Средиземноморская диета и достаточность питательных микроэлементов в связи с риском повторного возникновения множественных склерозов: тематическое исследование.

Introduction

Multiple sclerosis (MS) is a chronic autoimmune and neurodegenerative disease that affects the central nervous system, causing symptoms such as fatigue, motor impairment, and cognitive decline. With a global prevalence of approximately 35.9 per 100,000 and impacting around 2.8 million individuals [ 1 ], MS poses significant challenges to patients' quality of life and places considerable economic and social burdens on society [ 2 ]. While genetic factors play a crucial role in MS susceptibility, environmental influences, including diet, have been increasingly recognized as modifiable risk factors that can affect disease onset and progression [ 3 ].

Among various dietary patterns, the Mediterranean Diet (MeDi) has garnered attention for its potential neuroprotective effects. Characterized by high consumption of fruits, vegetables, whole grains, legumes, fish, and olive oil, the MeDi is rich in anti‐inflammatory and antioxidant compounds that may mitigate the inflammatory processes underlying MS [ 4 ]. The Mediterranean Diet Score (MDS) is a tool used to quantify adherence to this dietary pattern, with higher scores linked to reduced risks of chronic diseases, including neurodegenerative disorders [ 5 ]. Furthermore, the MeDi provides essential micronutrients, including vitamin D, vitamin B12, selenium, zinc, magnesium, vitamin C, and vitamin B9, which are crucial for immune function and neuroprotection. The Micronutrient Adequacy Ratio (MAR) assesses the adequacy of these nutrient intakes, and studies have suggested that adequate micronutrient levels may be associated with reduced inflammation and less severe MS outcomes [ 6 , 7 , 8 ].

Recent research has further supported the association between the MeDi and MS. For instance, Felicetti et al. found that higher adherence to the MeDi was associated with lower disability scores in people with MS [ 9 ]. Additionally, a recent study indicated that the MeDi might play a protective role against the development of MS [ 10 ]. These findings underscore the importance of dietary factors in MS management and highlight the need for further investigation into how specific dietary patterns and micronutrient intakes influence MS risk and progression.

This case‐control study aims to examine whether higher MDS and MAR are associated with a reduced risk of MS in newly diagnosed patients compared to healthy controls. By elucidating the relationship between diet, micronutrient adequacy, and MS, this research could provide valuable insights into dietary strategies that may help in the prevention and management of MS.

Materials and Methods

Investigating the associations between adherence to MD and MAR and the risk of MS was the main objective of the present research. All enrolled participants agreed to the inclusion of this research and signed the informed consent form.

Study Design

This case‐control study involves 197 new diagnostic relapsing–remitting MS (RRMS) patients aged 18–65 years old with no changes in their diets in the past 6 months.

The patients were selected from the MS Association Registry in 2015.

A total of 200 potential controls were included to our study based on following inclusion criteria: having no acute medical conditions or neurological diseases, be same in hospitalized center with cases. The exclusion criteria of the control group included intentional dietary modifications, pregnancy, and lactation. Also, the exclusion criteria for both groups were starting adherence to a specific dietary approach within the last 12 months, consuming any dietary supplements, and energy intake of less than 800 or higher than 4200 kcal per day. Matching of the control group with cases was performed based on sex, body mass index (BMI), education levels, and age (in 10‐year groups).

Data Collection

Demographic and Body Composition Assessments

Smoking habits and demographic data were collected by interviewing the participants.

Weight and body composition were assessed using a body impedance analyzer (Tanita BC‐418) for each included individual when they were without shoes and wearing minimal clothes.

In addition, anthropometric measurements were performed according to the CDC anthropometry procedures manual 2007 of the National Health and Nutrition Examination Survey (NHANES). Height measurement was performed for participants in Frankfurt Plane using the stadiometer with an accuracy of 0.5 cm. Furthermore, the midpoint of the iliac crest and the lowest limb were measured twice to obtain the waist circumference.

Dietary Intake Assessments

Usual food intakes were recorded by face‐to‐face personal interview using a semi‐quantitative food frequency questionnaire (FFQ) and were described in our previous study [ 11 ]. Also, this FFQ was valid in Iranian populations, as was reported in Ghazizahedi et al. [ 12 ]. The frequency of each food item intake was converted to daily intake. Also, by using household measures, the serving size of each recorded food was converted to grams. Nutritionist IV software package (First Databank Inc., Hearst Corp.) was used to estimate nutrient intakes from foods.

Mediterranean Diet Score (MDS) Calculation

The MDS was calculated according to the Trichopoulou et al. [ 13 , 14 ]. approach by using nine dietary components. In this method, MDS was calculated based on six positive components, including nuts, ratio of monounsaturated fatty acids (MUFAs) to saturated fatty acids (SFAs), legumes, fruit, vegetable, and fish, and three negative components, including dairy, grains, and meats, including red meat, processed meat, and poultry meat. Participants received one score if they had a higher intake of median for positive components or a lower intake of median for negative components. In addition, if they had a higher dietary intake of negative or had a lower intake of positive components, they received a zero score. Finally, by summing the scores of all components, the MDS was calculated, which ranges from 0 to 9.

Mean Adequacy Ratio Calculation

The Mean Adequacy Ratio (MAR) was calculated to assess the diet quality [ 15 ] by using the Nutrient Adequacy Ratio (NAR) of 7 nutrients, including magnesium, zinc, vitamin B12, vitamin C, selenium, vitamin D, and folate [ 16 , 17 ]. NAR was calculated by dividing the Daily nutrient intake by the Reference intake for each nutrient. To avoid compensating for a nutrient with an NAR exceeding 1 with a nutrient having a lower NAR, the NAR values are truncated at 1. Finally, the average of all‐NAR values was used to calculate MAR based on the following formula: MAR = ΣNAR (each truncated at 1)/number of nutrients [ 18 ].

Statistical Analysis

All analyses were performed using SPSS version 18. Also, p value < 0.05 was interpreted as statistical significance in all conducted analyses. In the present study, categorical and continuous variables were presented as frequency (%), and mean ± standard deviation (SD), respectively. Comparisons between categorical variables between the case and control group, as well as across the MAR and MD tertiles, were performed using the χ 2 test. Also, continuous variables with normal distribution were compared between cases and control groups as well across the MAR and MD tertiles by conducting the independent sample t ‐test and one‐way ANOVA test, respectively. However, comparing continuous variables without normal distribution was performed by the Mann–Whitney U test for comparing case and control, and the Kruskal–Wallis test for comparing the tertiles of MAR and MD with each other. Binary logistic regression was performed to investigate the association between adherence to the MD or MAR and risk of MS by reporting the odds ratio (OR) with 95% confidence interval (CI). In addition, multivariable analysis was conducted to assess these relationships, followed by adjusting for the cofounders, including age, sex, smoking, and energy intake. In all crude and adjusted models, the first tertiles of MAR and MD were considered as reference. Due to the use of secondary data in this study, the power of the analyses for investigating the association between the highest adherence to the MAR and MD and the risk of MS, compared to the first tertile, was calculated using the GPower 3.1 software. In the fully adjusted models with the most covariates, the statistical powers were 100% and 99%, respectively, which are considered acceptable according to the cutoff points proposed by Cohen [ 19 ].

Results

Table 1 summarizes the characteristics of the participants in the case and control groups. Compared to the control groups, FM and the prevalence of smoking were significantly higher in cases. However, FFM was significantly higher in control groups than in individuals with MS. No significant differences were observed in other variables between these groups, including age, gender, BMI, and WC. Also, as shown in Table 2 , there were no significant differences in total energy intake as well as macronutrient consumption, including carbohydrate, fat, protein, and fiber (Figure 1 ).

Associations Between MAR and MS

There was no significant difference in MAR between MS patients and the control group (Table 1 ). In addition, a significant difference was observed in age across the MAR tertiles, while no differences were observed in other variables (Table 3 ). Furthermore, total energy and macronutrient intake were significantly higher in the second or third tertile of MAR in comparison to the first (Supporting Information S1: Table S1 ). As was shown in Table 3 , in the crude model, no significant association was detected between MAR and MS, while multivariate analysis revealed that higher MAR was significantly associated with lower odds of MS ( p trend = 0.002). In addition, the second tertile of MAR and the third tertile of MAR were significantly associated with 50% and 75% lower odds of MS, respectively (Table 4 ).

Associations Between MD and MS

No significant difference in MD was observed between individuals with MS and the control group (Table 1 ). A significant difference was detected in the prevalence of genders across the tertiles of MD. Also, height was significantly higher in the highest tertile of MD than lowest. However, no significant difference was detected in other variables between MD tertiles (Table 3 ). In addition, energy intake as well as each macronutrient consumption were significantly higher in the highest tertile of MD tertiles compared to the first (Supporting Information S1: Table S2 ). Binary logistic showed that adherence to the MD as the second tertile, in contrast to the third, was significantly associated with 44% lower odds of MS. Furthermore, multivariable analysis revealed that adherence to higher MD was significantly associated with lower odds of MS. In addition, it was shown that adherence to the MD as second and third tertiles was significantly related to the 45% and 47% lower odds of MS, respectively (Table 5 , Figure 2 ).

Discussion

The present case‐control study provides compelling evidence that higher adherence to the MeDi, as measured by the MDS, and better micronutrient adequacy, as assessed by the MAR, are associated with a reduced risk of MS. Specifically, individuals in the highest tertiles of MDS and MAR exhibited 47% and 75% lower odds of having MS, respectively, after adjusting for potential confounders such as age, sex, smoking status, and energy intake. These findings underscore the potential of diet as a modifiable risk factor in MS prevention, offering valuable insights for public health strategies.

Our results are consistent with prior research highlighting the beneficial effects of the MeDi on MS outcomes. For instance, a pilot randomized controlled trial, complemented by two cross‐sectional studies, indicated that greater adherence to the MeDi was associated with diminished disease severity, reduced disability, and lower levels of fatigue and depression among individuals with MS [ 20 , 21 , 22 ]. Similarly, a study on pediatric‐onset MS found that higher MDS and increased intake of specific nutrients were linked to a lower probability of developing the disease [ 23 ]. A recent prospective study suggested that dietary patterns resembling the MeDi may play a protective role against MS development [ 10 ]. These consistent findings across different study designs strengthen the evidence base for the role of diet in MS, emphasizing the need for dietary interventions as part of MS management.

The biological plausibility of these associations can be attributed to the anti‐inflammatory and antioxidant properties of the Mediterranean diet. Its high content of fruits, vegetables, and olive oil provides vitamins C, A, E, folate, and polyphenols, which combat oxidative stress and inflammation, protecting neural tissues and supporting immune function, with studies linking higher intakes to reduced MS progression [ 24 , 25 , 26 , 27 ]. Whole grains, legumes, and nuts supply dietary fiber, magnesium, zinc, and B vitamins (niacin, riboflavin, thiamin), promoting a healthy gut microbiome that modulates immune responses and reduces neuroinflammation, with fiber intake associated with lower MS odds [ 28 , 29 , 30 , 31 ]. Omega‐3 fatty acids from fish reduce pro‐inflammatory cytokines (e.g., TNF‐α, IL‐6) and enhance anti‐inflammatory mediators, while olive oil's monounsaturated fats and polyphenols further mitigate inflammation [ 32 , 33 , 34 , 35 ]. Additionally, the diet's low consumption of ultra‐processed foods, saturated fats, and sodium minimizes gut dysbiosis and immune dysregulation, potentially delaying MS onset [ 36 ]. Collectively, these components ensure comprehensive micronutrient adequacy, supporting the protective role of the MeDi in MS, as evidenced by the associations between MAR nutrients and reduced disease risk [ 37 ].

Notably, this study is innovative in simultaneously evaluating both MDS and MAR, addressing a gap in the literature where dietary patterns and nutrient adequacy are often examined in isolation. By integrating these metrics, our findings highlight the synergistic effects of overall dietary quality and specific nutrient intake on MS risk. However, several limitations must be acknowledged. As a case‐control study, our design is susceptible to recall bias, particularly in the assessment of dietary intake, which relied on self‐reported data. While we adjusted for key confounders, residual confounding cannot be entirely ruled out. Furthermore, the study was conducted in Iran, where cultural dietary practices may differ from other regions, potentially limiting the generalizability of our findings. For example, while the Iranian diet shares similarities with the MeDi in terms of vegetable and legume consumption, it may differ in fish and olive oil intake, which are central to the traditional Mediterranean pattern [ 38 , 39 ]. Future research should aim to replicate these results in diverse populations to confirm the universality of the observed associations. Additionally, the cross‐sectional nature of our study precludes the establishment of causality. Longitudinal studies are essential to determine whether adherence to the MeDi and adequate micronutrient intake precede MS onset. Intervention trials could further elucidate the potential of dietary modifications as a preventive strategy for MS, particularly in high‐risk populations. Such studies could also explore the impact of region‐specific dietary adaptations on MS risk, ensuring that recommendations are culturally relevant and feasible [ 40 , 41 ].

Conclusion

In conclusion, our findings suggest that higher MDS and MAR are associated with a reduced risk of MS, providing further support for the role of diet in MS prevention. Public health initiatives should consider promoting Mediterranean dietary patterns and ensuring adequate micronutrient intake, particularly in populations at higher risk for MS. Integrating dietary counseling into MS care, tailored to optimize micronutrient adequacy, could complement existing treatment strategies. Future research should focus on longitudinal and interventional studies to establish causality and to explore the mechanisms underlying these associations, paving the way for evidence‐based dietary guidelines in MS prevention and management.

Author Contributions

Maryam Ahmadi‐Khorram: conceptualization, data curation, investigation, project administration, supervision, writing – review and editing, writing – original draft, visualization. Alireza Hatami: conceptualization, data curation, investigation, project administration, supervision, writing – original draft, writing – review and editing. Mostafa Shahraki Jazinaki: writing – original draft, writing – review and editing. Yasaman Aali: writing – original draft, writing – review and editing, software, formal analysis. Maedeh Nojoumi: writing – review and editing. Fatemeh Keykhaei: writing – review and editing, writing – original draft, data curation, investigation. Ali Jafarzadeh Esfehani: writing – original draft, writing – review and editing, methodology. Mohsen Nematy: writing – review and editing, supervision, funding acquisition, resources, validation.

Ethics Statement

The research received approval from the Research Committee of the Mashhad University of Medical Sciences, Iran. The study adheres to the principles outlined in the Declaration of Helsinki. All participants provided written informed consent before participating in this study. Moreover, it was approved by the Ethics Committee of the Research Vice‐Chancellor at Mashhad University of Medical Sciences (IR.MUMS.REC.1393.182), and all personal information about participants will be kept secure in a database.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The corresponding author, Dr. Mohsen Nematy, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Supporting information

Supporting File

Acknowledgments

The authors would like to express their thanks to the patients enrolled in this study. This study was financially supported by a grant from Mashhad University of Medical Sciences (MUMS), Mashhad, Iran. (award/grant numbers: 930169).

Ahmadi‐Khorram M., Hatami A., Shahraki Jazinaki M., et al., “Mediterranean Diet and Micronutrient Adequacy in Relation to Relapsing‐Remitting Multiple Sclerosis Risk: A Case‐Control Study,” Health Science Reports 9 (2026): e73139. 10.1002/hsr2.73139.

Maryam Ahmadi‐Khorram and Alireza Hatami share first authorship.

Contributor Information

Alireza Hatami, Email: Hatami@nutr.mui.ac.ir, Email: hatami.alireza031@gmail.com.

Mohsen Nematy, Email: NematyM@mums.ac.ir.

Data Availability Statement

Data described in the manuscript, will be made available upon written request to the corresponding author.

References

1. Walton C., King R., Rechtman L., et al., “Rising Prevalence of Multiple Sclerosis Worldwide: Insights From the Atlas of MS,” Multiple Sclerosis Journal 26, no. 14 (2020): 1816–1821.

2. World Health Organization , 2023. Multiple Sclerosis Fact Sheet, “MSFS.”

3. Ascherio A. and Munger K. L., “Environmental Risk Factors for Multiple Sclerosis. Part I: The Role of Infection,” Annals of Neurology 61, no. 4 (2007): 288–299.

4. Davis C., Bryan J., Hodgson J., and Murphy K., “Definition of the Mediterranean Diet; A Literature Review,” Nutrients 7, no. 11 (2015): 9139–9153.

5. Panagiotakos D. B., Pitsavos C., Arvaniti F., and Stefanadis C., “Adherence to the Mediterranean Food Pattern Predicts the Prevalence of Hypertension, Hypercholesterolemia, Diabetes and Obesity, Among Healthy Adults; the Accuracy of the Meddietscore,” Preventive Medicine 44, no. 4 (2007): 335–340.

6. Castro‐Quezada I., Román‐Viñas B., and Serra‐Majem L., “Nutritional Adequacy of the Mediterranean Diet,” in The Mediterranean Diet (Elsevier, 2020), 119–128.

7. Fitzgerald K. C., Tyry T., Salter A., et al., “Diet Quality Is Associated With Disability and Symptom Severity in Multiple Sclerosis,” Neurology 90, no. 1 (2018): e1–e11.

8. Hatami A., Ahmadi‐khorram M., Keykhaei F., Esfehani A. J., and Nematy M., “Association Between the Risk of Multiple Sclerosis and Dietary Proinflammatory/Anti‐Inflammatory Food Intake and Dietary Diversity: A Case‐Control Study,” Clinical Nutrition Research 13, no. 1 (2024): 61–73.

9. Felicetti F., Tommasin S., Petracca M., et al., “Eating Hubs in Multiple Sclerosis: Exploring the Relationship Between Mediterranean Diet and Disability Status in Italy,” Frontiers in Nutrition 9 (2022): 882426.

10. Barbero Mazzucca C., Scotti L., Comi C., Vecchio D., Chiocchetti A., and Cappellano G., “The Role of Diet in Multiple Sclerosis Onset: A Prospective Study Using UK Biobank,” Nutrients 16, no. 11 (2024): 1746.

11. Hatami A., Ahmadi‐Khorram M., Keykhaei F., et al., “Dietary Acid Load as Well as Dietary Phytochemical Index, and Association With Multiple Sclerosis: Results From a Case‐Control Study,” BMC Nutrition 10, no. 1 (2024): 93.

12. Ghazizahedi S., Nouri M., and Norouzy A., et al., “Scientific: Validity and Reproducibility of Iranian Food Frequency Questionnaire,” Nutrition And Food Sciences Research 1, no. 1 (2014): 16.

13. Trichopoulou A., “Mediterranean Diet, Traditional Foods, and Health: Evidence From the Greek EPIC Cohort,” Food and Nutrition Bulletin 28, no. 2 (2007): 236–240.

14. Trichopoulou A., “Mediterranean Diet: The Past and the Present,” Nutrition, Metabolism, and Cardiovascular Diseases: NMCD 11, no. S4 (2001): S1–S4.

15. Project I , “Data4Diets: Building Blocks for Diet‐Related Food Security Analysis,” USAID Advancing Nutrition, 2018.

16. Akter R., Yagi N., Sugino H., et al., “Household Engagement in Both Aquaculture and Horticulture Is Associated With Higher Diet Quality Than Either Alone,” Nutrients 12, no. 9 (2020): 2705.

17. Hatløy A., Torheim L., and Oshaug A., “Food Variety—A Good Indicator of Nutritional Adequacy of the Diet? A Case Study From An Urban Area in Mali, West Africa,” European Journal of Clinical Nutrition 52, no. 12 (1998): 891–898.

18. Akter R., Sugino H., Akhter N., Brown C. L., Thilsted S. H., and Yagi N., “Micronutrient Adequacy in the Diet of Reproductive‐Aged Adolescent Girls and Adult Women in Rural Bangladesh,” Nutrients 13, no. 2 (2021): 337.

19. Cohen J., “A Power Primer,” Psychological Bulletin 112, no. 1 (1992): 155–159.

20. Esposito S., Sparaco M., Maniscalco G. T., et al., “Lifestyle and Mediterranean Diet Adherence in a Cohort of Southern Italian Patients With Multiple Sclerosis,” Multiple Sclerosis and Related Disorders 47 (2021): 102636.

21. Katz Sand I., Levy S., Fitzgerald K., Sorets T., and Sumowski J. F., “Mediterranean Diet Is Linked to Less Objective Disability in Multiple Sclerosis,” Multiple Sclerosis Journal 29, no. 2 (2023): 248–260.

22. Sand I. K., Benn E. K., Fabian M., et al., “Randomized‐Controlled Trial of a Modified Mediterranean Dietary Program for Multiple Sclerosis: A Pilot Study,” Multiple Sclerosis and Related Disorders 36 (2019): 101403.

23. Mirza A. I., Zhu F., Knox N., et al., “Mediterranean Diet and Associations With the Gut Microbiota and Pediatric‐Onset Multiple Sclerosis Using Trivariate Analysis,” Communications Medicine 4, no. 1 (2024): 148.

24. Holt E. M., Steffen L. M., Moran A., et al., “Fruit and Vegetable Consumption and Its Relation to Markers of Inflammation and Oxidative Stress in Adolescents,” Journal of the American Dietetic Association 109, no. 3 (2009): 414–421.

25. Nanri A., Moore M. A., and Kono S., “Impact of C‐Reactive Protein on Disease Risk and Its Relation to Dietary Factors,” Asian Pacific Journal of Cancer Prevention: APJCP 8, no. 2 (2007): 167–177.

26. Graham I. M. and O'Callaghan P., “The Role of Folic Acid in the Prevention of Cardiovascular Disease,” Current Opinion in Lipidology 11, no. 6 (2000): 577–587.

27. Wannamethee S. G., Lowe G. D., Rumley A., Bruckdorfer K. R., and Whincup P. H., “Associations of Vitamin C Status, Fruit and Vegetable Intakes, and Markers of Inflammation and Hemostasis,” American Journal of Clinical Nutrition 83, no. 3 (2006): 567–574.

28. Alahmari L. A., “Dietary Fiber Influence on Overall Health, With an Emphasis on CVD, Diabetes, Obesity, Colon Cancer, and Inflammation,” Frontiers in Nutrition 11 (2024): 1510564.

29. La Torre D., Verbeke K., and Dalile B., “Dietary Fibre and the Gut‐Brain Axis: Microbiota‐Dependent and Independent Mechanisms of Action,” Gut Microbiome 2 (2021): e3.

30. Hossain K. S., Amarasena S., and Mayengbam S., “B Vitamins and Their Roles in Gut Health,” Microorganisms 10, no. 6 (2022): 1168.

31. Kennedy D., “B Vitamins and the Brain: Mechanisms, Dose and Efficacy—A Review,” Nutrients 8, no. 2 (2016): 68.

32. Ebrahimi Y., AL‐Baghdady H. F. A., Hameed N. M., et al., “Common Fatty Acids and Polyphenols in Olive Oil and Its Benefits to Heart and Human Health,” Caspian Journal of Environmental Sciences (2022): 1–7, 10.22124/cjes.2022.5976.

33. Caramia G., Gori A., Valli E., and Cerretani L., “Virgin Olive Oil in Preventive Medicine: From Legend to Epigenetics,” European Journal of Lipid Science and Technology 114, no. 4 (2012): 375–388.

34. Tagliamonte S., De Luca L., Donato A., et al., “A ‘Mediterranean Ice‐Cream’: Sensory and Nutritional Aspects of Replacing Milk Cream With Extra Virgin Olive Oil,” Journal of Functional Foods 102 (2023): 105470.

35. Calder P. C., “Omega‐3 Fatty Acids and Inflammatory Processes,” Nutrients 2, no. 3 (2010): 355–374.

36. Stoiloudis P., Kesidou E., Bakirtzis C., et al., “The Role of Diet and Interventions on Multiple Sclerosis: A Review,” Nutrients 14, no. 6 (2022): 1150.

37. Armon‐Omer A., Waldman C., Simaan N., Neuman H., Tamir S., and Shahien R., “New Insights on the Nutrition Status and Antioxidant Capacity in Multiple Sclerosis Patients,” Nutrients 11, no. 2 (2019): 427.

38. Bohlouli J., Namjoo I., Borzoo‐Isfahani M., et al., “Modified Mediterranean Diet vs. Traditional Iranian Diet: Efficacy of Dietary Interventions on Dietary Inflammatory Index Score, Fatigue Severity and Disability in Multiple Sclerosis Patients,” British Journal of Nutrition 128, no. 7 (2022): 1274–1284.

39. Sobhani S. R., Omidvar N., Abdollahi Z., and Al Jawaldeh A., “Shifting to a Sustainable Dietary Pattern in Iranian Population: Current Evidence and Future Directions,” Frontiers in Nutrition 8 (2021): 789692.

40. Carriquiry A. L., “Assessing the Prevalence of Nutrient Inadequacy,” Public Health Nutrition 2, no. 1 (1999): 23–34.

41. Bemelmans W. J., Broer J., de Vries J. H., Hulshof K. F., May J. F., and Jong B. M., “Impact of Mediterranean Diet Education Versus Posted Leaflet on Dietary Habits and Serum Cholesterol in a High Risk Population for Cardiovascular Disease,” Public Health Nutrition 3, no. 3 (2000): 273–283.

Associated Data

Supplementary Materials

Supporting File

Data Availability Statement

Data described in the manuscript, will be made available upon written request to the corresponding author.