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The Mediterranean-type diet combines several foods and nutrients already individually proposed as potential protective factors against adverse health outcomes, such as cardiovascular diseases. The aim of the present study was to describe the association between adherence to a Mediterranean diet (MeDi) and intake of energy, macronutrients, and micronutrients. The study sample consisted of 1,595 individuals from Bordeaux, France, included in 2001-2002 in the Three-City Study. Adherence to a MeDi (scored as 0 to 9) was computed from a food frequency questionnaire (FFQ). Total energy intake (EI) and nutrient intake were evaluated on a 24 h recall. Statistical analyses were stratified by gender. Both in men and women, greater MeDi adherence was associated with higher total vegetal protein, polyunsaturated fatty acids (PUFA), notably n - 6 PUFA, and lower total saturated fat intakes, as expressed in percentage of EI. Higher total monounsaturated fat and oleic acid intakes (% EI) were observed with greater MeDi adherence in men. Women with the highest MeDi adherence exhibited a higher mean carbohydrate, polysaccharide, and total n - 3 PUFA intakes (% EI). The consumption of fibers; vitamins B6, C, and E; folate; magnesium; potassium; and iron increased with greater MeDi adherence, both in men and women. However, consumption of calcium significantly decreased with greater MeDi adherence in women, while the ratio of n - 6/n - 3 PUFA precursors increased. This cross-sectional study provides the nutrient-related basis of the Mediterranean-type diet of French elderly community dwellers, which might participate to its well-documented beneficial effects on health.
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Adherence to a Mediterranean diet and energy,
macro-, and micronutrient intakes in older persons
Catherine Feart &Benjamin Alles &
Bénédicte Merle &Cécilia Samieri &
Pascale Barberger-Gateau
Received: 10 February 2012 /Accepted: 6 June 2012
#University of Navarra 2012
Abstract The Mediterranean-type diet combines sev-
eral foods and nutrients already individually proposed as
potential protective factors against adverse health out-
comes, such as cardiovascular diseases. The aim of the
present study was to describe the association between
adherence to a Mediterranean diet (MeDi) and intake of
energy, macronutrients, and micronutrients. The study
sample consisted of 1,595 individuals from Bordeaux,
France, included in 20012002 in the Three-City Study.
Adherence to a MeDi (scored as 0 to 9) was computed
from a food frequency questionnaire (FFQ). Total ener-
gy intake (EI) and nutrient intake were evaluated on a
24 h recall. Statistical analyses were stratified by gender.
Both in men and women, greater MeDi adherence was
associated with higher total vegetal protein, polyunsat-
urated fatty acids (PUFA), notably n6 PUFA, and
lower total saturated fat intakes, as expressed in percent-
age of EI. Higher total monounsaturated fat and oleic
acid intakes (% EI) were observed with greater MeDi
adherence in men. Women with the highest MeDi ad-
herence exhibited a higher mean carbohydrate, polysac-
charide, and total n3 PUFA intakes (% EI). The
consumption of fibers; vitamins B6, C, and E; folate;
magnesium; potassium; and iron increased with greater
MeDi adherence, both in men and women. However,
consumption of calcium significantly decreased with
greater MeDi adherence in women, while the ratio of
n6/n3 PUFA precursors increased. This cross-
sectional study provides the nutrient-related basis of
the Mediterranean-type diet of French elderly commu-
nity dwellers, which might participate to its well-
documented beneficial effects on health.
Keywords Mediterranean diet .Energy intake .
Nutrient intake
In developed countries, the increasingly higher life
expectancy is mostly attributed to a decline of mortal-
ity at older ages. Better living conditions and notably
healthy dietary practices may explain this greater lon-
gevity in addition to considerable improvement in
health care of older persons [37]. Among the general
lifestyle recommendations, the traditional Mediterra-
nean diet (MeDi) seems an optimal dietary strategy for
J Physiol Biochem
DOI 10.1007/s13105-012-0190-y
C. Feart (*)
Equipe Epidémiologie de la nutrition et des
comportements alimentaires, INSERM, U897,
Université Bordeaux Ségalen,
ISPED Case 11, 146 rue Léo-Saignat,
33076 Bordeaux Cedex, France
B. Alles :B. Merle :C. Samieri :P. Barberger-Gateau
Bordeaux 33076, France
B. Alles :B. Merle :C. Samieri :P. Barberger-Gateau
Université Bordeaux Segalen,
Bordeaux 33076, France
health, since greater MeDi adherence has been associ-
ated with longer survival, reduced risk of cardiovas-
cular or cancer mortality, and reduced risk of
neurodegenerative diseases [22,29,30]. The tradition-
al MeDi is characterized by high consumption of plant
foods (vegetables, fruits, legumes, and cereals), high
intake of olive oil as the principal source of monoun-
saturated fat but low intake of saturated fat, moderate
intake of fish, low to moderate intake of dairy prod-
ucts, low consumption of meat and poultry, and wine
consumed in low to moderate amounts, normally with
meals [36,39]. Therefore, the MeDi combines several
foods and nutrients already proposed as potential pro-
tective factors against several conditions that may
contribute to the development and progression of
age-related diseases [6,12,13,22,23,26,29,30,
34]. However, due to its computation method [36], a
similar score on the MeDi does not mean a similar
intake of nutrients across populations. Only few stud-
ies have yet conducted precise descriptions of its nu-
tritional value [8]. Thus, a better knowledge of the
dietary characteristics of individuals adhering more
closely to a MeDi is necessary to support the biolog-
ical plausibility of its protective effects before promot-
ing this dietary pattern as a universal healthy diet. The
purpose of the current study was to describe the intake
of macronutrients, micronutrients, minerals, and trace
elements according to MeDi adherence among French
older community dwellers, in order to explain the
potential contribution of these nutrients to the health
benefits of the MeDi.
The data come from the Three-City (3C) study, a pro-
spective cohort study of vascular risk factors of demen-
tia which methodology has been described elsewhere
[33]. The 3C study protocol was approved by the Con-
sultative Committee for the Protection of Persons par-
ticipating in Biomedical Research at Kremlin-Bicêtre
University Hospital (Paris). A sample of 9,294 commu-
nity dwellers aged 65 and over was selected in 1999
2000 from the electoral rolls of three French cities
(Bordeaux, Dijon, and Montpellier). All participants
gave written informed consent. At baseline, data collec-
tion included sociodemographic information, lifestyle,
symptoms and medical complaints, medical history,
blood pressure, smoking status, drug use, anthropomet-
ric data, neuropsychological testing, and blood sam-
pling. These data were completed by a comprehensive
dietary survey only in the Bordeaux center in 2001
2002. The study sample comprises 1,595 participants
from Bordeaux, without missing nutritional data.
Dietary assessment
Participants were visited at home by a specifically
trained dietician who administered a food frequency
questionnaire (FFQ) and a 24-h dietary recall [11,25].
During the 24-h recall, the dietician registered all the
meals and beverages consumed in a period of exactly
24 h before the subject awoke on the day of the
interview. No weekend day was recorded. Quantities
were assessed according to a book of photographs [32]
edited for the SUVIMAX study [16]. A table gave the
correspondence between the portion size and the
weight of the food item. Photographs of dishes and
glasses with the corresponding volume were also
available. The same dietician then entered the data of
the 24-h recall in the Bilnut® software to obtain an
estimation of the daily nutrient intake of each partici-
pant. Food composition tables were already included
in the Bilnut® software and complemented as earlier
described [11]. Among the whole nutrient database,
key macronutrients (proteins, carbohydrates, fats, and
alcohol) were used to compute total energy intake
(EI). The different classes of lipids (saturated (SFA),
monounsaturated (MUFA), and polyunsaturated
(PUFA) fatty acids) were recorded, as the consump-
tion of carotenes; fibers; retinol; vitamins B1, B2, B5,
B6, B12, C, D, and E; folate; and of minerals and trace
elements (calcium, phosphorus, magnesium, potassi-
um, iron, and zinc).
Computation of the MeDi score
Based on the FFQ, frequency of consumption of 40
categories of foods and beverages for each of the three
main meals and three between-meal snacks was
recorded in 11 classes. The number of usual weekly
servings, but not portion size, of each of the 148 food
items and alcohol, ranging as a result from 0 to 42 was
recorded (with a maximum of six meals a day). The food
items were aggregated into 20 food and beverage groups
[25] and we identified those considered to be part of the
C. Feart et al.
MeDi: vegetables, fruits, legumes, cereals (including
bread, pasta, and rice, without distinction between
whole and refined grains), fish, meat, and dairy prod-
ucts. The number of servings per week for each food
group was determined and the MeDi score was comput-
ed as follows: a value of 0 or 1 was assigned to each
food group using sex-specific medians of the population
as cutoffs [35]. Briefly, subjects received one point if
their intake was higher than the sex-specific median for
a presumed protective component (vegetables, fruits,
legumes, cereals, fish, and MUFA to SFA ratio) and
lower than the sex-specific median for a presumed del-
eterious component (meat and dairy products). For al-
cohol, one point was given to mild to moderate
consumers. Cutoffs, chosen to be close to the second
quartile of distribution of total alcohol consumption,
were defined in men and women separately [13]. One
point was attributed for men if consumption was within
six to 14 glasses per week (8.5 to 20 g/day) and for
women if consumption was within one to four glasses
per week (1.4 to 5.7 g/day). Data from the 24-h recall
were used to compute the MUFA to SFA ratio (ratio of
the nutrient intake in gram per day). The MeDi score
was generated by adding the scores for each food cate-
gory for each participant. Thus, the MeDi score could
range from 0 to 9, with higher scores indicating greater
MeDi adherence [13].
Sociodemographic information included age, gender,
education, income, and marital status. Vascular risk
factors included measured Body Mass Index (BMI in
kilogram per square meter), diabetes, hypercholester-
olemia (total cholesterol 6.2 mmol/L), and hyperten-
sion (measured blood pressure 140/90 mmHg or
Statistical analyses
All statistical analyses were performed with SAS Sta-
tistical package (Version 9.1 SAS Institute). Partici-
pants were classified according to categories of MeDi
adherence (Low MeDi adherence, score 03; Middle
MeDi adherence, score 45; or High MeDi adherence,
score 69) defined to be nutritionally relevant, as
previously described and used in the literature [13,
26,35]. Demographic and clinical characteristics were
compared between the three categories of the MeDi
score. We then explored associations between the
MeDi adherence at baseline and EI and macronutrient
intakes, as expressed in proportion of total energy
intake (% EI) with alcohol. We also compared micro-
nutrient intakes, expressed in gram per day, across
categories of MeDi adherence. Separate analyses were
performed for each gender, since the MeDi score was
computed according to the sex-specific medians of
consumption of food groups.
The study sample consisted of 1,595 individuals (607
men and 988 women), aged 76.1 years on average
(range 67.794.9) in 20012002. The MeDi score
ranged from 0 to 9 with 1.1 % of the total population
in the extreme values (0 or 9); 43.5 % participants had
a MeDi score of 4 or 5. The mean (SD) MeDi score
was 4.36 (1.67) and was slightly but significantly
higher in men (4.54 (1.72) vs. 4.25 (1.63) in women,
P00.0006). High MeDi adherence (score 69) was
significantly more frequent in men (30.1 % vs.
23.0 % in women, P00.003). As expected, greater
MeDi adherence was characterized by higher intake
of vegetables, fruits, legumes, cereals, and fish and
lower intake of meat and dairy products (Table 1).
Greater MeDi adherence was associated with male
sex and being married (Table 2). Individuals in the
middle or high MeDi categories had a lower mean
BMI than those in the lowest category of MeDi score.
Greater MeDi adherence was not associated with hyper-
tension, hypercholesterolemia, or diabetes (Table 2).
In men, mean EI did not significantly differ across
categories of MeDi adherence (Table 3). However,
men in the middle MeDi category (MeDi score 45)
had a significant higher mean EI computed without
alcohol than the others. Regarding total protein intake,
there was no significant difference among the three
MeDi categories, although the mean protein intake
from vegetal origin was higher with greater MeDi
adherence. The mean carbohydrate and total fat
intakes did not vary with MeDi adherence. MeDi
adherence was inversely associated with total SFA
intake and consumption of myristic, palmitic, and
stearic acids in men. Total MUFA intake was higher
in men in the middle and highest MeDi categories, and
oleic acid intake was only higher in the middle MeDi
category compared with the others. Total PUFA,
Mediterranean diet adherence and nutrient intakes
notably total n6 PUFA and linoleic acid intakes,
were higher in the middle MeDi category. Moreover,
there was no association between n3 PUFA intake
and MeDi adherence in men. The consumption of
alcohol was lower in men with the highest MeDi
adherence (Table 3).
Regarding the consumption of macronutrients in
gram per day, similar trends were observed, since the
MeDi adherence was positively associated with vegetal
proteins, total MUFA, oleic acid, total PUFA, n6
PUFA, and linoleic acid intakes in men. Moreover, an
inverse association between total SFA and myristic acid
intakes (gram per day) and MeDi adherence was ob-
served (data not shown). In men, the mean linoleic/α-
inolenic acid ratio was positively associated with MeDi
adherence, ranging from 8.78 (SD 5.51) among low
MeDi adherents to 9.46 (SD 6.09) and 10.42 (SD
6.00) among middle and high MeDi adherents, respec-
tively (P00.034).
In women, the total mean EI computed with or
without alcohol was positively associated with MeDi
adherence (Table 3). As expressed in percent of EI
computed with alcohol (Table 3), MeDi adherence in
women was positively associated with intake of vegetal
protein, total carbohydrate, polysaccharides, total
PUFA, total n6 PUFA, linoleic acid, total n3PUFA,
and alpha-linolenic acid, and inversely associated with
total SFA and myristic, palmitic, and stearic acid intake
(Table 3). Regarding the macronutrient intake as
expressed in gram per day, similar trends between MeDi
adherence and higher mean consumptions of total pro-
tein, total MUFA, and oleic acid were observed (data
not shown). In addition, the mean (SD) linoleic/α-lino-
lenic acid ratios were statistically different among wom-
en with low, middle, and high MeDi adherence (i.e.,
8.46 (5.51), 10.71 (7.93), and 10.61 (7.69), respectively,
Regarding micronutrient, mineral and trace element
intake (Table 4), there was a positive significant asso-
ciation between MeDi adherence and the mean con-
sumption of fibers; vitamins B6, C, and E; folate;
magnesium; potassium; and iron both in men and
women. In men, there was also a significant associa-
tion between carotene intake and MeDi adherence,
which was not observed in women. Conversely, vita-
Table 1 Mean number of servings per week for individual food
categories, proportion of mild to moderate alcohol consumers
and mean ratio of daily intake of MUFA to SFA by categories of
Mediterranean diet score among older persons living in Bor-
deaux, the Three-City study (20012002) (N01,595)
Low category
(MeDi score 03) n0492
Middle category
(MeDi score 45) n0693
High category
(MeDi score 69) n0410
Food categories
Mean serving/week (SD)
Dairy products 20.65 (8.02) 18.08 (7.69)
16.14 (6.71)
Meat 5.36 (2.59) 4.80 (2.41)
4.18 (2.22)
Vegetables 15.56 (6.41) 19.37 (7.11)
23.44 (6.61)
Fruits 10.66 (6.79) 13.84 (6.55)
16.45 (6.50)
Legumes 0.42 (0.68) 0.62 (0.62)
0.82 (0.65)
Cereals 19.78 (6.52) 22.16 (5.76)
24.54 (5.48)
Fish 2.02 (1.49) 2.91 (1.69)
3.76 (1.73)
Mild to moderate alcohol (%) 14.63 25.40
MUFA to SFA ratio, mean (SD) 0.77 (0.26) 0.88 (0.32)
1.00 (0.31)
MeDi Mediterranean diet, MUFA to SFA monounsaturated fatty acid to saturated fatty acid ratio (intake g/d)
All Pvalues <.0001 for the analysis of variance (ANOVA) or for the Chi-square test (proportion of mild to moderate alcohol
consumers) among categories of Mediterranean diet score
2×2 significant comparisons (P< 0.05) for mean number of servings per week for individual food categories, proportion of mild to
moderate alcohol consumers, and mean ratio of daily intake of MUFA to SFA between categories of Mediterranean diet score taking the
lowest category as reference group
2×2 significant comparisons (P< 0.05) for mean number of servings per week for individual food categories, proportion of mild to
moderate alcohol consumers, and mean ratio of daily intake of MUFA to SFA between individuals in middle and high categories of
Mediterranean diet score
C. Feart et al.
with MeDi adherence in women only. Finally, there was
an inverse association between MeDi adherence and
calcium intake which was the lowest in the middle and
highest MeDi categories in women, while this inverse
association was of borderline significance in men
(Table 4).
This large population-based cross-sectional study in
older persons living in South-western France shows a
high coherence between dietary data collected by FFQ
and used to assess a diet modeled on the traditional
MeDi, and the nutrient intake estimated by 24-h recall.
As expected, greater MeDi adherence was associated
with total mean higher vegetal protein intake (% EI),
lower total mean SFA intake (% EI), higher total mean
PUFA intake (% EI), but also notably with total n6
PUFA and linoleic acid intakes, both in men and
women. In men, higher total mean MUFA and oleic
acid intakes but less alcohol consumption (% EI) were
observed with greater MeDi adherence. Total carbohy-
drate and polysaccharide intakes (% EI) and total mean
n3 PUFA and alpha-linolenic acid intakes (% EI) were
positively associated with MeDi adherence in women
but not in men. The consumption of several micronu-
trients, minerals, and trace elements (i.e., fibers; vita-
mins B6, C, and E; folate; magnesium; potassium; and
iron) increased with higher MeDi adherence, in both
men and women. Only the consumption of calcium
decreased with greater MeDi adherence in women and
with borderline significance in men.
The concept of MeDi has been first introduced in
the Seven-Country study by Keys et al. who reported
low all-cause and coronary heart disease death rates in
cohorts of the Mediterranean basin with olive oil as
the main fat [18]. Not a specific pattern but a collec-
tion of eating habits traditionally followed by the
populations of the Mediterranean basin first defined
the so-called traditionalMeDi. However, there is no
single MeDi but several definitions because dietary
habits vary considerably across the Mediterranean
countries bordering the sea [3,28]. Compared with
Table 2 Demographic and clin-
ical characteristics by categories
of Mediterranean diet score
among older persons living in
Bordeaux, the Three-City study,
20012002 (N01,595)
Pvalue for the Chi-square test or
analysis of variance (ANOVA)
among categories of Mediterra-
nean diet score
MeDi Mediterranean diet, BMI
Body Mass Index
2× 2 significant comparisons (P
<0.05) for means of age and BMI
between categories of Mediterra-
nean diet score taking the lowest
category as reference group
Low category
(MeDi score 03)
Middle category
(MeDi score 45)
High category
(MeDi score 69)
Demographic characteristics
Age (n), mean (SD) (y) (492) 76.4 (5.1) (693) 76.2 (5.1) (410) 75.8 (4.7) 0.13
Wom en (n) (%) (325) 66.1 (436) 62.9 (227) 55.4 0.003
Education (n)(%)
No or primary school (182) 37.1 (221) 32.1 (125) 30.7 0.11
Secondary (136) 27.8 (192) 27.9 (106) 26.0
High school (102) 20.8 (143) 20.8 (90) 22.1
University (70) 14.3 (133) 19.3 (86) 21.1
Monthly income ()(n)(%)
Refused to answer (40) 8.1 (55) 7.9 (26) 6.3 0.06
<750 (36) 7.3 (53) 7.7 (22) 5.4
7501,500 (168) 34.1 (202) 29.1 (109) 26.6
1,5002,250 (122) 24.8 (166) 24.0 (111) 27.1
>2,250 (126) 25.6 (217) 31.3 (142) 24.6
Marital status (n)(%)
Married (237) 48.2 (371) 53.5 (257) 62.7 0.0006
Divorced/separated (43) 8.7 (49) 7.1 (29) 7.1
Widowed (183) 37.2 (227) 32.8 (97) 23.7
Single (29) 5.9 (46) 6.6 (27) 6.6
Clinical characteristics
BMI (n), mean (SD) (480) 26.9 (4.8) (676) 25.2 (4.1)
(408) 26.1 (3.7)
Hypertension (n) (%) (371) 75.9 (529) 76.6 (322) 78.5 0.62
Hypercholesterolemia (n) (%) (257) 56.0 (372) 57.8 (237) 59.9 0.52
Diabetes (n) (%) (55) 11.2 (64) 9.2 (35) 8.6 0.36
Mediterranean diet adherence and nutrient intakes
usual single-food or nutrient methods, the dietary pat-
tern approach is appealing because analyses based on
single nutrients ignore important interactions (addi-
tive, synergistic, or antagonist effects) between com-
ponents of diet and because people did not eat isolated
nutrients [17]. The computation of the MeDi score
[35], as used in the present study, combines several
foods providing nutrients which have been identified
as potential protective factors against cardiovascular
diseases such as fruit and vegetables, fish, as the main
provider of long-chain n3 PUFA, olive oil as main
source of MUFA, and a moderate consumption of
Table 3 Energy, macronutrient, and alcohol intakes as expressed in proportion of energy intake by categories of Mediterranean diet
score among older persons living in Bordeaux, the Three-City study, 20012002 (N01,595)
Men Women
Low MeDi
(score 03)
Middle MeDi
(score 45)
High MeDi
(score 69)
PLow MeDi
(score 03)
Middle MeDi
(score 45)
High MeDi
(score 69)
Total energy intake
(kcal) mean (SD)
1,967 (555) 2,058 (533) 2,004 (498) 0.19 1,453 (457) 1,540 (449)
1,585 (467)
Energy intake without alcohol
(kcal) mean (SD)
1,786 (516) 1,909 (510)
1,873 (494) 0.049 1,400 (441) 1,492 (435)
1,538 (451)
Nutrient intake mean (SD)
Proteins 17.1 (4.6) 17.3 (4.2) 17.3 (4.2) 0.85 18.6 (5.1) 18.5 (5.0) 18.3 (4.7) 0.77
Animal proteins 12.3 (4.8) 12.2 (4.4) 12.1 (4.6) 0.89 13.9 (5.4) 13.3 (5.4) 12.8 (5.0) 0.07
Vegetal proteins 4.8 (1.5) 5.1 (1.3) 5.3 (1.5)
0.005 4.7 (1.6) 5.1 (1.6)
5.5 (1.7)
Carbohydrates 44.5 (10.0) 44.3 (10.0) 46.1 (9.3) 0.14 46.1 (10.0) 46.9 (9.9) 48.2 (9.6)
Mono/disaccharides 20.0 (10.3) 18.7 (8.0) 20.0 (6.7) 0.18 23.3 (9.8) 22.6 (8.1) 23.1 (8.0) 0.50
Polysaccharides 24.5 (8.4) 25.6 (7.3) 26.1 (7.4) 0.16 22.8 (8.7) 24.3 (8.4)
25.2 (8.0)
Total fat 29.7 (8.3) 31.2 (8.7) 30.0 (8.6) 0.13 31.9 (9.2) 31.6 (8.8) 30.6 (8.9) 0.26
Total SFA 13.6 (4.3) 13.4 (4.3) 11.9 (4.1)
<0.0001 14.8 (5.1) 13.4 (4.6)
11.9 (4.1)
Myristic acid 1.58 (0.75) 1.49 (0.70) 1.22 (0.64)
<0.0001 1.78 (0.89) 1.48 (0.76)
1.20 (0.62)
Palmitic acid 6.64 (2.18) 6.59 (2.22) 6.12 (2.26)
0.042 7.21 (2.60) 6.66 (2.52)
6.15 (2.36)
Stearic acid 2.97 (1.22) 2.87 (1.27) 2.58 (1.17)
0.0007 3.06 (1.29) 2.86 (1.37) 2.56 (1.19)
Total MUFA 10.2 (3.7) 11.3 (4.1)
11.2 (4.1)
0.01 10.9 (3.9) 11.2 (4.1) 11.5 (4.1) 0.23
Palmitoleic acid 0.72 (0.45) 0.78 (0.63) 0.78 (0.71) 0.51 0.80 (0.60) 0.83 (0.83) 0.74 (0.67) 0.32
Oleic acid 8.70 (3.44) 9.73 (3.95)
9.60 (3.82) 0.017 9.37 (3.67) 9.63 (3.85) 10.04 (3.95) 0.13
Total PUFA 3.8 (2.1) 4.3 (2.6) 4.7 (2.3)
0.004 3.9 (2.1) 4.6 (2.6)
5.0 (3.2)
Total n6 PUFA 2.9 (1.9) 3.4 (2.3) 3.7 (2.1)
0.005 2.9 (2.0) 3.6 (2.4)
3.8 (2.8)
Linoleic acid 2.85 (1.87) 3.28 (2.31) 3.58 (2.12)
0.006 2.84 (2.01) 3.49 (2.40)
3.76 (2.80)
Arachidonic acid 0.07 (0.07) 0.08 (0.08) 0.09 (0.09) 0.13 0.09 (0.10) 0.09 (0.09) 0.09 (0.09) 0.81
Total n3 PUFA 0.6 (0.5) 0.6 (0.6) 0.7 (0.6) 0.36 0.6 (0.7) 0.7 (0.8) 0.8 (0.8)
a-Linolenic acid 0.37 (0.25) 0.42 (0.39) 0.40 (0.28) 0.32 0.37 (0.19) 0.39 (0.32) 0.44 (0.44)
EPA 0.07 (0.17) 0.06 (0.15) 0.08 (0.18) 0.39 0.06 (0.19) 0.08 (0.21) 0.09 (0.18) 0.26
DHA 0.12 (0.29) 0.12 (0.31) 0.17 (0.40) 0.24 0.14 (0.41) 0.16 (0.40) 0.20 (0.42) 0.23
Alcohol 9.0 (7.7) 7.2 (6.1) 6.6 (5.9)
0.007 3.5 (4.8) 3.0 (4.3) 2.9 (4.2) 0.23
P-value for ANOVA comparing energy intake, macronutrient, and alcohol intakes in g/d among the three Mediterranean Diet Score
MeDi Mediterranean diet, SFA saturated fatty acids, MUFA monounsaturated fatty acid, PUFA polyunsaturated fatty acid, EPA
eicosapentaenoic acid, DHA docosahexaenoic acid
Expressed as percentage of energy intake (computed with alcohol)
2×2 significant comparisons (P< 0.05) for means of nutrient intake between categories of Mediterranean diet score taking the lowest
category as reference group
2×2 significant comparisons (P<0.05) for means of nutrient intake between individuals in middle and high categories of Mediterranean
diet score
C. Feart et al.
alcohol. On the other hand, higher total fat and SFA
intake have been considered as harmful factors for car-
diovascular diseases and related mortality [7,20,24].
Our findings support the presumed beneficial effects
of the MeDi. Regarding macronutrients, higher adher-
ence to a MeDi was characterized by a high intake of
vegetal protein but not animal protein; complex carbo-
hydrates, hence a lower glycemic index; a low con-
sumption of SFA which detrimental effects are well
documentedalthough debated [1], and a high con-
sumption of MUFA, especially oleic acid, and PUFA.
Despite a higher intake of n3 PUFA with great er MeDi
adherence, notably in women, the ratio of n6/n3
PUFA precursors increased with MeDi score. This
may be, in part, due to the high proportion of consumers
of oils from various vegetal origins, which are providers
of linoleic acid, the precursor of n6 PUFA. Indeed,
60 % of the whole sample were regular consumers (i.e.,
preferred dietary fats used for dressing or cooking) of
olive oil and 44 % of sunflower oil, although 32 % were
simultaneously regular consumers of both oils (data not
shown). Hence, the ratio of n6/n3 PUFA precursors,
Table 4 Micronutrient intakes, as expressed in mg/d, by categories of Mediterranean diet score among older persons living in
Bordeaux, the Three-City study, 20012002 (N01,595)
Men Women
Low MeDi
(score 03)
Middle MeDi
(score 45)
High MeDi
(score 69)
PLow MeDi
(score 03) (n0325)
Middle MeDi
(score 45)
High MeDi
(score 69)
Nutrient intake, mean (SD)
Carotenes 2.97 (4.59) 3.06 (4.07) 4.58 (6.67)
0.003 3.60 (5.65) 3.38 (5.11) 3.73 (4.72) 0.69
Fibres 16.82 (7.20) 20.28 (8.24)
21.47 (8.01)
<0.0001 13.88 (6.88) 16.41 (6.89)
18.20 (8.07)
Retinol 708.1 (1,851.6) 644.1 (1,545.2) 736.7 (2,021.0) 0.85 840.7 (4,652.4) 628.5 (2,621.7) 607.4 (1,828.3) 0.62
Vitamin B1 1.08 (0.41) 1.15 (0.52) 1.17 (0.44) 0.20 0.88 (0.39) 0.95 (0.40) 1.01 (0.41)
Vitamin B2 1.69 (0.66) 1.72 (0.63) 1.68 (0.66) 0.85 1.50 (0.81) 1.46 (0.75) 1.50 (0.66) 0.76
Vitamin B5 4.31 (1.76) 4.56 (1.59) 4.60 (1.71) 0.20 3.76 (1.94) 3.85 (1.68) 4.05 (1.72) 0.17
Vitamin B6 1.52 (0.54) 1.69 (0.62)
1.68 (0.58)
0.008 1.22 (0.51) 1.34 (0.53)
1.42 (0.58)
Folates 271.3 (119.9) 305.2 (128.7)
325.9 (144.5)
0.0005 230.8 (125.9) 257.9 (119.8)
294.0 (143.6)
Vitamin B12 6.17 (10.39) 5.91 (8.19) 6.00 (10.23) 0.96 5.45 (12.78) 5.44 (12.20) 5.23 (0.64) 0.97
Vitamin C 74.7 (63.6) 84.74 (60.52) 95.25 (67.72)
0.011 74.05 (57.53) 82.16 (57.01) 92.10 (66.30)
Vitamin D 1.68 (1.91) 2.13 (3.11) 1.78 (2.15) 0.16 1.55 (2.70) 1.64 (2.96) 1.71 (2.93) 0.79
Vitamin E 5.72 (4.99) 7.02 (4.17)
8.59 (5.58)
<0.0001 5.10 (3.47) 6.39 (4.63)
6.86 (4.30)
Minerals and trace elements
Calcium 947.7 (481.9) 953.7 (433.6) 862.1 (415.7) 0.07 892.9 (471.9) 810.2 (402.1)
773.5 (381.4)
Phosphorus 1.24 (0.42) 1.27 (0.39) 1.22 (0.35) 0.38 1.02 (0.39) 1.03 (0.36) 1.04 (0.36) 0.87
Magnesium 276.0 (78.5) 294.7 (83.3) 301.2 (80.0)
0.01 221.0 (71.5) 235.1 (74.8)
252.6 (83.7)
Potassium 2.90 (0.88) 3.04 (0.86) 3.13 (0.83)
0.04 2.37 (0.76) 2.52 (0.83) 2.72 (0.88)
Iron 12.53 (5.56) 13.01 (4.71) 14.44 (8.14)
0.01 8.79 (4.53) 9.73 (4.76)
10.88 (5.62)
Zinc 6.41 (4.98) 7.24 (5.27) 7.21 (5.76) 0.24 7.30 (7.51) 7.53 (7.19) 8.40 (7.42) 0.20
P-value for the ANOVA comparing energy, macronutrient, alcohol and micronutrients intakes among the three Mediterranean Diet
Score categories
MeDi Mediterranean diet
Expressed as mean intake in mg/d except for fibres, sodium, phosphorus, and potassium, all expressed in g/d, and for retinol, vitamin
D, and folates, all expressed in μg/d
2×2 significant comparisons (P< 0.05) for means of energy and nutrient intake between categories of Mediterranean diet score taking
the lowest category as reference group
2×2 significant comparisons (P< 0.05) for means of energy and nutrient intake between individuals in middle and high categories of
Mediterranean diet score
Mediterranean diet adherence and nutrient intakes
high in our sample and far above the recommended
value of 5 [19], might be a restriction to beneficial
effects of the MeDi. Higher adherence to the MeDi
was also associated with higher intake of various anti-
oxidants (vitamins C and E, carotenes in men, and also
probably polyphenols from plants although we could
not ascertain their amount) which contribute to protect
long-chain n3 PUFA from lipid peroxidation. The
MeDi also provided B vitamins, especially folate. Nev-
ertheless, higher MeDi adherence is characterized by
lower intake of dairy products. Therefore, the lower
dietary intake of calcium associated with higher MeDi
adherence in women, may be a threat to their bone
health. This finding suggests that the MeDi as presently
defined may not be a universally protective diet. Refine-
ment in the computation of the score is needed to
disentangle the presumed detrimental effects of some
SFA from the beneficial effects of calcium found in
dairy products.
Overall, the results of the present analysis showed a
high coherence between the two methodologies used
in the 3C study to describe the anatomy of the
Mediterranean-type diet of older participants of the
3C cohort. However, some expected associations be-
tween MeDi adherence and various nutrient intakes
(for instance, total mean n3 PUFA in men, carotene
in women, and vitamins D and B12) have not been
highlighted. This may be due to the use of a single 24-
h recall which cannot handle high intraindividual var-
iation [11]. Thus, a reported single day of intake is
unlikely to be representative of usual individual in-
take. However, a sufficiently large sample may allow
to determine average intake of defined subgroups [38].
Moreover, a single 24-h recall prevented us to capture
the intake of nutrients which are not consumed on a
daily basis, but less often. The FFQ used in the present
study assessed number of servings but not portion size.
The lack of consideration of amount of each food con-
sumed may lead to consider people with the same fre-
quency of each food group of the MeDi score, and the
same MeDi score, as comparable, although they may
have different quantitative food consumptions. We can-
not exclude that the quantity of presumed protective or
deleterious nutrients consumed by men and women with
a similar MeDi score may differ, which reduced our
chance to evidence associations between food and nutri-
ent intakes. Finally, alcohol was an important component
of total EI, notably in men [11], leading us to consider
this nutrient provider of energy in the computation of the
total EI in the present analysis. However, a low to
moderate alcohol consumption is also one of the nine
components of the MeDi score, which may have added
bias in the present study.
Analyses of single nutrients using 24-h dietary recalls
could help understand specific mechanisms involved in
physiopathological processes leading to diseases, by
establishing biological plausibility. Therefore, the bio-
logical basis for the well-documented health benefits of
the MeDi involves a decrease in oxidative stress and
inflammation which also participates in the dysregula-
tion of cellular function, the exacerbation of degenerative
diseases, such as cardiovascular diseases or atheroscle-
rosis [5,7,20,31]. Individuals with higher MeDi adher-
ence have been shown to have higher reduced to
oxidized glutathione ratio and lower insulin resistance,
oxidized low-density lipoprotein, C-reactive protein, and
interleukin-18 levels [4,9,15]. It has been hypothesized
that the n3 PUFA and a balanced n6/n3PUFAratio
associated with a high intake of antioxidant in the MeDi
could be important determinants in influencing cardio-
vascular and cerebral diseases [14,21,27]. In the current
study, participants with lower MeDi adherence exhibited
also greater BMI. Surprisingly, there were no apparent
vascular benefits of a greater MeDi adherence in the
current sample where the prevalence of hypertension,
hypercholesterolemia, and diabetes did not differ across
MeDi categories. This has already been observed in
similar samples of elderly people involved in the 3C
study, who exhibited a global healthy lifestyle [13,33].
Finally, the computation of the MeDi score was able to
assess associations between a diet modeled on the tradi-
tional MeDi, but which is specific to the sample studied.
Indeed, the use of sex-specific cutoff points does not
measure adherence to a universal traditional MeDi pat-
tern but rather to a specific pattern, which precludes
generalizing results of the present study to other popula-
tions who have, on the whole, different food intake and
MeDi adherence [2]. Moreover, including only nine food
groups, the MeDi score does not consider the overall
correlation between all foods [17], among which some
food groups could reflect specific health concerns and
behavior, such as the consumption of dietary supple-
ments. Despite these limitations, the strengths of the
present study are its sample size, the population-based
design, and the accuracy of food intake assessment
which validates the methodology employed.
In conclusion, this study conducted in French el-
derly community dwellers allowed to describe the
C. Feart et al.
basis of their Mediterranean-type diet and the actual
consumption of nutrients associated with MeDi adher-
ence. As residual confounding by other aspects of
lifestyle cannot be ruled out, these nutrients probably
do not fully explain the better health of persons who
adhere to this MeDi, but they likely contribute direct-
ly. At least regarding clinical parameters, old consum-
ers who conform with MeDi have only a lower BMI
and no adverse effects of an elevated n6/n3 PUFA
ratio. This dietary pattern may indirectly constitute an
indicator of a complex set of favorable social and
lifestyle factors that contribute to global better health.
Indeed, food choices and dietary habits which reflect
individual food preferences are highly sensitive to
culture, education, socioeconomic status, sociodemo-
graphic characteristics, environmental and lifestyle
determinants, as well as to age- or nutrition-related
diseases [10].
Funding/Support The Three-City Study is conducted under a
partnership agreement between the Institut National de la Santé
et de la Recherche Médicale (INSERM), the Institut de Santé
Publique et Développement of the Victor Segalen Bordeaux 2
University, and Sanofi-Aventis. The Fondation pour la Recher-
che Médicale funded the preparation and initiation of the study.
The 3C Study is also supported by the Caisse Nationale Maladie
des Travailleurs Salariés, Direction Générale de la Santé,
Mutuelle Générale de lEducation Nationale, Institut de la Lon-
gévité, Regional Governments of Aquitaine and Bourgogne,
Fondation de France, and Ministry of ResearchINSERM
Programme Cohortes et collections de données biologiques.
Role of the sponsors Study sponsors played no role in the
design and conduct of the study; collection, management, anal-
ysis, and interpretation of the data; and preparation, review, or
approval of the manuscript.
Conflict of interest P. Barberger-Gateau received fees for
conferences from Danone, Lesieur, Bauch & Lomb, and Aprifel
and benefits from research grants from Danone and Lesieur. The
other authors declared no support from any institution for the
submitted work.
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C. Feart et al.
... In addition, a study of the Australian population found relatively good adherence among Australian females [15]. However, although a systematic overview of evidence is lacking as yet, there seems to be a trend of decline of adherence to the MD in many Mediterranean countries [13,[16][17][18][19]. For instance, Veronese et al. noted a significant decrease in adherence to MD in Italy between the years 1985-1986 and 2005-2006, which was more prominent among younger than older participants, and was mainly caused by a reduction in olive oil consumption [20]. ...
... Twenty-one studies reported mean MD adherence for men and women separately [8,16,20 [61,62,73]. One paper reported high adherence in women and moderate adherence in men [51], while another reported low adherence in women and moderate adherence in men [59] and in contrast one reported low adherence in men and moderate adherence in women [74]. ...
... One study reported high adherence across age groups (18 + years old) [56]. Out of the nine studies that included a sample composed of the elderly aged 65 years and above, six reported moderate MD adherence [16,39,48,[57][58][59], two studies [8,60] reported a low adherence level, and one study [71] found that the majority of the population (41.7%) were classified in the highest category of adherence. More details about mean MD adherence and/or distribution per age subgroups are provided in supporting information 3 (S3). ...
Full-text available
Background and aim While the Mediterranean diet (MD) is promoted in non-Mediterranean countries, inhabitants of Mediterranean countries seem to be shifting away from this healthy diet. The aim of this study is to provide an overview of MD adherence in the general adult population of Mediterranean countries. Methods A systematic review was conducted following the PRISMA 2020 (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines and registered in the Prospero database (CRD42020189337). Literature was searched in PubMed, Web of Science and PsycINFO databases for studies published from 2010 up to and including 2021. The following inclusion criteria were used: age 18 years and older, sample size > 1000 participants, and using a validated MD adherence score. Studies that only included participants with nutrition-related or other severe chronic disorders, as well as studies that only included specific subpopulations (e.g., pregnant women), were excluded in order to focus on the general adult population. A quality analysis of the included studies was done using the NCCMT scale. Results A total of 50 studies were included. The number of participants in the included studies ranged between 1013 and 94,113. Most of the included studies pertained to the European Mediterranean countries, with fewer studies from the Middle Eastern and North African Mediterranean countries. The vast majority of the included studies reported low or moderate MD adherence, both based on the mean adherence as well as the low or moderate adherence category often being the most prevalent. There were no clear differences noted between sex and age groups. The quality assessment generally showed weak or moderate scores. Conclusions Mediterranean populations have been showing moderate adherence to MD in the past 10 years, indicating room for improving adherence to the MD in countries of its origin.
... A Mediterranean dietary pattern (MD) is widely recommended for the prevention of chronic diseases (1,2). Although only a few studies have estimated the nutritional value of the Mediterranean diet, they consistently report that higher adherence results in higher iron intakes (3)(4)(5). However, serum ferritin concentrations, a marker of body iron stores, were reported to be 2-fold lower in Crete (Southern Europe) than Zutphen (Northern Europe) (6), suggesting that higher iron intakes from a Mediterranean diet do not necessarily result in higher iron statuses. ...
... The daily intake of iron was nearly twice the average requirement of 6 mg/d (40). We observed a significant increase in iron intake for those in the MD group, which agrees with other published findings (5). It appears that despite a reduction in meat intake, the MD provides sufficient bioavailable iron to maintain body iron; depending on the baseline habitual diet, changing to an MD may actually induce a subtle increase in iron status. ...
Full-text available
Background: Mediterranean diets limit red meat consumption and increase intakes of high-phytate foods, a combination that could reduce iron status. Conversely, higher intakes of fish, a good source of selenium, could increase selenium status. Objectives: A 1-y randomized controlled trial [New Dietary Strategies Addressing the Specific Needs of the Elderly Population for Healthy Aging in Europe (NU-AGE)] was carried out in older Europeans to investigate the effects of consuming a Mediterranean-style diet on indices of inflammation and changes in nutritional status. Methods: Selenium and iron intakes and status biomarkers were measured at baseline and after 1 y in 1294 people aged 65-79 y from 5 European countries (France, Italy, the Netherlands, Poland, and the United Kingdom) who had been randomly allocated either to a Mediterranean-style diet or to remain on their habitual, Western diet. Results: Estimated selenium intakes increased significantly with the intervention group (P < 0.01), but were not accompanied by changes in serum selenium concentrations. Iron intakes also increased (P < 0.001), but there was no change in iron status. However, when stratified by study center, there were positive effects of the intervention on iron status for serum ferritin for participants in Italy (P = 0.04) and France (P = 0.04) and on soluble transferrin receptor (sTfR) for participants in Poland (P < 0.01). Meat intake decreased and fish intake increased to a greater degree in the intervention group, relative to the controls (P < 0.01 for both), but the overall effects of the intervention on meat and fish intakes were mainly driven by data from Poland and France. Changes in serum selenium in the intervention group were associated with greater changes in serum ferritin (P = 0.01) and body iron (P = 0.01), but not sTfR (P = 0.73); there were no study center × selenium status interactions for the iron biomarkers. Conclusions: Consuming a Mediterranean-style diet for 1 y had no overall effect on iron or selenium status, although there were positive effects on biomarkers of iron status in some countries. The NU-AGE trial was registered at as NCT01754012.
... In terms of the adherence to the Mediterranean diet, we found no literature on nutrition intakes with respect to the MEDAS. Studies on other measures confirm the complexity in this regard 28 . We identified subjects' physical activity to address the limitations of MEDAS as a tool in dietary interventions. ...
Full-text available
We aimed to determine whether the 14-item Mediterranean diet adherence screener (MEDAS) is suitable in Taiwan and associate the MEDAS score with the risk of prediabetes. In this cross-sectional study 346 patients were recruited between 2014 and 2019 at Taipei Tzu Chi Hospital. The MEDAS score was obtained with a 14-item MEDAS used in the PREDIMED trial. The blood glucose level is measured by fasting glucose and HbA1c. The results of the screener were analyzed for internal consistency and compared with the blood glucose level using multivariate regression models. The MEDAS score was significantly (p = 0.001) and inversely associated with both measures of blood glucose level. Adjusted data (95% CI) showed that each additional point in the MEDAS score decreases the risk of prediabetes with abnormal fasting glucose (> 100 mg/dL) level by 60% and the risk of prediabetes with abnormal HbA1c (> 5.7%) by 22.4%. Consuming at least 3 servings of legumes each week was significantly (p = 0.007) related to a lower risk of prediabetes under logistic regression. A higher score on the 14-item MEDAS screener was significantly associated with a lower risk of prediabetes.
... Dietary assessment through self-reporting methods (e.g., food frequency questionnaires, dietary recalls) has repeatedly evidenced a positive association between the adherence to a MD, micronutrient intake, and nutritional adequacy in young (19,20), adult (21), and older populations (22). However, the measurement of dietary biomarkers in biological matrices has emerged in recent years as a more reliable strategy to get a closer and more objective understanding of the crosstalk between diet and health within the complex meshwork of bioavailability, metabolism, biodistribution, and excretion processes. ...
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Diet is one of the most important modifiable lifestyle factors for preventing and treating obesity. In this respect, the Mediterranean diet (MD) has proven to be a rich source of a myriad of micronutrients with positive repercussions on human health. Herein, we studied an observational cohort of children and adolescents with obesity (N = 26) to explore the association between circulating blood trace elements and the degree of MD adherence, as assessed through the KIDMED questionnaire. Participants with higher MD adherence showed better glycemic/insulinemic control and a healthier lipid profile, as well as raised plasma levels of selenium, zinc, cobalt, molybdenum, and arsenic, and increased erythroid content of selenium. Interestingly, we found that these MD-related mineral alterations were closely correlated with the characteristic metabolic complications behind childhood obesity, namely hyperglycemia, hyperinsulinemia, and dyslipidemia (p < 0.05, |r| > 0.35). These findings highlight the pivotal role that dietary trace elements may play in the pathogenesis of obesity and related disorders.
... A food frequency questionnaire was administered at baseline (49) but was not appropriate (no portion size) for assessing the carbohydrate consumptions, the adherence to a low-carbohydrate diet, and for computing the glycemic load. Although misclassification A c c e p t e d M a n u s c r i p t 16 is always an issue with use of a single 24-hour recall, we previously found acceptable correlations between various nutrients estimated from that recall and food groups from our food frequency questionnaire (50). Moreover, misclassification is more likely with foods not consumed on a daily basis than macronutrients, such as carbohydrates, consumed every day. ...
Insulin resistance is a major mechanism involved in the onset of physical frailty (PF). Although rich carbohydrate diets may promote insulin resistance, few studies have examined their association with PF risk. This study aimed to investigate the spectrum of carbohydrate exposure, including carbohydrate intake (simple, complex, and total), glycemic load (measure of the diet-related insulin-demand), and adherence to a low-carbohydrate diet with the incident risk of PF in community-dwelling older adults. Baseline carbohydrate exposure was assessed in non-frail participants of the Three-City-Bordeaux cohort using a 24H dietary recall. Over 15 years of follow-up, participants were screened for PF, defined by the FRAIL scale (≥3 criteria out of Fatigue, Resistance, Ambulation, Illnesses, and weight Loss). Associations were estimated using mixed-effects logistic models adjusted for sex, age, education, smoking status, alcohol consumption, depressive symptomatology, global cognitive performances, and protein and energy intakes. The sample included 1,210 participants (62% females, mean age 76 years). Over the follow-up, 295 (24%) incident cases of PF were documented (28% in females, 18% in males). Higher intake of simple carbohydrates was significantly associated with greater odds of incident PF (per 1-SD increased: OR = 1.29; 95% CI = 1.02–1.62), specifically among males (OR = 1.52; 95% CI = 1.04–2.22). No association was observed with complex or total carbohydrate intake, glycemic load, or low-carbohydrate diet. Among the whole carbohydrate exposure, only higher consumption of simple carbohydrates in older age was associated with a higher risk of developing PF. Further studies are required to explore underlying mechanisms.
... Our survey data showed that the recruited athletes consumed macronutrients consistent with the Mediterranean diet as described by Davis et al. and Feart et al. [12,24]. Italy being a country with a moderate-to-high degree of Mediterranean diet adherence [25], it was expected that the athletes surveyed follow the Mediterranean Diet, but there was a slight variation in which the athletes sacrificed fat intake with protein. ...
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1) Background: It is recommended that an athlete, in order to ensure correct nutrition and performance, should consume between 1.2 and 2.0 g/kg/day of protein, while the daily recommended protein intake for a non-athlete is 0.8and 0.9 mg/kg/day. It is unclear if athletes living in Mediterranean countries are able to meet protein requirements without supplementation, since Mediterranean diet de-emphasizes meat and meat products. (2) Methods: 166 athletes (125 males) enrolled between 2017 and 2019 were required to keep a dietary journal for three consecutive days (2 workdays and 1 weekend day). Athletes had to be >18 years old, train in a particular sport activity more than 3 h a week and compete at least at an amateur level. Journal data were collected and then translated into macro-nutrient content (grams of protein, carbohydrates, and lipids) by a nutritionist. (3) Results: The protein intake reported by this specific population vary slightly from the Academy of Nutrition and Dietetics (AND), Dietitians of Canada (DC), and the American College of Sports Medicine (ACSM) joint statement recommendation level. Average protein levels without protein supplementation fell within the protein guidelines. Counterintuitively, the intake among those who supplemented their diet with protein was higher compared with those who did not, even when excluding the contribution of supplements. Although the majority of subjects participating in the study were able to meet protein intake recommended for athletes without protein supplementation, 27% of athletes were below the guideline range. (4) Conclusions: these data suggest that athletes' nutrition should be more often evaluated by a nutritionist and that they will benefit from increasing their nutritional knowledge in order to make better food choices, resorting to protein supplementation only when effectively needed.
... Micronutrient deficiencies are increasingly common, especially among the women of childbearing age (5,101) , and may be exacerbated during gestation by increased nutritional requirements (102,103) . Some studies have reported a greater contribution of some of these micronutrients (vitamins C, E, B, folate, Mg, Ca, Fe, vitamin D or Zn) associated with MD (21,64,104,105) . ...
Objective The objective was to evaluate maternal Mediterranean diet (MD) pattern adherence during pregnancy and its association with small for gestational age (SGA) and preterm birth. A secondary objective of the current study was to describe the sociodemographic, lifestyle and obstetric profile of the mothers studied as well as the most relevant paternal and newborn characteristics. Design The current study is a two-phase retrospective population-based study of maternal dietary habits during pregnancy and their effect on newborn size and prematurity. The descriptive first phase examined maternal dietary habits during pregnancy along with the maternal sociodemographic, lifestyle and obstetric profile in a cross-sectional period study. In the second phase, newborn outcomes were evaluated in a nested case–control study. Adherence to MD during pregnancy was measured with the Spanish version of Kidmed index. Setting Obstetrics ward of the La Fe Hospital in Valencia. Participants All mother–child pairs admitted after delivery during a 12-month period starting from January 2018 were assessed for eligibility. A total of 1118 provided complete outcome data after signing informed consent. Results 14·5 % met the criteria of poor adherence (PA); 34·8 %, medium adherence (MA); and 50·7 %, optimal adherence (OA). Medium adherence to MD was associated in the adjusted scenarios with a higher risk of giving birth to a preterm newborn. No association was found between MD adherence and SGA. Conclusions Early intervention programmes geared towards pregnant women, where women were aided in reaching OA to MD, might reduce the risk of preterm newborn.
... The associations between nutrient pattern factor scores and repeated MMSE scores were estimated using linear mixed models with random effects. As the distribution of the MMSE scores was highly skewed, the square root of the number of errors was calculated as (30 − MMSE) 1/2 and used as the dependent variable in mixed models [25]. The beta coefficient for each nutrient factor score represents the association between the factor score and the mean cognitive score at baseline, whereas the factor score × time interaction represents the association between the scores and the slope of cognitive change over time. ...
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Dietary patterns, or the combination of foods and beverages intake, have been associated with better cognitive function in older persons. To date, no study has investigated the link between a posteriori nutrient patterns based on food intake, and cognitive decline in longitudinal analyses. The aim of this study was to evaluate the relationship between nutrient patterns and cognitive function and decline in two longitudinal cohorts of older persons from France and Canada. The study sample was composed of participants from the Three-City study (3C, France) and the Quebec Longitudinal Study on Nutrition and Successful Aging (NuAge, Quebec, Canada). Both studies estimated nutritional intakes at baseline, and carried out repeated measures of global cognitive function for 1,388 and 1,439 individuals, respectively. Nutrient patterns were determined using principal component analysis methodology in the two samples, and their relation with cognitive function and decline was estimated using linear mixed models. In 3C, a healthy nutrient pattern, characterized by higher intakes of plant-based foods, was associated with a higher global cognitive function at baseline, as opposed to a Western nutrient pattern, which was associated with lower cognitive performance. In NuAge, we also found a healthy nutrient pattern and a Western pattern, although no association was observed with either of these patterns in the Canadian cohort. No association between any of the nutrient patterns and cognitive decline was observed in either cohort. There is a need for longitudinal cohorts focusing on nutrient patterns with substantial follow-up, in order to evaluate more accurately associations between nutrition and cognition in older persons.
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A Mediterranean style dietary pattern (MDP) is considered beneficial for health. The MD Score (MDS) definition has evolved, resulting in considerable variability in the foods and nutrients associated with MDS adherence. We systematically investigated food and nutrient composition of the MD between studies, countries, and methods of classifying the MDS. We searched Embase for MD systematic reviews and selected observational studies reporting intakes of foods, macronutrients, or micronutrients by categories of MDS adherence. The percentage differences in food and nutrient intakes between categories of high and low adherence to the MDS were calculated for each study. A total of 369 full‐text primary papers were reviewed from the included systematic reviews and 74 papers selected (66 adults, 8 children). We found considerable differences in MDS definitions and scoring criteria. Between‐study variation in food intake between high‐ and low‐adherence MDS adherence categories ranged from a mean of −23% for meat, to 119% for fruit, and 278% for fish. Greater variability was evident in non‐Mediterranean than Mediterranean regions. We conclude that few studies report food and nutrient intakes across the range of the MDP in adults and even fewer in children. The considerable variability in the foods and nutrients reported makes comparison of results from studies and translation into dietary guidelines difficult. We recommend that future publications of MD studies include full details of the range of food and nutrient intakes across the distribution of MD adherence in order to facilitate translation into health policy and practice.
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The global population is ageing with many older adults suffering from age-related malnutrition, including micronutrient deficiencies. Adequate nutrient intake is vital to enable older adults to continue living independently and delay their institutionalisation, as well as to prevent deterioration of health status in those living in institutions. This systematic review investigated the insufficiency of trace minerals in older adults living independently and in institutions. We examined 28 studies following a cross-sectional or cohort design, including 7203 older adults (≥60) living independently in 13 Western countries and 2036 living in institutions in seven Western countries. The estimated average requirement (EAR) cut-off point method was used to calculate percentage insufficiency for eight trace minerals using extracted mean and standard deviation values. Zinc deficiency was observed in 31% of community-based women and 49% of men. This was higher for those in institutional care (50% and 66%, respectively). Selenium intakes were similarly compromised with deficiency in 49% women and 37% men in the community and 44% women and 27% men in institutions. We additionally found significant proportions of both populations showing insufficiency for iron, iodine and copper. This paper identifies consistent nutritional insufficiency for selenium, zinc, iodine and copper in older adults.
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The Mediterranean diet is known to be one of the healthiest dietary patterns in the world due to its relation with a low morbidity and mortality for some chronic diseases. The purpose of this study was to review literature regarding the relationship between Mediterranean diet and healthy aging. A MEDLINE search was conducted looking for literature regarding the relationship between Mediterranean diet and cardiovascular disease (or risk factors for cardiovascular disease), cancer, mental health and longevity and quality of life in the elderly population (65 years or older). A selection of 36 articles met the criteria of selection. Twenty of the studies were about Mediterranean diets and cardiovascular disease, 2 about Mediterra- nean diets and cancer, 3 about Mediterranean diets and mental health and 11 about longevity (overall survival) or mental health. The results showed that Mediterranean diets had benefi ts on risks factors for cardiovascular disease such as lipoprotein levels, endothelium vasodilatation, insulin resistance, the prevalence of the metabolic syndrome, antioxidant capacity, the incidence of acute myocardial infarction, and cardiovascular mortality. Some positive associations with quality of life and inverse associations with the risk of certain cancers and with overall mortal- ity were also reported.
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Objective: To systematically review all the prospective cohort studies that have analysed the relation between adherence to a Mediterranean diet, mortality, and incidence of chronic diseases in a primary prevention setting. Design: Meta-analysis of prospective cohort studies. Data sources: English and non-English publications in PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials from 1966 to 30 June 2008. Studies reviewed Studies that analysed prospectively the association between adherence to a Mediterranean diet, mortality, and incidence of diseases; 12 studies, with a total of 1 574,299 subjects followed for a time ranging from three to 18 years were included. Results: The cumulative analysis among eight cohorts (514,816 subjects and 33,576 deaths) evaluating overall mortality in relation to adherence to a Mediterranean diet showed that a two point increase in the adherence score was significantly associated with a reduced risk of mortality (pooled relative risk 0.91, 95% confidence interval 0.89 to 0.94). Likewise, the analyses showed a beneficial role for greater adherence to a Mediterranean diet on cardiovascular mortality (pooled relative risk 0.91, 0.87 to 0.95), incidence of or mortality from cancer (0.94, 0.92 to 0.96), and incidence of Parkinson's disease and Alzheimer's disease (0.87, 0.80 to 0.96). Conclusions: Greater adherence to a Mediterranean diet is associated with a significant improvement in health status, as seen by a significant reduction in overall mortality (9%), mortality from cardiovascular diseases (9%), incidence of or mortality from cancer (6%), and incidence of Parkinson's disease and Alzheimer's disease (13%). These results seem to be clinically relevant for public health, in particular for encouraging a Mediterranean-like dietary pattern for primary prevention of major chronic diseases.
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Context Higher adherence to a Mediterranean-type diet is linked to lower risk for mortality and chronic diseases, but its association with cognitive decline is unclear. Objective To investigate the association of a Mediterranean diet with change in cognitive performance and risk for dementia in elderly French persons. Design, Setting, and Participants Prospective cohort study of 1410 adults (>= 65 years) from Bordeaux, France, included in the Three-City cohort in 20012002 and reexamined at least once over 5 years. Adherence to a Mediterranean diet ( scored as 0 to 9) was computed from a food frequency questionnaire and 24-hour recall. Main Outcome Measures Cognitive performance was assessed on 4 neuropsychological tests: the Mini-Mental State Examination (MMSE), Isaacs Set Test (IST), Benton Visual Retention Test (BVRT), and Free and Cued Selective Reminding Test (FCSRT). Incident cases of dementia (n=99) were validated by an independent expert committee of neurologists. Results Adjusting for age, sex, education, marital status, energy intake, physical activity, depressive symptomatology, taking 5 medications/d or more, apolipoprotein E genotype, cardiovascular risk factors, and stroke, higher Mediterranean diet score was associated with fewer MMSE errors (beta=-0.006; 95% confidence interval [CI], -0.01 to -0.0003; P=.04 for 1 point of the Mediterranean diet score). Performance on the IST, BVRT, or FCSRT over time was not significantly associated with Mediterranean diet adherence. Greater adherence as a categorical variable (score 6-9) was not significantly associated with fewer MMSE errors and better FCSRT scores in the entire cohort, but among individuals who remained free from dementia over 5 years, the association for the highest compared with the lowest group was significant (adjusted for all factors, for MMSE: beta=-0.03; 95% CI, -0.05 to -0.001; P=.04; for FCSRT: beta=0.21; 95% CI, 0.008 to 0.41; P=. 04). Mediterranean diet adherence was not associated with the risk for incident dementia (fully adjusted model: hazard ratio, 1.12; 95% CI, 0.60 to 2.10; P=.72), although power to detect a difference was limited. Conclusions Higher adherence to a Mediterranean diet was associated with slower MMSE cognitive decline but not consistently with other cognitive tests. Higher adherence was not associated with risk for incident dementia. JAMA. 2009; 302(6):638-648
In 15 cohorts of the Seven Countiles Study, compnsing 11,579 men aged 40-59 years and "healthy" at entry, 2,288 died n 15 years. Death rates differed among cohorts. Differences in mean age, blood pressure, serum cholesterol, and smoking habits "explained" 46% of vailance in death rate from all causes, 80% from coronary heart dIsease, 35% from cancer, and 45% from stroke. Death rate differences were unrelated to cohort differences in mean relative body weight, fatness, and physical activity. The cohorts differed in average diets. Death rates were related positively to average percentage of dietary energy from saturated fatty acids, negatively to dietary energy percentage from monounsaturated fatty acids, and were unrelated to dietary energy percentage from polyunsaturated fatty acids, proteins, carbohydrates, and alcohol. All death rates were negatively related to the ratio of monounsaturated to saturated fatty acids. Inclusion of that ratio with age, blood pressure, serum cholesterol, and smoking habits a independent variables accounted for 85% of variance in rates of deaths from all causes, 96% coronary heart disease, 55% cancer, and 66% stroke. Oleic acid accounted for almost all differences in monounsaturates among cohorts. All-cause and coronary heart disease death rates were low In cohorts with olive oil as the main fat Causal relationships are not claimed but consideration of characteri8tlcs of populations as well as of Individuals within populations is urged n evaluating risks.
This chapter provides an overview of nutritional epidemiology for those unfamiliar with the field. The field of nutritional epidemiology developed from an interest in the concept that aspects of diet may influence the occurrence of human disease. Although it is relatively new as a formal area of research, investigators have used basic epidemiologic methods for more than 200 years to identify numerous essential nutrients. The most serious challenge to research in nutritional epidemiology has been the development of practical methods to measure diet. Because epidemiologic studies usually involve at least several hundred and sometimes hundreds of thousands of subjects, dietary assessment methods must be not only reasonably accurate but also relatively inexpensive. Epidemiologic approaches to diet and disease and the interpretation of epidemiologic data are discussed.
Objective: To describe the baseline characteristics of the participants in the Three-City (3C) Study, a study aiming to evaluate the risk of dementia and cognitive impairment attributable to vascular factors. Methods: Between 1999 and 2001, 9,693 persons aged 65 years and over, institutionalized, were recruited from the electoral rolls of three French cities, i.e. Bordeaux, Dijon and Montpellier. Health-related data were collected during face-to-face interviews using standardized questionnaires. The baseline examination included cognitive testing and diagnosis of dementia, and assessment of vascular risk factors, including blood pressure measurements, ultrasound examination of the carotid arteries, and measurement of biological parameters (glycemia, total, high-density lipoprotein and low-density lipoprotein cholesterol, triglycerides, creatinemia); 3,442 magnetic resonance imaging (MRI) examinations were performed in subjects aged 65-79. Measurements of ultrasound, blood, and MRI parameters were centralized. Two follow-up examinations (at 2 and 4 years) were planned. Results: After exclusion of the participants who had subsequently refused the medical interview, the 3C Study sample consisted of 3,649 men (39.3%) and 5,645 women, mean age 74.4 years, with a relatively high level of education and income. Forty-two percent of the participants reported to be followed up for hypertension, about one third for hypercholesterolemia, and 8% for diabetes; 65% had elevated blood pressure measures (systolic blood pressure greater than or equal to 140 or diastolic blood pressure greater than or equal to 90). The proportion of Mini-Mental State Examination scores below 24 was 7% and dementia was diagnosed in 2.2% of the participants. Conclusion: Distribution of baseline characteristics of the 3C Study participants suggests that this study will provide a unique opportunity to estimate the risk of dementia attributable to vascular factors. Copyright (C) 2003 S. Karger AG, Basel.
The apports nutritionnels conseilles (ANC) for the French population are the reference which are used in France to assess the nutritional status of the population. These references have been claborated by a transparent and collective expert process, conferring on them an official reference. The originality of the French method was to add to the classical analysis of each nutrient an analysis concerning both a global approach to specific groups (children, pregnant women, elderly people, sportsment and the links between nutrients and foods, Many original works, which have been specifically performed for this revision, highlight the absolute need for rigorous evaluation of food consumption patterns and for valuable food composition tables.