{"paper_id":"abe03264-38d0-49d4-97b1-92a95d60d6aa","body_text":"Research\nCopyright© 2025 The Author(s). Published by Galenos Publishing House on behalf of Bakırköy Dr. Sadi Konuk Training and Research Hospital. \nThis is an open access article under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY-NC-ND) International License.\n419\nMed J Bakirkoy 2025;21(4):419-429\nReceived: 17.09.2024\nAccepted: 04.03.2025\nPublication Date: 18.12.2025\nAddress for Correspondence: Assist, Prof, Nihan Çakır Biçer, PhD, Acıbadem Mehmet Ali Aydınlar University \nFaculty of Health Sciences, Department of Nutrition and Dietetics, İstanbul, Türkiye; Kocaeli University Institute of \nGastroenterology and Hepatology, Department of Molecular Gastroenterology and Hepatology, Kocaeli, Türkiye\nE-mail: nihan.bicer@acibadem.edu.tr, nihancakir@gmail.com ORCID ID: orcid.org/0000-0002-7581-9083\nCite as: Deveci T, Çakır Biçer N, Yalçın Bahat P . Evaluation of the effect of dietary habits on the health profile in \nwomen with endometriosis. Med J Bakirkoy. 2025;21(4):419-429\nABSTRACT\nObjective: Healthy eating habits in women with endometriosis play a role in the treatment and improvement of quality of life. This study aimed \nto evaluate the effect of adherence to the Mediterranean diet (MD) and polyphenol intake on health profile in endometriosis. \nMethods: The study was conducted with 34 endometriosis patients admitted to Gynecology and Obstetrics Clinic of University of Helath Sciences \nTürkiye, İstanbul Kanuni Sultan Süleyman Training and Research Hospital. Demographic characteristics and food consumption were recorded, \nthe Healthy Eating Index (HEI)-2015 scores were calculated, and the polyphenol consumption questionnaire, the 14-item MD Adherence Scale \n(MEDAS), and the Endometriosis Health Profile-30 (EHP-30) were applied. \nResults: The mean body mass index of the participants was 22.92±2.94 kg/m2, total polyphenol intake was 657.70±304.56 mg/day, and MEDAS, \nHEI-2015, and EHP-30 scores were 7.85±2.26, 61.71±18.51, and 41.25±20.77, respectively. 26.5% of participants had low; 44.1% had medium; \n29.4% had high adherence to the MD; and 44.1% had low HEI-2015 scores. While no relationship was found between the MEDAS score and EHP-\n30 total and subscale scores, an inverse relationship was found between the HEI-2015 score and EHP-30 pain subscale score (r=-0.34, p=0.04).\nConclusion: Despite the role of nutrition in endometriosis, the adherence of the participants to the MD and their HEI-2015 scores were found to \nbe low. It is predicted that a multidisciplinary treatment approach for endometriosis with the implementation of the MD and the promotion of \nhealthy lifestyle habits will improve symptom management and quality of life.\nKeywords: Endometriosis, Mediterranean diet, polyphenols, health profile\nÖZ\nAmaç: Endometriozisli kadınlarda sağlıklı beslenme alışkanlıklarının hastalığın tedavisinde rol oynayacağı ve yaşam kalitesinin artırılmasına destek \nolacağı bildirilmektedir. Bu çalışmada Akdeniz diyetine uyumun ve polifenol alımının endometriozis sağlık profili üzerine etkisinin değerlendirilmesi \namaçlanmıştır. \nGereç ve Yöntem: Sağlık Bilimleri Üniversitesi, İstanbul Kanuni Sultan Süleyman Eğitim ve Araştırma Hastanesi Kadın Hastalıkları ve Doğum \nPolikliniği’ne başvuran 34 endometriozis hastasının demografik özellikleri ve besin tüketimleri kaydedilmiş, Sağlıklı Yeme İndeksi (HEI)-2015 \npuanları hesaplanmış ve katılımcılara polifenol tüketim sıklığı anketi, 14 maddeli Akdeniz Diyeti Uyum Ölçeği (MEDAS), Endometriozis Sağlık \nProfili Anketi (EHP-30) uygulanmıştır. \nBulgular: Katılımcıların ortalama beden kütle indeksi 22,92±2,94 kg/m2, MEDAS puanı 7,85±2,26, HEI-2015 puanı 61,71±18,51 ve EHP-30 toplam \npuanı 41,25±20,77 ve toplam polifenol alımı 657,70±304,56 mg/gün’dür. %26,5’inin Akdeniz diyetine düşük, %44,1’inin orta, %29,4’ünün yüksek \ndüzeyde uyum gösterdiği, %44,1’inin HEI-2015 puanının düşük olduğu bulunmuştur. MEDAS puanı, EHP-30 toplam ve alt boyut puanları arasında \nilişki saptanmazken, HEI-2015 puanı ile EHP-30 ağrı alt boyut puanı arasında ters yönlü ilişki belirlenmiştir (r=-0,34, p=0,04).\n Tuğçe Deveci1,  Nihan Çakır Biçer2,3,  Pınar Yalçın Bahat4\n1Acıbadem Mehmet Ali Aydınlar University Institute of Health Sciences, Department of Nutrition and Dietetics, İstanbul, Türkiye\n2Acıbadem Mehmet Ali Aydınlar University Faculty of Health Sciences, Department of Nutrition and Dietetics, İstanbul, Türkiye\n3Kocaeli University Institute of Gastroenterology and Hepatology, Department of Molecular Gastroenterology and Hepatology, Kocaeli, Türkiye\n4University of Health Sciences Türkiye, İstanbul Kanuni Sultan Süleyman Training and Research Hospital, Clinic of Obstetrics and Gynecology, \nİstanbul, Türkiye\nEndometriozisli Kadınlarda Beslenme Alışkanlıklarının Sağlık Profili Üzerine \nEtkisinin Değerlendirilmesi\nEvaluation of the Effect of Dietary Habits on the Health \nProfile in Women with Endometriosis\nDOI: 10.4274/BMJ.galenos.2025.2024.9-4\n\nMed J Bakirkoy 2025;21(4):419-429\n420\nINTRODUCTION\nEndometriosis, which usually affects women of reproductive \nage, is defined as a chronic gynecological disease associated \nwith estrogen-dependent infertility and pelvic pain. It \nhas been reported that the prevalence of endometriosis \nvaries according to ethnicity, with black women having a \nhigher prevalence than Asian women (1). 10% of women of \nreproductive age (~190 million women) and 18% of Turkish \nwomen are affected by endometriosis (2,3). At least one-third \nof women with chronic pelvic pain and 5% of women without \npain or infertility have endometriosis (4). Endometriosis \nmay be accompanied by fibromyalgia, allergic rhinitis and \nasthma, iron deficiency anemia, lipedema, depression, \nfibrocystic breasts, polycystic ovaries, adenomyosis, and \ncentral-peripheral nervous system diseases (5-7). In addition \nto medical, pharmacological, and surgical treatment in \nendometriosis, healthy eating habits and positive lifestyle \nchanges have been reported to be effective in alleviating \nthe symptoms of the disease (8).\nAccording to Casas et al. (9) and Cirillo et al. (10), the \nMediterranean diet (MD) has a protective and therapeutic \neffect on many chronic diseases and can reduce \ninflammation and associated pain symptoms. Vegetables \nand fruits are the main antioxidant sources of MD due to \ntheir rich content of vitamins, minerals, and phytochemicals, \nand these foods have been associated with a reduced \nrisk of developing the disease. In the management of \nendometriosis, while saturated fat, red meat, and alcohol \nconsumption have been associated with an increased risk of \nthe disease (11). Additionally, the olive oil composition and \nomega-3 fatty acids of the MD has been associated with a \nreduced risk of endometriosis (8,10). It has been reported \nthat dietary fatty acid composition has the potential to \naffect endogenous hormone metabolism and endogenous \nestrogen levels (12). Polyphenols, which are secondary \nmetabolites of plants, are defined as compounds that \nare naturally found in foods and are generally considered \nsafer than traditional pharmaceutical drugs. They also \nhave antioxidant properties. Polyphenols are divided into \ndifferent categories such as flavonoids, stilbenes, lignans, \nand phenolic acids according to the number of phenol rings \nthey contain and the structural elements that connect these \nrings (13). It has been reported that these components \nmay improve the quality of life by modulating estrogen \nnetworks, thanks to their anti-inflammatory and potential \nphytoestrogenic effects, without causing serious adverse \neffects, unlike anti-estrogenic treatment (14). Nutrition \nalso contributes to the management of endometriosis, a \ndisease characterized by inflammation and affecting life in \nmany ways. This study aimed to evaluate the relationship \nbetween the nutritional status of endometriosis patients as \nassessed by the Healthy Eating Index (HEI), their adherence \nwith the MD, their polyphenol intake, and their health status \nassessed by the Endometriosis Health Profile-30 (EHP-30).\nMETHODS\nResearch Design and Sample of the Study\nAcıbadem Mehmet Ali Aydınlar University and Acıbadem \nHealthcare Institutions Medical Research Ethics Committee \n(ATADEK) approval was received (approval no: 2023-13/447, \ndate: 17.08.2023). All patients were informed about the \nstudy, and written informed consent was obtained for \nthe protocol. This prospective, cross-sectional study was \nconducted with women who applied to the Obstetrics and \nGynecology Clinic of University of Helath Sciences Türkiye, \nİstanbul Kanuni Sultan Süleyman Training and Research \nHospital between September and December 2023. Women \naged 18-55 years, who were not pregnant or breastfeeding, \nnot in menopause, and diagnosed with endometriosis \nstage I, II, or III by a physician, were included in the study. \nIndividuals on a special diet were not included in the study. \nThe sample of the study was determined as 34 participants, \nbased on the research of Asencio et al. (15), by performing a \npower analysis using the R v3.6.1 program (Vienna, Austria), \ntaking the margin of error as 5% and the beta error as 20%.\nData Collection Tools\nDescriptive characteristics form: Sociodemographic and \nmenstrual characteristics and health status were questioned. \nAnthropometric measurements (height, body weight, waist, and \nhip circumference) were taken by the researcher. Body mass index \n(BMI) was calculated and grouped by the recommendations of \nthe World Health Organization (WHO) (16).\nÖZ\nSonuç: Endometrioziste beslenmenin rolüne dikkat çekilmesine rağmen, çalışmaya katılan kadınların sağlıklı bir beslenme modeli olan Akdeniz \ndiyetine uyumu ve HEI-2015 puanları düşük saptanmıştır. Endometriozis tedavisinde multidisipliner bir tedavi yaklaşımı ile Akdeniz diyetinin \nuygulanmasının ve sağlıklı yaşam tarzı alışkanlıklarının teşvik edilmesinin semptom yönetimini ve yaşam kalitesini iyileştireceği ön görülmektedir.\nAnahtar Kelimeler: Endometriozis, Akdeniz diyeti, polifenol, sağlık profili\n\nDeveci et al. Dietary Habits and Health Profile in Endometriosis\n421\n14-Point Mediterranean Diet Adherence Screener \n(MEDAS): The MEDAS was developed by Martínez-\nGonzález et al. (17) in 2012 to assess adherence with the \nMD, and its Turkish validation was conducted by Bekar and \nGoktas (18) in 2023. The MEDAS consists of 14 questions \nthat evaluate the daily consumption of vegetables, fruits, \nmeat, butter, margarine, cream, alcohol and sugary drinks, \nolive oil, and the weekly consumption of legumes, fish, \noilseeds, pastries, sauces, and the type of oil used in meals. \nA score of <7 indicates low adherence with the MD, 7-9 \npoints indicate moderate adherence, and >9 points indicate \nhigh adherence. The Cronbach’s alpha value of the MEDAS \nwas reported as 0.829 (18).\nFood Records: Food consumption was evaluated using \na 24-hour recall method, and energy, macronutrient, and \nmicronutrient intakes were calculated using the Nutrition \nInformation System software (Türkiye, İstanbul).\nPolyphenol Consumption Frequency Survey: To \ndetermine polyphenol intake, the Phenol-Explorer \n(version 3.6) database and literature were scanned, and a \nquestionnaire was created focusing on the frequency and \namount of consumption of 64 foods with high polyphenol \ncontent in the last year. According to the survey, daily \nintake was determined, and polyphenol consumption was \ncalculated using Phenol-Explorer (19).\nHEI-2015: The HEI-2015 was developed by the Center \nfor Nutrition Policy and Promotion of the United States \nDepartment of Agriculture to measure adherence \nto dietary guidelines. The HEI-2015 consists of 13 \ncomponents, the first 9 of which determine the adequacy \nof the diet and the last 4 of which should be consumed in \nlimited amounts. The total score is calculated out of 100 \npoints by adding the adequacy and limited consumption \ncomponents and is defined as “poor diet quality” if ≤50, \n“dietary quality that needs improvement” if 51-80, and \n“good diet quality” if >80 (20). In addition, letter grades \nare given to the score ranges: 90-100 points: A, 80-\n89 points: B, 70-79 points: C, 60-69 points: D, and 0-59 \npoints: F (21).\nEndometriosis Health Profile-30: EHP-30 was developed \nby Jones et al. (22) to determine health-oriented quality \nof life criteria for women with endometriosis. The Turkish \nvalidation was conducted by Şahin (23). The survey consists \nof 53 questions and 11 subscales, including pain, control, \npowerlessness, emotional well-being, social support, self-\nimage, work, sexual intercourse, relationship with children, \nthe medical profession, treatment, and infertility. The \nsurvey is answered by considering the last four weeks, and \nis scored between 0 to 100, with 0 indicating the best and \n100 indicating the worst health status. The Cronbach’s alpha \nvalue of the EHP-30 was reported as 0.980 (23).\nStatistical Analysis\nThe data were analyzed using the SPSS statistics 25.0 \nprogram (Armonk, NY). The skewness and kurtosis values   \nof the variables were calculated to assess conformity with \nthe normal distribution, and if the values   were within ±2, it \nwas assumed that they showed a normal distribution. The \nPearson correlation analysis and the Spearman correlation \nanalysis were used to evaluate the relationship between \ncontinuous variables. P<0.05 was accepted as significant. \nFor this study, Cronbach’s alpha values   for the MEDAS and \nEHP-30 were found to be 0.747 and 0.963, respectively.\nRESULTS\nThe demographic and anthropometric characteristics of the \nparticipants are shown in Table 1. The mean age of the 34 \nwomen was 35.44±6.72 years. It was determined that 17.6% \n(n=6) of the participants had secondary education, 79.4% \n(n=27) had higher education, 58.8% (n=20) were married, \n88.2% (n=30) were employed, 35.3% (n=12) had income \ngreater than their expenses, and 38.2% (n=13) had income \nequal to their expenses. The mean BMI of the participants \nwas 22.92±2.94 kg/m 2, and 64.7% (n=22) of the women  \nhad normal weight, while 32.4% (n=11) were overweight \n(Table 1).\nTable 2 presents the characteristics of disease status and \nmenstrual cycle. 64.7% (n=22) of the women had a disease \ndiagnosed by a physician other than endometriosis, and \n17.6% (n=6) of these women had bowel problems, 5.9% \n(n=2), fibromyalgia, 5.9% (n=2), allergic rhinitis and asthma, \n5.9% (n=2), fibrocystic breast, and 5.9% (n=2), PCOS and \nadenomyosis. 79.4% (n=27) of the participants reported \nregular menstruation (Table 2).\nAccording to food consumption records, it was determined \nthat participants consumed a mean of 1337.25±403.19 \nkcal/day of energy, 133.58±70.07 g/day carbohydrate, \n59.68±17.28 g/day protein, 61.21±22.34 g/day fat, \n15.29±6.03 g/day fiber, and 10.22±9.51 g/day added \nsugar. According to the recommendations of the Türkiye \nDietary Guidelines (TDG), the ratio of energy intake from \ncarbohydrates to total daily energy intake of the participants \n(38.45±12.74%) was below the daily recommendations (45-\n60%), and the ratio of lipid intake (41.00±12.07%) was above \nthe recommendations (20-35%). In addition, fiber intake \nwas below the recommendations, while added sugar intake \n(3.47±3.94%) was in line with them. \n\nMed J Bakirkoy 2025;21(4):419-429\n422\nTable 2. Disease and menstrual cycle status of the participants\nWomen with endometriosis (n=34)\nHaving a disease diagnosed by a physician n %\n Yes 22 64.7\n No 12 35.3\nDiseases diagnosed by a physician* (n=22)\n Intestinal problems 6 17.6\n Fibromyalgia 2 5.9\n Allergic rhinitis and asthma 2 5.9\n Iron deficiency anemia 2 5.9\n Fibrocystic breast - cyst in the breast 2 5.9\n PCOS-adenomyosis 2 5.9\n Lipedema 1 2.9\n Depression 1 2.9\n Other diseases 10 29.4\nHaving a regular menstrual cycle\n Yes 27 79.4\n No 7 20.6\n*: Multiple response, PCOS: Polycystic ovary syndrome\nTable 1. Demographic and anthropometric characteristics of the participants\nWomen with endometriosis (n=34)\nMean SD Min Max\nAge (year) 35.44 6.72 23.00 51.00\nHeight (cm) 163.09 5.98 150.00 175.00\nWeight (kg) 60.98 8.69 44.00 82.00\nBMI (kg/m2) 22.92 2.94 16.98 29.05\nWaist circumference (cm) 77.32 8.59 63.00 100.00\nHip circumference (cm) 100.94 7.71 86.00 118.00\nWaist/hip ratio 0.77 0.07 0.57 0.93\nEducation status n %\nPrimary school 1 2.9\nSecondary education 6 17.6\nHigher education 27 79.4\nMarital status\nMarried 20 58.8\nSingle 14 41.2\nOccupational status\nEmployee 30 88.2\nRetired/non-employed 4 11.8\nBMI category\nUnderweight (<18.5 kg/m2) 1 2.9\nNormal (18.5-24.9 kg/m2) 22 64.7\nOverweight (25.0-29.9 kg/m2) 11 32.4\nBMI: Body mass index, Min: minimum, Max: Maximum, SD: Standard deviation\n\nDeveci et al. Dietary Habits and Health Profile in Endometriosis\n423\nAccording to the polyphenol consumption frequency \nquestionnaire, participants consumed a mean of 339.86 \nmg/day of flavonoids, 207.66 mg/day of phenolic acids, and \n657.70 mg/day of total polyphenols (Table 3). \nThe mean MEDAS score was 7.85±2.26; the HEI-2015 \nscore was 61.71±18.51 and the EHP-30 total score was \n41.25±20.77. According to MEDAS scores, it was determined \nthat 26.5% (n=9) of the participants had low, 44.1% (n=15) \nmoderate, and 29.4% (n=10) high adherence with the MD; \nand according to HEI-2015 scores, in the distribution of \nletter categories, 5.9% (n=2) received A grade, 14.7% (n=5) \nreceived B grade, 20.6% (n=7) received C grade, 14.7% \n(n=5) received D grade and 44.1% (n=15) received F grade \n(Table 4).\nTable 3. The energy, nutrient, and polyphenol intakes of the participants\nWomen with endometriosis (n=34)\nMean SD Min Max TDG %* TDG \nrecommendations\nEnergy (kcal/day) 1337.25 403.19 577.30 2253.30 77.20a -a\nCHO (g/day) 133.58 70.07 28.30 298.80 -b,c 130c\nCHO (%) 38.45 12.74 12.61 60.23 -b 45-60b\nProtein (g/day) 59.68 17.28 24.10 93.00 112.7a,b -a\nProtein (%) 18.58 5.64 9.13 30.51 -b 10-20b\nLipid (g/day) 61.21 22.34 20.10 118.00 -b -d\nLipid (%) 42.00 12.07 19.36 57.96 -b 20-35b\nFiber (g/day) 15.29 6.03 5.00 27.20 61.16c 25c\nAdded sugar (g/day) 10.22 9.51 0.00 32.50 -e -e\nAdded sugar (%) 3.47 3.42 0.00 16.70 -e <10e\nSFA (g/day) 20.82 10.67 0.00 46.40 -c -c\nSFA (%) 14.91 4.73 7.47 24.56 -c -c\nMUFA (g/day) 21.60 8.51 6.80 39.20 -d -d\nPUFA (g/day) 11.87 9.02 2.90 49.90 -d -d\nOmega-3 (g/day) 1.47 1.11 0.40 4.30 -d -d\nOmega-6 (g/day) 10.2 3 8.44 2.10 46.00 -d -d\nPolyphenols (mg/day) \n Flavonoids 339.86 183.05 33.42 682.68 -d -d\n Flavonols 57.56 35.59 1.89 130.87 -d -d\n Flavanons 20.99 18.65 0.95 78.82 -d -d\n Flavanols 246.43 158.49 8.07 507.92 -d -d\n Flavons 8.43 6.26 2.49 31.61 -d -d\n Anthocyanidin 17.75 29.13 0.12 151.86 -d -d\nStilbens 0.37 0.44 0.00 1.96 -d -d\nLignans 10.51 6.44 2.98 31.20 -d -d\nPhenolic acids 207.66 118.03 37.38 440.50 -d -d\n Hydroxycinnamic acid 156.96 113.74 23.77 424.87 -d -d\n Hydroxybenzoic acid 50.70 32.19 0.75 107.25 -d -d\n Other polyphenols 94.70 153.68 5.09 769.48 -d -d\n Total polyphenols 657.70 304.56 146.85 1313.44 -d -d\n*: TDG %: The rate of meeting Türkiye Dietary Guidelines (TDG) recommendations.\na: Calculated according to age and the Türkiye Nutrition Guide adequate requirement of energy and AR/population reference intakes. b: Reference intake \nranges for macronutrients (%) are recommended.\nc: Population reference intakes is recommended as 130 g/day for CHO, and adequate intake is recommended as 25 g/day for fiber and as little as possible for \nSFA.\nd: There is no specific intake recommendation.\ne: It is recommended not to exceed 10% of energy intake.\nCHO: Carbohydrate, SFA: Saturated fatty acids, MUFA: Monounsaturated fatty acids, PUFA: Polyunsaturated fatty acids, SD: Standard deviation, Min: Minimum, \nMax: Maximum\n\nMed J Bakirkoy 2025;21(4):419-429\n424\nThe relationship between MEDAS, HEI-2015, and EHP-\n30 total, and subscales scores is shown in Table 5. A weak \nnegative correlation was found between the EHP-30 pain \nsubscale score and the HEI-2015 score (r=-0.34, p<0.05), \nbut no correlation was found between the EHP-30 total \nand other subscales scores and the HEI-2015, and MEDAS \nscores (p>0.05, for all).\nDISCUSSION\nThe MD is reported to be effective in relieving endometriosis-\nrelated pain, especially with its antioxidant content and \nanti-inflammatory effects. It is a nutritional model that has \npositive effects on the treatment process of endometriosis \n(10). This study aimed to evaluate the relationship \nbetween the nutritional habits in women diagnosed with \nendometriosis, and their health profile.\nAccording to the Turkish Statistical Institute (TURKSTAT) \n2023 data, the rate of higher education graduates among \nwomen was reported to be 20.9%, and the labor force \nparticipation rate for those over the age of 15 was reported \nto be 32.8% (24). The rate of higher education graduates or \nemployed individuals in this study was found to be above \nthe Turkish average, indicating that the women participating \nin the study were more informed and economically active \nindividuals.\nAccording to TURKSTAT 2023 data, 23.6% of women \nare obese (24). In a study conducted in Türkiye on \nendometriosis, the mean waist circumference (WC) was \n75.02 cm, and BMI was 22.43 kg/m 2, and there were no \nunderweight or obese subjects in the study (25). Similarly, \nin this study, WC was 77.32 cm and BMI was 22.92 kg/m 2, \nand although there were no obese women, the majority of \nwomen (64.7%) were found to be of normal weight. \nTable 4. The MEDAS, HEI-2015, and EHP-30 scores of the participants\nWomen with endometriosis (n=34) Mean SD Min Max\nMEDAS 7.85 2.26 2.00 11.00\nHEI-2015 61.71 18.51 25.59 94.25\nEHP-30 41.25 20.77 3.92 91.18\n Pain 43.32 25.18 0.00 100.00\n Control and powerlessness 48.04 31.69 0.00 100.00\n Emotional well-being 40.44 29.36 0.00 100.00\n Social support 44.36 28.39 0.00 87.50\n Self-image 40.69 31.37 0.00 100.00\n Work 31.62 27.95 0.00 100.00\n Relationship with children 11.03 24.57 0.00 100.00\n Sexual intercourse 35.48 35.59 0.00 100.00\n Medical profession 15.99 21.22 0.00 100.00\n Treatment 48.53 34.17 0.00 100.00\n Infertility 36.95 32.87 0.00 100.00\n MEDAS n %\n Low adherence 9 26.5\n Medium adherence 15 44.1\n High adherence 10 29.4\nHEI-2015 letter categories\n A (90-100 point) 2 5.9\n B (80-89 point) 5 14.7\n C (70-79 point) 7 20.6\n D (60-69 point) 5 14.7\n F (0-59 point) 15 44.1\nMEDAS: Mediterranean diet adherence screener, HEI-2015: Healthy eating index-2015, EHP-30: Endometriosis health profile-30, SD: Standard deviation, Min: \nMinimum, Max: Maximum\n\nDeveci et al. Dietary Habits and Health Profile in Endometriosis\n425\nTable 5. Relationship between the MEDAS, HEI-2015, and EHP-30 scores\nn=34 BMI Total \npolyphenols MEDAS HEI-\n2015 EHP-30 1 2 3 4 5 6 7 8 9 10 11\nMEDAS\nr -0.05 0.11 1.00\np 0.78 0.52 -\nHEI-2015\nr -0.18 -0.07 0.15 1.00\np 0.30 0.71 0.40 -\nEHP-30\nr 0.19 0.06 -0.01 -0.19 1.00\np 0.29 0.74 0.94 0.29 -\n1. Pain\nr 0.22 0.06 -0.23 -0.34 0.83 1.00\np 0.20 0.72 0.18 0.04* <0.001* -\n2. Control and \npowerlessness \nr 0.21 0.04 -0.05 -0.21 0.87 0.71 1.00\np 0.24 0.82 0.80 0.23 <0.001* 0.00 -\n3. Emotional \nwell-being\nr 0.02 -0.15 0.08 0.15 0.79 0.53 0.74 1.00\np 0.91 0.39 0.66 0.39 <0.001* <0.001* <0.001* -\n4. Social \nsupport\nr 0.15 0.02 0.07 0.11 0.76 0.48 0.71 0.82 1.00\np 0.39 0.91 0.69 0.53 <0.001* <0.001* <0.001* <0.001* -\n5. Self-image\nr 0.29 -0.07 0.09 0.09 0.52 0.41 0.48 0.46 0.45 1.00\np 0.09 0.69 0.63 0.61 <0.001* 0.02* <0.001* 0.01* 0.01* -\n6. Work\nr 0.16 0.09 -0.16 -0.08 0.64 0.64 0.48 0.45 0.26 0.28 1.00\np 0.38 0.60 0.35 0.65 <0.001* <0.001* <0.001* 0.01* 0.14 0.11 -\n7. Relationship \nwith children\nr 0.26 0.35 0.11 0.06 0.16 0.18 0.30 0.04 0.18 -0.02 -0.05 1.00\np 0.37 0.04* 0.55 0.75 0.37 0.32 0.09 0.84 0.31 0.93 0.78 -\n8. Sexual \nintercourse\nr 0.05 0.28 0.14 -0.12 0.61 0.47 0.45 0.46 0.44 0.08 0.37 0.20 1.00\np 0.80 0.11 0.44 0.52 <0.001* 0.01* 0.01* 0.01* 0.01* 0.64 0.03* 0.27 -\n9. Medical \nprofession\nr 0.08 0.12 0.01 -0.10 0.45 0.27 0.32 0.27 0.19 0.20 0.05 0.02 0.35 1.00\np 0.91 0.51 0.94 0.58 0.01* 0.13 0.07 0.13 0.28 0.27 0.80 0.89 0.04* -\n10. Treatment\nr -0.14 0.12 0.18 -0.02 0.52 0.30 0.44 0.37 0.33 0.03 0.23 0.35 0.23 0.60 1.00\np 0.44 0.52 0.31 0.89 <0.001* 0.09 0.01* 0.03** 0.06 0.86 0.18 0.04* 0.19 <0.001* -\n11. Infertility\nr -0.06 -0.06 -0.05 -0.30 0.50 0.27 0.28 0.22 0.20 0.01 0.42 -0.18 0.26 0.30 0.38 1.00\np 0.74 0.74 0.77 0.08 <0.001* 0.12 0.11 0.21 0.26 0.96 0.02* 0.30 0.14 0.08 0.03* -\nBMI: Body mass index, MEDAS: Mediterranean diet adherence screener, HEI-2015: Healty eating index-2015, EHP-30: Endometriosis healt profile-30, *p<0.05\n\nMed J Bakirkoy 2025;21(4):419-429\n426\nIn addition, the WC of women was found to be below the \nWHO recommendations (<80 cm) (16). Although these \nresults may be due to the demographic characteristics \nof women, they are similar to the literature also showing \nthe anthropometric characteristics of women with \nendometriosis (26). Holdsworth-Carson et al. (27) reported \nthat chronic pain symptoms related to endometriosis trigger \ngastrointestinal symptoms or emotional stress, leading to \ndecreased appetite and food intake, which in turn leads \nto reduced body size in women with endometriosis. In this \nstudy, no significant difference was observed between BMI \nand EHP-30 subscale scores.\nAccording to the Türkiye Nutrition and Health Survey 2019 \ndata, the rate of women aged 15 years and older with a \ndisease diagnosed by a physician was 48.5% (28). The rate \nof women with a disease diagnosed by a physician other \nthan endometriosis was higher in this study (64.7%). It is \nthought that this may be due either to the characteristics of \nthe sample group or to the educational level of the women, \nand differences in their access to health services.\nThe risk of endometriosis has been reported to be more \nthan double in women with short menstrual cycles (≤27 days) \nand longer bleeding durations (≥1 week) (29). Consistent \nwith the literature, more than two-thirds of women in this \nstudy reported regular menstruation, occurring at intervals \nof one month or less.\nAccording to the food consumption records of the \nparticipants, the energy intake from carbohydrates is \nbelow the recommendations of the TDG 2022 (30). This is \nbecause fat consumption is above the recommendations. \nSFA intake at levels approximately three times higher than \nthe recommended limit of 7% of daily energy intake also \ncontributes to this result. A saturated fat intake of ≤8% of \ntotal energy has been reported to score the highest on \nthe HEI-2015 (31). In this study, the number of individuals \nwith high HEI-2015 scores is low, since SFA consumption \nis above the recommended limits. Furthermore, the \nrecommendation for an optimal omega-6/omega-3 ratio \nvaries from 1/1 to 4/1, depending on the disease, although \nin Western diets this ratio is 15/1 to 16.7/1 (32). In this \nstudy, the omega-6/omega-3 ratio that was determined as \napproximately 10/1 does not meet the recommendation. \nadded sugar consumption (3.47%), which is associated \nwith chronic diseases and inflammation, is below the \nWHO recommendations of “not exceeding 5-10% of daily \nenergy” (33). It is thought that this result may be related \nto the socio-demographic characteristics of the population. \nAdditionally, Bogusz and Górnicka (8) reported that 77.3% \nof women with endometriosis increased their consumption \nof anti-inflammatory foods after diagnosis. However, they \nhad lower MD Score and Pro-Healthy Diet Index scores \nthan the healthy control group and consumed fewer \nfruits, vegetables, dairy products, and whole grains than \nrecommended. Similarly, in this study, the low number of \nindividuals with adequate adherence to the MD according \nto the MEDAS score (29.4%) and the high number of \nindividuals in the worst letter category according to the \nHEI-2015 score (44.1%) draw attention to the importance of \nthe quality and nutrient diversity of the foods in the diet, as \nwell as the daily energy and macronutrient consumption of \nindividuals.\nIn adherence to the MD, polyphenol intake, which is one of \nthe bioactive components in plant foods, also increases (9). \nPolyphenols have antioxidant properties, and a diet high in \npolyphenols may help relieve symptoms of endometriosis, \nan inflammatory disease (14).\nAlthough there are no intake recommendations for \npolyphenols as there are for micronutrients, intake of \npolyphenol types has been evaluated in different studies. \nPolyphenol intake was reported to be higher in Japan \n(≥1277 mg/day) than in other regions. No significant \ndifferences were observed among European countries. \nHigher intakes were reported in Poland (≥500 mg/day) and \nFrance (≥1000 mg/day), intakes with lower Italy and Spain. \nFlavonoid and phenolic acid consumption was highest in \nPoland and Australia (34). In a study conducted in Türkiye, \nthe total polyphenol intake of women was reported as 333.9 \nmg/day and the consumption of some polyphenol types, \nsuch as flavanols, flavonols, and phenolic acids, was lower in \ncomparison to our study (13). In this study, total polyphenol \nconsumption (657.70 mg/day) was higher than previously \nreported values. It is thought that the reason for this \ndifference may be because the other study was conducted \nduring the pandemic period, and with participants from \ndifferent regions.\nEHP-30 is a questionnaire developed to measure the quality \nof life of endometriosis patients and aims to evaluate the \neffects on their physical, mental, and social health (22). When \nthe studies conducted with EHP-30 in the literature are \nevaluated, there are results both similar and different from \nthose of this study (35-37). These differences may be due to the \ndemographic or cultural characteristics of the participants. In \nthis study, a positive correlation was found between the EHP-\n30 total score and all subscales except the relationship with \nchildren subscale. This shows that the EHP-30 is consistent \namong its subscales. In addition, the correlations between \nEHP-30 total and pain, control, and powerlessness subscales’ \nscores were found to be very strong. This may be explained \n\nDeveci et al. Dietary Habits and Health Profile in Endometriosis\n427\nby the fact that the subscales of the EHP-30, such as pain, \ncontrol, and powerlessness, are the main factors that directly \nreflect the physical and emotional burden of the disease \nand seriously affect the quality of life. In the literature, these \nsubscales are reported to have a significant impact on \nwomen with endometriosis (38). Another study reported that \nwomen with endometriosis experienced a loss of control and \npower due to pain and loss of functionality, which prevented \nthem from participating in necessary and enjoyable activities \nthat make life worth living (39). In a study on chronic pelvic \npain, it was reported that women experienced a lack of \nsocial support and that this was associated with deep pain \nand suffering (40). In this study, a significant relationship was \nobserved between pain and the scores of the emotional \nwell-being and social support subscales’ scores. All these \nresults emphasize that pain management, especially, and \npsychosocial and holistic approaches are critical in coping \nwith endometriosis. Studies have reported that pelvic pain \ndue to endometriosis is associated with impaired body \nimage, decreases quality of life and sexual satisfaction, \nand self-image is significantly weakened in women with \ndyspareunia (41,42). It was also reported that impaired body \nimage was significantly associated with greater emotional \nloneliness and lower perceived social support (43). This \nstudy found positive correlations that are similar to those in \nthe literature, specifically between pain and self-image and \nsexual life subscale scores, as well as between social support \nand self-image subscale scores. This suggests that women \nwith higher perceived social support have a more positive \nself-image.\nRecent studies on the role of the MD and its components \nin the treatment of endometriosis are notable for their \ncontributions. In an endometriosis animal model study with \nUrtica dioica L. (above-ground parts of nettle), a significant \nand promising difference was found in TNF-alpha and IL-6 \nlevels compared to the control group (44). In a study on \nclove and its components, clove and its components were \nreported to cause regression in endometrial implants without \naffecting fertility in animal models with endometriosis (45). \nIn another study, clove, one of the important spices of the \nMD, showed a suppressive effect on pro-inflammatory \ncytokines (IL-6, TNF-alpha) with its antioxidant activity (46). \nOtt et al. (47) reported that the MD was effective in reducing \nendometriosis-associated pain. Another study reported \nan inverse association between adherence to the MD \nand pain, with adherence being associated with a higher \nintake of polyphenols (48). While Zhou et al. (49) found no \nassociation between pain and adherence to the MD in their \nstudy on middle-aged Chinese, Cirillo et al. (10) reported a \nsignificant association between the MD and pain-relieving \neffect. Dougan et al. (50) similarly reported that adherence \nto the alternative HEI would be beneficial for pelvic pain. \nIn the present study, no correlation was found between the \nMEDAS scores assessing adherence to the MD and the \nHEI-2015 scores assessing diet quality, and the EHP-30 total \nscore, but a negative correlation was found between the \nHEI-2015 and the pain subscale scores. This result points to \nthe importance of nutrition in pain management in women \nwith endometriosis. Although the effect of dietary changes \nvaries individually, a period of several weeks to several \nmonths is usually required to reduce the inflammation and \nsymptoms associated with endometriosis (51-53). The length \nof this period depends on the initial state of health, the level \nof inflammation and the degree of dietary compliance (52). \nDietary patterns based on food restriction are feasible in the \nshort term but are not sustainable in the long term. \nTherefore, the literature recommends implementing \nsuch diets with personalized plans for a few weeks before \nswitching to the MD for both its anti-inflammatory effects \nand sustainability (54).\nStudy Limitations\nThis study provides a detailed assessment of the nutritional \nstatus of women with endometriosis by applying MEDAS, \nHEI-2015, and polyphenol consumption frequency \nquestionnaires. In addition, EHP-30, which provides \nassessments of many health-related areas for women \nwith endometriosis, was applied and its relationship with \nnutrition was determined. While this situation constitutes \na strength of the study, there are also some limitations. \nConsidering the demographic characteristics of the \nindividuals participating in this cross-sectional study, the \nsample does not reflect the general population. In addition, \nthe calculation of the HEI-2015 score was based on the self-\nreport of a one-day food consumption record. On the other \nhand, polyphenol consumption was determined through a \nretrospective consumption frequency questionnaire. The \naccuracy of the consumption frequency data depends on \nthe information declared by the participants. As in studies in \nboth national and international literature, when calculating \ndaily polyphenol intake, the Phenol-Explorer database was \nused (19) as there is no polyphenol database that provides \nanalysis results of foods specific to Türkiye. The polyphenol \ncontent of foods is affected by many factors, such as the \nconditions in which the food is grown, geographical region, \nseason, post-harvest processing, and storage conditions.\nTherefore, it is difficult to precisely determine the polyphenol \nintake of individuals, although international databases \nare used, there is a need for geographically specific food \ncomposition databases developed with a more consistent \n\nMed J Bakirkoy 2025;21(4):419-429\n428\napproach. Although the results obtained in this study \nshed light on future studies on adherence to the MD, diet \nquality, and health profile of women with endometriosis, \nprospective studies with a more comprehensive sample and \ndesign are needed.\nCONCLUSION\nIn conclusion, this study, which evaluated the nutritional \nstatus and health profile of women with endometriosis, draws \nattention to the importance of nutrition in the treatment \nof endometriosis. The findings indicate that women with \nendometriosis have low adherence to the MD a healthy \ndietary model and low diet quality. Nutrition should be \nemphasized, especially in the management of pain, which \nis a common complaint in endometriosis. At this point, \nnutrition education and counseling provided through a \nmultidisciplinary approach to women with endometriosis \nafter diagnosis will be an important step towards improving \nquality of life. More research is needed to develop nutritional \nstrategies to improve the health and well-being of women \nwith endometriosis.\nETHICS\nEthics Committee Approval: Acıbadem Mehmet Ali \nAydınlar University and Acıbadem Healthcare Institutions \nMedical Research Ethics Committee (ATADEK)  approval \nwas received (approval no: 2023-13/447, date: 17.08.2023).\nInformed Consent: All patients were informed about the \nstudy, and written informed consent was obtained for the \nprotocol.\nAcknowledgement\nThis study was carried out within the scope of Tuğçe \nDeveci’s master’s thesis in 2024 and was presented in 13 th \nNational Healthy Life Congress as an oral presentation. The \nauthors would like to thank all participated in the study and \nto the research and the health professionals who facilitated \nthe conduct of the study. \nFOOTNOTES\nAuthor Contributions\nConcept: T.D., N.Ç.B., Desing: T.D., N.Ç.B., P .Y.B., Data \nCollection or Proccessing: T.D., N.Ç.B., P .Y.B., Analysis or \nInterpretation: T.D., N.Ç.B., Literature Search: T.D., N.Ç.B., \nWriting: T.D., N.Ç.B., P .Y.B.\nConflict of Interest: The authors declare no potential \nconflicts of interest with respect to the research, authorship \nand/or publication of this article.\nFinancial Disclosure: This research was supported by \nthe Acıbadem Mehmet Ali Aydınlar University Scientific \nResearch Projects Commission (ABAPKO) [TYL-2023-136].\nREFERENCES\n1. Bougie O, Yap MI, Sikora L, Flaxman T, Singh S. Influence of race/\nethnicity on prevalence and presentation of endometriosis: a \nsystematic review and meta-analysis. BJOG. 2019;126:1104-15.\n2. World Health Organization. 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