascular Diseases, https://doi.org/10.1016/j.numecd.2019.11.003