Dietary inflammatory index or Mediterranean diet score as risk factors for total and cardiovascular mortality

Background and Aims

Dietary patterns are associated with risk of cardiovascular disease (CVD). We aimed to examine associations of the Dietary Inflammatory Index (DII) and the Mediterranean Diet Score (MDS) with total, cardiovascular disease (CVD) and coronary heart disease (CHD) mortality in the Melbourne Collaborative Cohort Study; and compare the strengths of the associations.

Protective role of the Mediterranean diet on several cardiovascular risk factors: Evidence from Sicily,southern Italy

Background and aimsEpidemiological studies conducted in European countries demonstrated that the adoption of a Mediterranean diet protect against clustered risk factors but those evaluating such benefits specifically in southern Italy are scarce. Thus, the aim of this study was to assess the association between the adherence to the Mediterranean diet and cardiovascular risk factors obesity, diabetes, and hypertension.Methods and resultsA cross-sectional population-based survey including 3090 subjects was conducted in Sicily, southern Italy. Food intake was evaluated through a validated food frequency questionnaire and adherence to the dietary pattern was assessed using the MedDietScore. Linear and logistic regression models were performed to estimate odds ratios (ORs) and respective confidence intervals (CIs). After adjusting for confounding factors such as age and gender, participants in the highest tertile of the MedDietScore were less likely to be obese (OR 0.35, 95% CI: 0.24–0.51), hypertensive (OR 0.73, 95% CI: 0.55–0.97), and diabetic (OR 0.43, 95% CI: 0.24–0.77). Linear inverse relation between the MedDietScore and BMI (r² = 0.34, P < 0.001), waist circumference (r² = 0.17, P < 0.001), and waist-to-hip ratio (r² = 0.06, P < 0.001) was found.ConclusionDespite the prevalence rates of nutrition-related diseases are high in Sicily, greater adherence to the Mediterranean dietary pattern is still associated with a better health status.     

Effect of the Mediterranean diet with and without weight loss on cardiovascular risk factors in men with the metabolic syndrome

Background and aims

No study has yet examined how weight loss modifies the impact of the Mediterranean diet (MedDiet) on cardiovascular risk factors in men with the metabolic syndrome (MetS). The objective of the study was to assess the efficacy of MedDiet, with and without weight loss, to modify the cardiometabolic risk profile of male patients with MetS.

Methods and results

Twenty-six men aged between 24 and 62 years with the MetS consumed a North American control diet for 5 weeks followed by a 5-week MedDiet, both under weight-maintaining conditions. Participants then underwent a 20-week weight loss period, after which they consumed the MedDiet for five weeks under weight stable conditions. Body weight was reduced by 10.2% ± 2.9% after the weight loss period (p < 0.001). All foods were provided to participants during the weight stable phases of the study. The MedDiet in the absence of weight loss decreased total plasma cholesterol (C) (−7.1%), LDL-C (−9.3%) and the total/HDL-C ratio (−6.5%) compared to the control diet (all p < 0.04). The MedDiet combined with weight loss led to reductions in systolic blood pressure (−4.7%), diastolic blood pressure (−7.7%), triglycerides (−18.2%), ApoB (−10.7%), fasting glucose (−4.2%) and insulin (−29.9%) compared to the control diet (all p < 0.001). Conclusion: The MedDiet in the absence of weight loss leads to significant changes in plasma cholesterol concentrations but has little effects on other cardiometabolic risk factors associated with the MetS in men.     

Melatonin in traditional Mediterranean diets

Abstract: Compared with other industrialized countries, the lower incidence of chronic‐degenerative disorders in Mediterranean populations has been emphasized in recent decades. The health‐promoting effects arising from Mediterranean dietary habits have been attributed to the large intake of plant foodstuffs rich in bioactive phytochemicals, such as melatonin. Recently, it has been suggested that melatonin present in edible plants may improve human health, by virtue of its biological activities and its good bioavailability. Plant melatonin, besides contributing to optimize the physiological functions regulated, in humans, by endogenous melatonin, may be involved in nutritional therapy to reduce the risk of cancer, cardiovascular and neurodegenerative diseases in western populations. In this view, the presence of melatonin in some Mediterranean foods and beverages adds a new element to the hypothesis of health benefits associated to Mediterranean dietary patterns, although the available data are still preliminary and incomplete.     

Effects of common weight loss plans on diabetes mellitus and cardiovascular risk factors

Diabetes mellitus is globally considered one of the most common chronic diseases, management of which is critically asscociated with an adequate dietary approach. With overweight and obesity being a global epidemic, choosing the appropriate weight loss plan for patients with diabetes seems to be of particular concern for healthcare professionals. Since diabetes and cardiovascular diseases frequently coexist, modern pharmacological therapeutic models aim at addressing both. Therapeutic targets in diabetic population that address glycemic control, adequate lipid and blood pressure control proves to limit the incidence of cardiovascular events, reduce the risk of chronic complications and improve patients quality of life. Similarly, dietary managment in this population should also concentrate on the reduction of reversible cardiovascular risk factors. Nutritional recommendations for diabetic patients should be individualized to meet their expectations and lifestyle in order to ensure compliance and long-term effects. As diabetic population is more vulnerable to further health risks associated with diet induced metabolic changes, inadequate intake of dietary components and increased cardiovascular risk, nutrition plans should be addressed more carefully in this group.     

Effects of a dietary intervention with Mediterranean vs lacto-ovo vegetarian diets on HDL function: Results from the CARDIVEG study

Background and aimHDL-cholesterol efflux capacity (CEC) has been shown to be a better cardiovascular (CVD) risk marker than serum HDL concentration. Several foods and nutrients have been shown to improve HDL functions, however no effective dietetic nor pharmacological strategy is available to increase CEC. This study aims to evaluate the possible effect of Mediterranean diet (MD) and lacto-ovo-vegetarian diet (VD) on HDL function in a group of clinically healthy subjects at low-to-moderate CVD risk.Methods and resultsThirty apparently healthy subjects with a low-to-moderate cardiovascular risk profile (21 F; mean age: 51.3 ± 9.7 years) were randomly assigned to a 3-month MD or VD diet and then crossed.Participants on VD showed a reduction in total HDL CEC by 8.99% (p < 0.001) as well as a reduction in ABCA1 mediated-CEC by 18.62% (p < 0.001) compared to participants on MD. Regarding CEC mediated by aqueous diffusion, no significant changes were observed after treatment with either diet. Finally, a significant positive association between CEC mediated by the ABCA1 transporter and adiponectin was found (r = 0.462; p = 0.010).ConclusionThe results of this study suggest that HDL activity in promoting cholesterol efflux and thereby reducing the concentration of pro-atherogenic lipoproteins was more effective in participants undergoing MD than VD. Based on these findings, the MD could be considered a better therapeutic strategy for cardiovascular prevention than VD.Clinical Trial registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02641834.     

Effect of a plant stanol ester-containing spread, placebo spread, or Mediterranean diet on estimated cardiovascular risk and lipid, inflammatory and haemostatic factors

Background and aims

Mediterranean diet is associated with a reduced risk for cardiovascular disease (CVD). Use of plant stanols decreases low density lipoprotein cholesterol (LDL-C) concentrations. We compared the effects of the Mediterranean diet and plant stanol esters on vascular risk factors and estimated CVD (eCVD) risk.

Methods and results

In this prospective, randomized, placebo-controlled study, 150 mildly hypercholesterolaemic subjects were randomized to Mediterranean diet, a spread containing plant stanol esters (2 g/day) or a placebo spread. Vascular risk factors were assessed every month for 4 months and the eCVD risk was calculated using the PROspective- Cardiovascular-Munster (PROCAM), Framingham, and Reynolds risk engines. Placebo had no significant effect on risk factors or eCVD risk. Mediterranean diet gradually induced a significant reduction in total cholesterol (TC), LDL-C, triglycerides, high sensitivity C-reactive protein (hsCRP), blood pressure and eCVD risk (24-32%). The plant stanol ester spread reduced (by 1 month) TC (−14%), LDL-C (−16%), hsCRP (−17%), and estimated CVD risk (26-30%). eCVD risk reduction was sustained at 4th months when the gradual Mediterranean diet eCVD risk reduction became comparable to that of the stanol group.

Conclusions

Plant stanol esters yielded an early, by 1st treatment month, reduction of eCVD risk that resulted from a TC, LDL-C, and hsCRP decrease. eCVD risk reduction on the Mediterranean diet resulted from a change in several CVD risk factors and equaled that of plant stanol at 4 months. The consumption of plant stanol esters by moderately hypercholesterolaemic patients may be a useful option to reduce CVD risk in those who do not adopt a Mediterranean diet.     

Tissue factor expression is decreased in monocytes obtained from blood during Mediterranean or high carbohydrate diets

BACKGROUND: Mediterranean and high carbohydrate diets play a dominant role in the prevention of atherosclerosis as a result of their lipid lowering effect. However, diets can also have a protective effect in other ways, such as modulating tissue factor expression in circulating monocytes. METHODS AND RESULTS: Forty-one subjects participated in this randomised crossover study consisting of three dietary periods: a saturated fat enriched diet (SFA), a low fat and high carbohydrate diet (CHO), and a Mediterranean diet. Plasma levels of total cholesterol, triglycerides, low density lipoprotein (LDL-C) and high density lipoprotein (HDL-C) were determined at the end of each dietary period, as was the expression of tissue factor (TF) in circulating monocytes isolated from blood samples. Total cholesterol, LDL-C, HDL-C and TF expression were lower after the Mediterranean and high carbohydrate diets than after the SFA diet, and there was a positive correlation between LDL-C levels and monocyte TF expression. CONCLUSIONS: High carbohydrate and Mediterranean diets reduce the expression of TF in circulating monocytes.     

Mediterranean diet and the incidence of cardiovascular disease: A Spanish cohort

Background and aim

The Mediterranean diet is considered a model for healthy eating. However, prospective evidence in Mediterranean countries evaluating the relationship between this dietary pattern and non-fatal cardiovascular events is scarce. The aim of the present study was to evaluate the association between the adherence to the Mediterranean diet and the incidence of fatal and non-fatal cardiovascular events among initially healthy middle-aged adults from the Mediterranean area.

Methods and results

We followed-up 13,609 participants (60 percent women, mean age: 38 years) initially free of cardiovascular disease (CVD) during 4.9 years. Participants were part of a prospective cohort study of university graduates from all regions of Spain. Baseline diet was assessed using a validated 136-item food-frequency questionnaire. A 9-point score was used to appraise adherence to the Mediterranean diet. Incident clinical events were confirmed by a review of medical records. We observed 100 incident cases of CVD. In multivariate analyses, participants with the highest adherence to the Mediterranean diet (score > 6) exhibited a lower cardiovascular risk (hazard ratio = 0.41, 95% confidence interval [CI]: 0.18-0.95) compared to those with the lowest score (<3). For each 2-point increment in the score, the adjusted hazard ratios were 0.80 (95% CI: 0.62-1.02) for total CVD and 0.74 (0.55-0.99) for coronary heart disease.

Conclusions

There is an inverse association between adherence to the Mediterranean diet and the incidence of fatal and non-fatal CVD in initially healthy middle-aged adults.     

A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1‐year prospective randomized intervention study

Background: The appropriate dietary intervention for overweight persons with type 2 diabetes mellitus (DM2) is unclear. Trials comparing the effectiveness of diets are frequently limited by short follow‐up times and high dropout rates. Aim: The effects of a low carbohydrate Mediterranean (LCM), a traditional Mediterranean (TM), and the 2003 American Diabetic Association (ADA) diet were compared, on health parameters during a 12‐month period. Methods: In this 12‐month trial, 259 overweight diabetic patients (mean age 55 years, mean body mass index 31.4 kg/m²) were randomly assigned to one of the three diets. The primary end‐points were reduction of fasting plasma glucose, HbA1c and triglyceride (TG) levels. Results: 194 patients out of 259 (74.9%) completed follow‐up. After 12 months, the mean weight loss for all patients was 8.3 kg: 7.7 kg for ADA, 7.4 kg for TM and 10.1 kg for LCM diets. The reduction in HbA1c was significantly greater in the LCM diet than in the ADA diet (?2.0 and ?1.6%, respectively, p < 0.022). HDL cholesterol increased (0.1 mmol/l ± 0.02) only on the LCM (p < 0.002). The reduction in serum TG was greater in the LCM (?1.3 mmol/l) and TM (?1.5 mmol/l) than in the ADA (?0.7 mmol/l), p = 0.001. Conclusions: An intensive 12‐month dietary intervention in a community‐based setting was effective in improving most modifiable cardiovascular risk factors in all the dietary groups. Only the LCM improved HDL levels and was superior to both the ADA and TM in improving glycaemic control.     

The Mediterranean and CHO diets decrease VCAM-1 and E-selectin expression induced by modified low-density lipoprotein in HUVECs

Background and AimThe oxidative modifications of low-density lipoprotein (LDL) are crucial for the atherosclerosis process. The aim of this study was to determine if the minimally modified LDL, obtained after the ingestion of three different diets, produce differential effects on the vascular cell adhesion molecule-1 (VCAM-1) and E-selectin expression in human umbilical endothelial cells (HUVECs).Methods and ResultsTwenty healthy young males were exposed to three dietary periods. Each period lasted four weeks. During the first period, all subjects consumed a saturated fat (SFA) enriched diet (38% fat, 20% SFA). The second and third dietary periods were administered following a randomized crossover design: a low fat high carbohydrates diet (CHO diet) and a Mediterranean diet. LDL particles, isolated during each dietary period, were oxidized by exposure to UV light and incubated for 48 h with HUVEC. Thereafter, 100 U/mL of TNF-α was added and incubation continued for 6 h. Cellular ELISA determined adhesion molecules expression. Lag time, propagation rate and total amounts of formed conjugated dienes were calculated in LDL incubated with 10 μmol/L Cu²⁺. When compared to the SFA diet, LDL isolated from the Mediterranean and CHO diets induced a lower expression of VCAM-1 and E-selectin in HUVECS (P < 0.007). There were no differences between both lipid lowering diets. However, lag time of LDL from the Mediterranean diet was higher than with the CHO diet (P < 0.042). This parameter was inversely correlated with E-selectin expression (r = − 0.497; P < 0.04).ConclusionOur results suggest that both the Mediterranean and CHO diets may decrease the pro-inflammatory environment induced by modified LDL in endothelial cells.     

The effect of high-, moderate-, and low-fat diets on weight loss and cardiovascular disease risk factors

Over 60% of Americans are overweight and a number of popular diets have been advocated, often without evidence, to alleviate this public health hazard. This study was designed to investigate the effects of several diets on weight loss, serum lipids, and other cardiovascular disease risk factors. One hundred men and women followed one of four dietary programs for 1 year: a moderate-fat (MF) program without calorie restriction (28 patients); a low-fat (LF) diet (phase I) (16) ; a MF, calorie-controlled (phase II) diet (38 patients); and a high-fat (HF) diet (18 subjects) [corrected]. Weight, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), homocysteine (Ho), and lipoprotein(a) [Lp(a)], were measured every 4th month. The TC/HDL-C ratio was calculated and fibrinogen levels were measured at baseline and after one year. The MF diet resulted in a 2.6% (NS) decrease in weight compared with 18.4% (p=0.045) decrease in patients on phase I, 12.6% (p=0.0085) decrease in patients on phase II, and 13.7% (p=0.025) decrease in those on the HF diet. TC was reduced by 5% (NS) in the MF group, 39.1% (p=0.0005) in the phase I group, and 30.4% (p=0.0001) in the phase II group. HF group had a 4.3% (NS) increase in TC. LDL-C was reduced by 6.1% (NS) on MF, 52.0% (p=0.0001) on phase I, and 38.8% (p=0.0001) on phase II. Patients on HF had a 6.0% (NS) increase in LDL-C. There were nonsignificant reductions in HDL-C in those on MF (-1.5%) and HF (-5.8%). Patients on phase I showed an increase in HDL-C of 9.0% (NS), while those on phase II diet had a 3.6% increase (NS) in HDL-C. TC/HDL-C increased (9.8%) only in patients following the high-fat diets (NS). Patients on MF had a 5.3% (NS) reduction in TC/HDL-C, while those on LF had significant reductions on the phase I ( -45.8%; p=0.0001) diet and phase II diet (-34.7%; p=0.0001). TG levels increased on both the MF (1.0%) and HF (5.5%) diets, although neither was statistically significant. People following the phase I and II diets showed reductions of 37.3% and 36.9%, respectively. Ho levels increased by 9.7% when people followed the MF diet and by 12.4% when they followed the HF diet. Patients following the phase I and phase II diets showed reductions of 13.6% and 14.6%, respectively. Only those following phase II diets showed a tendency toward significant improvement (p=0.061). Lp(a) levels increased by 4.7% following the MF (NS) diet and by 31.0% (NS) on the HF diet. Patients following phase I showed a 7.4% (NS) reduction and a 10.8% reduction (NS) following phase II. Fibrinogen levels increased only in individuals following HF diets (11.9%), while patients following MF (-0.6%), phase I (-11.0%), and phase II (-6.3%) diets showed nonsignificant reductions in fibrinogen. Patients on MF demonstrated nonsignificant reductions in weight, LDL-C, TC, HDL-C, TC/HDL-C ratios, and fibrinogen and nonsignificant increases in TGs, Lp(a), and homocysteine. There was significant weight loss in patients on phase I and II and HF diets after 1 year. Reductions in TC, LDL-C, TGs, and TC/HDL ratios were significant only in patients either following a LF diet or a MF, calorically reduced diet. Only patients following HF diets showed a worsening of each cardiovascular disease risk factor (LDL-C, TG, TC, HDL-C, TC/HDL ratio, Ho, Lp(a), and fibrinogen), despite achieving statistically significant weight loss.     

Adherence to a predominantly Mediterranean diet decreases the risk of gastroesophageal reflux disease: a cross‐sectional study in a South Eastern European population

Our aim was to assess the association of a Mediterranean diet and gastroesophageal reflux disease among adult men and women in Albania, a former communist country in South Eastern Europe with a predominantly Muslim population. A cross‐sectional study was conducted in 2012, which included a population‐based sample of 817 individuals (≥18 years) residing in Tirana, the Albanian capital (333 men; overall mean age: 50.2 ± 18.7 years; overall response rate: 82%). Assessment of gastroesophageal reflux disease was based on Montreal definition. Participants were interviewed about their dietary patterns, which in the analysis was dichotomized into: predominantly Mediterranean (frequent consumption of composite/traditional dishes, fresh fruit and vegetables, olive oil, and fish) versus largely non‐Mediterranean (frequent consumption of red meat, fried food, sweets, and junk/fast food). Logistic regression was used to assess the association of gastroesophageal reflux disease with the dietary patterns. Irrespective of demographic and socioeconomic characteristics and lifestyle factors including eating habits (meal regularity, eating rate, and meal‐to‐sleep interval), employment of a non‐Mediterranean diet was positively related to gastroesophageal reflux disease risk (fully adjusted odds ratio = 2.3, 95% confidence interval = 1.2–4.5). Our findings point to a beneficial effect of a Mediterranean diet in the occurrence of gastroesophageal reflux disease in transitional Albania. Findings from this study should be confirmed and expanded further in prospective studies in Albania and in other Mediterranean countries.     

Critical evaluation of the questionnaires assessing adherence to the Mediterranean diet that are based on servings

Background and aimsThe Mediterranean Diet (MD) is characterized by a high intake of vegetables, fruit, legumes, nuts, and olive oil, and moderate fish, dairy, and wine intake. A high adherence to MD has been associated with numerous health benefits, including reduced risk of chronic diseases such as cardiovascular disease, cancer, and type 2 diabetes. The clinical assessment of MD adherence is complicated by the absence of a univocally accepted tool and by the abundance of questionnaires developed to determine adherence, whose reliability and validity is uncertain. In this inter-associative document, we critically evaluated servings-based questionnaires for the assessment of MD adherence, aiming to identify the most valuable tool for the use in clinical practice.Methods and resultsFor each questionnaire, we analyzed the structure, evidence on health-related outcomes and agreement with the recommendations of MD. We found that most questionnaires do not accurately reflect the principles of MD in terms of the food groups and their optimal consumption frequency. Additionally, the comparison of questionnaires revealed low agreement and some concerns with regard to the scoring assumptions.ConclusionsAmong the available questionnaires, we suggest the use of the 15-Items Pyramid based Mediterranean Diet Score (PyrMDS), which is the one with fewer flaws and a strong supporting body of theoretical and scientific evidence. The use of the PyrMDS may facilitate the assessment of MD adherence in clinical practice, which is instrumental in reducing the risk of non-communicable chronic diseases.     

Adherence to the Mediterranean diet and risk of metabolic syndrome and its components

Background and aimsThe role of diet in the aetiology of metabolic syndrome (MetS) is not well understood. The aim of the present study was to evaluate the relationship between adherence to the Mediterranean diet (MedDiet) and MetS.Methods and resultsA cross-sectional study was conducted with 808 high cardiovascular risk participants of the Reus PREDIMED Centre. MetS was defined by the updated National Cholesterol and Education Program Adult Treatment Panel III criteria.An inverse association between quartiles of adherence to the MedDiet (14-point score) and the prevalence of MetS (P for trend < 0.001) was observed. After adjusting for age, sex, total energy intake, smoking status and physical activity, participants with the highest score of adherence to the MedDiet (≥9 points) had the lowest odds ratio of having MetS (OR [95% CI] of 0.44 [0.27–0.70]) compared to those in the lowest quartile.Participants with the highest MedDiet adherence had 47 and 54% lower odds of having low HDL-c and hypertriglyceridemia MetS criteria, respectively, than those in the lowest quartile. Some components of the MedDiet, such as olive oil, legumes and red wine were associated with lower prevalence of MetS.ConclusionHigher adherence to a Mediterranean diet is associated with a significantly lower odds ratio of having MetS in a population with a high risk of cardiovascular disease.     

Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials

BACKGROUND: Low-carbohydrate diets have become increasingly popular for weight loss. However, evidence from individual trials about benefits and risks of these diets to achieve weight loss and modify cardiovascular risk factors is preliminary. METHODS: We used the Cochrane Collaboration search strategy to identify trials comparing the effects of low-carbohydrate diets without restriction of energy intake vs low-fat diets in individuals with a body mass index (calculated as weight in kilograms divided by the square of height in meters) of at least 25. Included trials had to report changes in body weight in intention-to-treat analysis and to have a follow-up of at least 6 months. Two reviewers independently assessed trial eligibility and quality of randomized controlled trials. RESULTS: Five trials including a total of 447 individuals fulfilled our inclusion criteria. After 6 months, individuals assigned to low-carbohydrate diets had lost more weight than individuals randomized to low-fat diets (weighted mean difference, -3.3 kg; 95% confidence interval [CI], -5.3 to -1.4 kg). This difference was no longer obvious after 12 months (weighted mean difference, -1.0 kg; 95% CI, -3.5 to 1.5 kg). There were no differences in blood pressure. Triglyceride and high-density lipoprotein cholesterol values changed more favorably in individuals assigned to low-carbohydrate diets (after 6 months, for triglycerides, weighted mean difference, -22.1 mg/dL [-0.25 mmol/L]; 95% CI, -38.1 to -5.3 mg/dL [-0.43 to -0.06 mmol/L]; and for high-density lipoprotein cholesterol, weighted mean difference, 4.6 mg/dL [0.12 mmol/L]; 95% CI, 1.5-8.1 mg/dL [0.04-0.21 mmol/L]), but total cholesterol and low-density lipoprotein cholesterol values changed more favorably in individuals assigned to low-fat diets (weighted mean difference in low-density lipoprotein cholesterol after 6 months, 5.4 mg/dL [0.14 mmol/L]; 95% CI, 1.2-10.1 mg/dL [0.03-0.26 mmol/L]). CONCLUSIONS: Low-carbohydrate, non-energy-restricted diets appear to be at least as effective as low-fat, energy-restricted diets in inducing weight loss for up to 1 year. However, potential favorable changes in triglyceride and high-density lipoprotein cholesterol values should be weighed against potential unfavorable changes in low-density lipoprotein cholesterol values when low-carbohydrate diets to induce weight loss are considered.     

Validation of a short questionnaire to record adherence to the Mediterranean diet: An Italian experience

Background and aims

A greater adherence to the Mediterranean diet has been associated with a reduced risk of major chronic diseases and cancer. The aim of the study was to assess the validity of a new short self-administered 15-item questionnaire (QueMD) to measure adherence to the Mediterranean diet in Italy.