The Association between dominant food patterns and intake of energy and macronutrients with endometriosis in women aged 15-45

The Association between dominant food patterns and intake of energy and macronutrients with endometriosis in women aged 15-45 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Association between dominant food patterns and intake of energy and macronutrients with endometriosis in women aged 15-45 Maryam Aminian, Tahereh Behroozi-Lak, Negin Ahmadi, Sevana Daneghian This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7168622/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Feb, 2026 Read the published version in BMC Nutrition → Version 1 posted 12 You are reading this latest preprint version Abstract Background Endometriosis is a chronic, inflammatory condition affecting women, characterized by the presence of endometrial tissue outside the uterus. This study aimed to explore the relationship between dominant food patterns and the incidence of endometriosis in women aged 15-45 years. Methods This case-control study involved 180 women, with 60 participants in the case group (with endometriosis) and 120 in the control group. Participants, aged 15-45, were recruited from the Kosar Educational and Therapeutic Center. Endometriosis diagnosis was confirmed via ultrasound or laparoscopy by a gynecologist. Dietary intake was assessed using a 146-item food frequency questionnaire. Factor analysis was used to identify dominant dietary patterns, and statistical tests (Chi-squared, Mann-Whitney U, T-tests) alongside logistic regression were used to assess the relationship between dietary patterns and endometriosis, adjusting for confounding factors (e.g., BMI, menstrual cycle characteristics, physical activity, education level). Results Three dominant dietary patterns were identified. Pattern one was high in red meat, solid oils, high-fat snacks, and processed foods. Pattern two featured vegetables, grains, and coffee, while pattern three included sugar, cereals, and jam. Significant associations were found between food pattern one (OR = 25.54, 95% CI: 111.72–5.84, P < 0.001) and food pattern three (OR = 1.86, 95% CI: 1.14–3.04, P = 0.01) with increased risk of endometriosis. Higher energy, lipid, and carbohydrate intake were significantly associated with endometriosis (P < 0.001). Conclusions Food patterns high in processed meats, oils, and sugars may increase the risk of endometriosis in women. Trial registration The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Urmia University of Medical Sciences, Urmia, Iran (Ethics Code IR.UMSU.REC.1400.396) . Carbohydrate Dietary Patterns Endometriosis Inflammation Lipids Figures Figure 1 Background Endometriosis is a hormone-dependent inflammatory disease marked by the presence of endometrial tissue outside the uterus ( 1 ), typically starting in adolescence ( 2 ). It is associated with pelvic pain (dysmenorrhea, dyspareunia, dyschezia) and infertility ( 2 ), which can greatly affect the physical, mental, sexual and social wellbeing, while also causing high societal costs ( 3 ), which is similar to the costs for other chronic conditions ( 4 ). Symptoms often appear up to 10 years before diagnosis, adding to these costs ( 3 ). Endometriosis affects about 10% of reproductive-age women worldwide( 5 ) Endometriosis has a multifactorial etiology, with retrograde menstruation being the most widely accepted theory( 3 ). Treatments include painkillers, hormonal therapies to lower or counter estrogen, and surgeries to remove affected organs. However, these options often fail, are costly, have side effects, and pain may recur( 2 , 6 – 8 ). Dietary factors may contribute to the development and severity of endometriosis by affecting estrogen, inflammation, prostaglandin metabolism, or muscle contractility. However the impact of specific food groups remains unclear.( 9 ). Many women with endometriosis use self-management strategies like nutrition, exercise, and meditation to manage symptoms and improve quality of life. Dietary interventions, particularly those rich in anti-inflammatory and anti-estrogen nutrients like antioxidants and omega-3 fatty acids, have shown promise in reducing symptoms.( 3 ). Recent studies has shown high-carbohydrate diets exacerbating endometriosis symptoms, as insulin may stimulate endometrial cell growth and increase estrogen levels.( 10 , 11 ). Large cohort studies also found a significant association between red meat consumption and endometriosis risk, while no link was observed for fish, poultry, eggs, or total fat( 6 , 12 , 13 ). Dietary pattern analysis has become a popular method for examining the link between diet and chronic diseases. Unlike examining individual nutrients or foods, pattern analysis evaluates the effects of overall diet( 14 ). This approach offers several advantages, including investigating the interactive or synergistic effects of foods when consumed together, as opposed to evaluating individual food intakes. Thus, the aim of this study was to investigating between dominant food patterns and intake of energy and macronutrients with endometriosis in women in reproductive age. Methods Study population This case-control study was conducted from December 2021 to March 2022 at the Kosar Women's Educational-Therapy Center in Urmia, Iran. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Urmia University of Medical Sciences, Urmia, Iran (Ethics Code IR.UMSU.REC.1400.396). The patients/participants provided their written informed consent to participate in this study. The study involved 180 women aged 15–45, including 60 diagnosed with endometriosis confirmed by laparoscopy in the case group and 120 healthy women in the control group. Inclusion criteria included being aged 15–45 and newly diagnosed with endometriosis. Exclusion criteria included a history of chronic diseases, dieting in the past three months, and mental or cognitive disorders affecting participation. Participants with implausible daily caloric intake based on the food frequency questionnaire (FFQ) (e.g., 5000 kcal) or those who left more than 70 items unanswered were also excluded. Controls were selected from relatives or friends of the cases to account for potential confounders such as home environment and socio-economic status, and they had no endometriosis or related conditions based on self-reporting. Demographic data collected included age, marital status, occupation, education level, and family history of endometriosis in mothers and sisters. Menstrual pattern factors most related to endometriosis, including menstrual cycle sequence, duration, and intensity, were gathered through interviews. The Metabolic Equivalent of Task (MET) questionnaire was used to assess participants' physical activity levels( 15 ). Dietary assessment A validated 146-item semi-quantitative food frequency questionnaire (FFQ) was used to assess dietary intake( 16 ). Participant reported the frequency of consumption of each food item over the past year, using daily (e.g., bread), weekly (e.g., meat), or monthly (e.g., fish) units. We calculated daily intake from the FFQ and converted food amounts into grams/day. The 146 food items were categorized into 30 groups based on nutrient similarity, with some items classified as single foods (e.g., egg, poultry)( 17 ). Completed FFQ data were entered into modified Nutritionist IV software, which calculated total energy and macronutrient intake for each participant. The reliability and validity of the questionnaire for the Iranian adult population were confirmed in previous studies using 24-hour dietary recalls for comparison. To ensure accuracy, we piloted the FFQ with 10% of our sample size and used 24-hour dietary recalls (two weekdays and one weekend day) to gather additional data, conducted by the researcher following a standardized protocol lasting about 20 minutes (supplementary file). Interviewers used a booklet with portion size images to enhance assessment accuracy. Statistical analysis The sample size was calculated according to prevalence of endometriosis (15%) and using the OR ratio equal to 3.42 for vegetable and animal oils in a previous study( 18 ), with the power of 90% and 95% confidence interval using the following formulas: $$\:{P}_{2}=\:\frac{{\text{P}}_{1}\text{}\times\:\text{O}\text{R}}{1\:+\:{\text{P}}_{1}\:(\text{O}\text{R}\:-\:1)}$$ $$\:p=\frac{{p}_{1+}\:{p}_{2}}{2}$$ $$\:C=\frac{control}{case}=\:\frac{2}{1}$$ $$\:n=\:\frac{\left(1+\frac{1}{c}\right)\text{*}{\left({Z}_{1-\frac{{\alpha\:}}{2}}+{Z}_{1-{\beta\:}\text{}}\text{}\right)}^{2}\text{*}P(1-P)}{{\left({P}_{1}-{P}_{2}\right)}^{2}}$$ $$\:n=\:\frac{\left(1+\frac{1}{2}\right)\text{*}\left({1.96+1.28)}^{2}\text{*}0.26\right(0.74)}{({0.15-0.38)}^{2}}\cong\:60$$ (Z1-α/2 = 1.96, Z1-β = 1.28, P1 = 0.15, P2 ≅ 0.38, OR = 3.42, P ≅ 0.26) Continuous and categorical variables were summarized as mean ± SD or number (%), respectively (Tables 1 and 2 ). Categorical demographic variables were compared using Pearson’s Chi-square Test, while independent t-tests were used for continuous variables between groups. Thirty food groups were included in the analysis based on food similarity (Table 3 ). Principal component analysis (PCA) and Kaiser-Meyer-Olkin (KMO) and Bartlett’s tests were used to find major dietary patterns and to assess factor analysis suitability, respectively. KMO ranges between 0 and 1, and the minimum value for proper factor analysis is 0.6. Besides, Bartlett’s test should be significant (p < 0.05). The sampling sufficiency of components was approved by the KMO test (value: 0.78). Moreover, the inter-correlation of components was confirmed using Bartlett’s test of sphericity 1.5 and scree plot examination (Fig. 1 ). To simplify the interpretation of data orthogonal rotation (varimax) was used. Food groups with absolute factor loadings of more than 0.3 were considered to have a significant contribution to the pattern. To name each dietary pattern, the principal food groups were considered. A score was assigned to all participants considering adherence to each dietary pattern. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression to examine the relationship between dietary pattern scores and endometriosis. Factor scores were treated as independent and dependent variables, respectively. In addition to the crude model, three models were used including a model adjusted for previous pregnancy, sequence of the menstrual cycle, duration of menstruation, and menstrual volume (model 1); and adjusted for BMI, level of physical activity, and education, in addition to first model variables (model 2); and adjusted for mean energy, carbohydrate and lipid intake in addition to second model variable (model 3). Data were analyzed using SPSS software version 22 (IBM Corp. IBM SPSS Statistics for Windows, Armonk, NY), and p-values < 0.05 were considered statistically significant. Results This study was started from December 2021 and completed in March 2022 and was performed on 180 participants, 60 case and 120 healthy control. Table 1and Table 2 presents the general characteristics of study participants in case and control groups. When the demographic characteristics of the women with endometriosis were compared with the control group, there were no significant differences detected in the marital status, occupation, family history of endometriosis, underlying disease and cigarette smoking. However, there was significant difference in weight, physical activity, BMI, education level, successful pregnancy, sequence of menstrual cycle, duration of menstruation, intensity of menstrual volume (all P < 0.05). Significant differences were also observed in terms of energy, carbohydrate, and lipid intake, with higher intake among case group (all P < 0.05). According to the results, participants in the case group had a significantly higher weight, BMI, energy intake, dietary carbohydrate and lipid intake (p < 0.001). In contrast, those in the control group had a higher physical activity, and educational status (11.7% in case versus 71.7% in control group). In addition, in control group menstrual pattern factors, including sequence of menstrual cycle (3.3% in case versus 90.8% in control group), duration of menstruation (65% of subjects had normal duration in case versus 94.2% in control group), and intensity of menstrual volume (53.3% of subjects had normal volume in case versus 94.2% in control group), were normal and had higher successful pregnancy history compare to case group. Among control group 68.3% of subjects had successful pregnancy, however this was 50% among case group. Table 1 Comparison of baseline qualitative characteristics between the endometriosis and control groups Characteristics Case (n = 60) Control (n = 120) P* Number of successful pregnancy Yes No 30 (50) 30 (50) 82 (68.3) 38 (31.7) 0.02 Level of education University High school Secondary school and less 7 (11.7) 28 (46.7) 25 (41.7) 86 (71.7) 31 (25.8) 86 (71.7) < 0.001 Marital status Single Married 11 (18.3) 49 (81.7) 35 (29.2) 85 (60.8) 0.12 Occupation Housewife Employed 41 (68.3) 19 (31.7) 66 (55) 54 ( 45 ) 0.08 Family history of Endometriosis Yes No 9 ( 15 ) 51 (85) 9 (7.5) 111 (92.5) 0.11 Underlying disease Yes No 9 ( 15 ) 51 (85) 13 (10.8) 107 (89.2) 0.42 Smoking Yes No 1 (1.7) 59 (98.3) 3 (2.5) 117 (97.5) 0.72 Sequence of menstrual cycle Low Normal More 36 (60) 2 (3.3) 22 (36.7) 3 (2.5) 109 (90.8) 8 (6.7) < 0.001 Duration of menstruation Low Normal More 21 ( 35 ) 39 (65) 7 (5.8) 113 (94.2) < 0.001 Intensity of menstrual volume Low Normal More 20 (33.3) 32 (53.3) 8 (13.3) 6 ( 5 ) 113 (94.2) 1 (0.8) < 0.001 *p values were computed by the Person’s Chi-square Test. Table 2 General characteristics of participants with endometriosis and controls. Characteristics endometriosis (n = 60) Control (n = 120) P* mean ± SD Min-Max mean ± SD Min-Max Age (y) 30.38 ± 5.36 21–40 28.88 ± 5.46 20–44 0.07* Height (cm) 162.08 ± 4.98 153–171 161.88 ± 5.51 151–175 0.83* Weight (kg) 67.6 ± 6.98 53–96 64.37 ± 7.27 47–83 0.008* BMI (kg/m2) 25.77 ± 2.2 21.4–36.5 24.62 ± 2.21 19.7–30.5 0.001** Physical activity (MET.min/week) 1745.37 ± 499.54 939–2870 1951.67 ± 545.65 1002–3360 0.01* Energy (Kcal) 2452.59 ± 394.7 1686–3592 2161.2 ± 265.09 1472–2950 < 0.001** Carbohydrate(gr) 318.04 ± 55.27 204–451 296.66 ± 49.27 182–447 0.009** Protein(gr) 87.52 ± 14.98 51.6-113.4 87.11 ± 12.58 59–118 0.85** Lipid(gr) 89.93 ± 18.94 54.6–143 74.43 ± 85.02 47.6–121 < 0.001* *p values were computed by the Mann–Whitney’s test. **p values were computed by the independent t test. Major dietary patterns and endometriosis By the use of factor analysis, 3 major dietary patterns were extracted. Totally, these factors explained 28.72% of the whole variance. We labeled these factors as following; 1. Dietary pattern 1 (high in red meat, hydrogenated fats, fast foods, Sweet dried fruit, soy, tea, nuts, Viscera), which explained 16.74% of the whole variance. 2. Dietary pattern 2 (high in vegetables, potato, egg, grains and coffee) which explained 6.19% of the whole variance. 3. Dietary pattern 3 (high in sugar, grain, fruit juice, jam, honey and hydrogenated fat) which explained 5.78% of the whole variance. Table 3 Food groups and factor-loading matrix for major dietary patterns, explored by factor analysisβ. Food groups Food items Dietary patterns* 1 2 3 grains White bread (lavash, baguette, sangak, barbari), noodles, pasta, starch, Buckwheat and oats, rice, wheat flour 0.382 0.347 Soybean Soybean 0.439 Beans Beans, chickpeas, lentils, mung beans, green beans -0.504 Low fat dairies Skim or low-fat milk, low-fat yogurt, cheese, curd and dough -0.405 High fat dairies High-fat milk, whole milk, chocolate milk, high-fat yogurt, cream yogurt, cream cheese, ice cream -0.502 Red meat Beef, lamb, ground meat, types of Kabab 0.680 Poultry Chicken -0.314 -0.421 Fish Fish -0.266 -0.467 Eggs Eggs 0.431 Viscera Heart, liver and intestines, head, stomach, tongue, brain 0.218 -0.372 Solid oils solid oil, animal oil, butter, margarine 0.653 0.431 Liquid oil Liquid oil -0.360 -0.265 Olive oil Olive oil, olive -0.594 Processed meat and fast foods Sausage, pizza, hamburger 0.474 -0.251 Fatty Foods Fried potatoes, fried onions, tuna fish, Potato and vegetable omelet (kookoo in persian), halva, mayonnaise sauce, Oily bread, cake, cream, creamy sweets, 0.613 Dried fruits Dried figs, raisin, dried mulberries, dates and other dried fruits 0.518 Snack Potato chips, corn puffs, crackers, popcorn 0.475 -0.235 Honey and jam Honey and jam 0.235 Sweets and sugars Vegetables Biscuit, cookies, confections, pastries, sugars, sugar cube, candies, gaz (an Iranian confectionery made of sugar, nuts, and tamarisk), chocolate 0.711 Spinach, lettuce, mixed vegetable, stew vegetables, local vegetables, kinds of cabbage, celery, carrots,, green squash, pepper,, tomato, green peas 0.723 -0.211 Other vegetables cucumber,, mixed vegetable, stew vegetables, local vegetables, Eggplant, onion, mushroom, garlic, pumpkin, corn 0.722 -0.220 Fruits Apple, banana, strawberry, white berry, cherry, apricot, peach, plum, fig, pear, grape, watermelon, cantaloupe, melon, persimmon, pomegranate, kiwi, pineapple, mango -0.358 Citrus Lemon, lime, tangerine, orange, grapefruit -0.408 -0.279 Soft drinks Soda, soft drinks 0.588 Fruit juices Fruit (apple, orange, cantaloupe, …) juices 0.420 Tea Tea 0.397 Coffee Coffee 0.318 Pickle Pickles, brine 0.555 Lemon juice Lemon juice - - - potato 0.659 *Absolute factor loading values < 0.20 for all patterns were excluded for simplicity. Β Bartlett’s test of sphericity < 0.001; Kaiser_Meyer_Olkin = 0.778; total variance = 28.72%. The logistic regression analysis of dietary pattern scores is presented in Table 4 . Among the three identified patterns, the 1st and 3rd showed significant associations with endometriosis (OR = 29.73, 95% CI = 11.09–79.7, p-value < 0.001, and OR = 1.84, 95% CI = 1.29–2.61, p = 0.001, respectively). This association remained significant after adjusting for confounders in model one (OR = 24.5, 95% CI = 8.68–69.15, p-value < 0.001, and OR = 1.57, 95% CI = 1.06–2.33, p = 0.02, respectively), model two (OR = 29.44, 95% CI = 7.46-116.12, p-value < 0.001, and OR = 1.57, 95% CI = 1.05–2.35, p = 0.03, respectively), and model three (OR = 25.54, 95% CI = 5.84-111.72, p-value < 0.001, and OR = 1.86, 95% CI = 1.14–3.04, p = 0.01). In contrast, no significant correlation was found for the second dietary pattern across crude or adjusted models (OR = 1.07, 95% CI = 0.79–1.47, p-value = 0.64, and OR = 0.87, 95% CI = 0.59–1.28, p = 0.47, OR = 0.86, 95% CI = 0.58–1.29, p-value = 0.48, OR = 0.89, 95% CI = 0.55–1.44, p-value = 0.63, respectively). Additionally, Table 5 shows that the case group had significantly higher mean scores for dietary patterns 1 and 3 compared to the control group (P < 0.05). These results suggest a potential link between high-fat and high-sugar food consumption and an increased risk of endometriosis. Table 4 Odds ratios and 95% confidence intervals for dietary patterns and endometriosis Dietary pattern Model OR 95% CI P-value Dietary pattern 1 Crude model Model 1a Model 2b Model 3c 29.73 24.5 29.44 25.54 11.09–79.7 8.68–69.15 7.46-116.12 5.84-111.72 < 0.001 < 0.001 < 0.001 < 0.001 Dietary pattern 2 Crude model Model 1a Model 2b Model 3c 1.07 0.87 0.86 0.89 0.79–1.47 0.59–1.28 0.58–1.29 0.55–1.44 0.64 0.47 0.48 0.63 Dietary pattern 3 Crude model Model 1a Model 2b Model 3c 1.84 1.57 1.57 1.86 1.29–2.61 1.06–2.33 1.05–2.35 1.14–3.04 0.001 0.02 0.03 0.01 OR, odds ratio; CI, confidence interval. a Adjusted for previous pregnancy, sequence of menstrual cycle, duration of menstruation, and menstrual volume. b Adjusted for variables in model 1 and BMI, level of physical activity, and education. Table 5 Comparison of mean and standard error of factor scores of dietary patterns in endometriosis and control groups Dietary pattern 1 Dietary pattern 2 Dietary pattern 3 Group Mean ± SE Mean ± SE Mean ± SE Case 1.23 ± 0.068 0.04 ± 0.14 0.37 ± 0.13 Control -0.38 ± 0.060 -0.02 ± 0.08 -0.18 ± 0.08 p < 0.001 0.66 0.001 *p values were computed by the independent t test. Discussion In this case-control study, we explored the relationship between dietary patterns and endometriosis in women. We found that dietary patterns 1 and 3 were significantly associated with higher odds of endometriosis, even after adjusting for confounders, while no association was found with dietary pattern 2. Dietary pattern 1 included high intake of red meat, hydrogenated fats, fatty and fast foods, dried fruit, soy, tea, nuts, viscera, fruits, low and high-fat dairy, and olive oil. Dietary pattern 3 was rich in sugar, grains, fruit juice, soft drinks, jam, honey, hydrogenated fat, poultry, and beans. One of the components of the first dietary pattern is meat. According to our study, a diet rich in meat was associated with higher odds of endometriosis. Our study showed that a diet rich in meat is associated with higher odds of endometriosis, aligning with previous findings, Parazzini et al. and a meta-analysis conducted in 2022, which reported a 17% increased risk with higher red meat consumption ( 6 , 19 ). This may be due to saturated fatty acids (SFAs) in animal protein( 20 ). Saturated fatty acids have the ability to trigger a pro inflammatory molecule known as LPS. Certain immune system cells, such as macrophages, possess a receptor named TLR4 that detects LPS( 21 ). Upon binding to TLR4, LPS initiates a signaling pathway that activates a transcription factor called NF-κB. NF-κB then prompts the expression of pro-inflammatory cytokines( 22 , 23 ). In vitro studies have shown that SFAs can directly induce the expression of inflammatory genes by binding to TLR4( 24 ). SFAs can cause inflammation in the body by imitating the effects of LPS. For instance, palmitic acid (PA), a common SFA, has been demonstrated to activate TLR4 receptors in hypothalamic microglia and promote the release of cytokines( 25 ). PA might also heighten the risk of endometriosis by generating estrogen, which can elicit inflammation in endometriosis by activating specific prostaglandins( 13 , 26 ). Another possible mechanism which contribute to the endometriosis, is the effect of red meat on steroid hormones( 27 ). red meat consumption may lower sex hormone-binding globulin (SHBG) and raise estradiol levels( 28 ), while its high iron content can induce oxidative stress and inflammation( 26 ). In contrast to our result, Samaneh et al. found that the consumption of red meat in the highest quartile was associated with a lower risk for endometriosis, It is argued due to the rich nutrient content, including protein, iron, and vitamin. However, no relationship was observed in the lower quartiles( 29 ). Other studies, such as those by Heilier and Trabert, found no significant association, which could be due to differences in the classifications servings/week( 30 , 31 ). Marcinkowska et al. also noted that the risk may increase with higher consumption of saturated fats, particularly palmitic acid and trans-unsaturated fatty acids( 22 ). Missmer et al. showed that increased trans fats intake is linked to a higher risk of endometriosis( 13 ). It is argued that, by consuming a high-fat diet, the inflammatory response in endometriosis is triggered due to the production of trans fatty acids during food processing. This diet leads to elevated levels of systemic inflammation markers such as CRP, IL-6, and TNF and promotes endogenous estrogen production. Additionally, this dietary pattern impacts the immune system, reduces phagocytosis ability, increases active macrophages, and activates the inflammatory pathway ROS NF-κB resulting in heightened endometriosis lesions( 32 ). In contrast to our result, Ghasemisedaghat et al. discovered that the association of fat consumption with endometriosis was not statistically significant, nonetheless individuals with a high MUFA/TFA ratio had lower odds of developing endometriosis( 20 ). The analysis of fat subgroups revealed no direct link between SFA and TFA with endometriosis, nor an inverse relationship between MUFA and PUFA( 19 ). Trabert et al. did not find a significant impact of trans fat consumption on the risk of endometriosis( 31 ). Our study's findings indicated a positive correlation between endometriosis and the consumption of dairy rich dietary pattern. Surprisingly, this differs from many previous studies. A meta-analysis showed that higher dairy intake is linked to a lower risk of endometriosis( 19 ). Possibly due to calcium and vitamin D in dairy products and their role in reducing growth factors like Insulin-like growth factor 1 IGF-I and increasing regulators like transforming growth factor β (TGF-β)( 31 ). Dairy consumption and higher calcium may also lower inflammation ( 33 ). The disagreement between our findings and others may stem from our focus on dietary patterns that include dairy alongside other foods, rather than isolating individual items or nutrients. This approach offers a different perspective on the dairy-endometriosis relationship( 34 ). As it has been shown in the present study, the consumption of foods with high glycemic index is predominant in food pattern 3 and is directly related to the increased risk of endometriosis. Similar to our study, Ghasemisedaghat et al. also found a significant positive association between glycemic load and endometriosis, they argued that this association might be due to the low levels of complex carbohydrates and fiber consumption in women with endometriosis, who followed a high glycemic diet( 20 , 35 ). High consumption of juice, soft drinks, jam, and generally simple carbohydrates in this pattern was associated with an increased levels of estrogen. High consumption of simple carbohydrates in the diet causes hyperinsulinemia, which increases the level of endogenous estrogen through the reduction of SHBG and the increase of IGF-1 in endometrial cells( 11 , 36 , 37 ). In contrast to our study, Schwartz et al. have not observed any correlation between glycemic load (GL) And laparoscopically confirmed endometriosis diagnosis, among premenopausal women( 35 ). Soy isoflavones may contribute to the development of estrogen-related diseases, and research on soy isoflavones has been complex and inconclusive( 38 – 40 ). This may be due to the agonistic and antagonistic properties of genistein and daidzein( 41 , 42 ). In our research, we discovered that high soy intake, when combined with other foods in food pattern one, is linked to a higher risk of endometriosis. Consistent with our results, Mvondo et al. showed that consuming over 10% soy during the prepubertal stage in rats could enhance the growth and survival of ectopic endometrial cells and worsen endometriosis-related pain in adulthood( 43 ). This was achieved by stimulating cell proliferation with daidzein( 44 ) and cell hypertrophy with genistein( 41 ). Contrary to our findings, Tsuchiya et al. showed that higher urinary isoflavones are inversely associated with advanced endometriosis, but not correlated with early-stage endometriosis( 45 ). Previous study also indicated that long-term genistein consumption can reduce estradiol response levels and estrogen receptor mRNA( 46 ). In our study, we found no significant link between the second dietary pattern, comprising high-fat snacks, Viscera, cereals, chicken, potatoes, eggs, vegetables, and coffee, and the risk of endometriosis. Previous research did not explore this specific dietary pattern, but a meta-analysis conducted by Arab and et al. on food groups and their components, such as vegetables yielded similar results to ours. While overall vegetable consumption appeared to decrease the risk of endometriosis, the change was not statistically significant( 19 ). However, the meta-analysis outcome was influenced by Harris et al.'s study, which demonstrated no association between total vegetable intake and endometriosis risk. Interestingly, women who consumed ≥ 1 serving of cruciferous vegetables (broccoli, cauliflower, cabbage and Brussel sprouts) daily had a 13% higher risk of endometriosis compared to those consuming < 1 serving per week( 47 ). This finding may suggest a link between gastrointestinal symptoms and the development and worsening of endometriosis-related pain( 48 ). Our study had some limitations, but we took steps to minimize biases, such as selecting newly diagnosed participants to reduce recall bias. Dietary patterns were assessed using a 12-month FFQ reflecting food intake over the year before the study. While the occurrence of disease might take place many years before. Thus, this assessment may not reflect eating patterns prior to the date of diagnosis. Conclusion dietary patterns high in red meat, hydrogenated fats, fatty and fast foods, sweet dried fruit, soy, tea, nuts, viscera, fruits, citrus, low and high-fat dairy, olive oil, and a pattern with higher amounts of sugar, grains, fruit juice, soft drinks, jam, honey, hydrogenated fat, poultry, and beans, as well, may increase the risk of endometriosis. More research is needed to understand the role of diet in endometriosis development and progression. Also more comprehensive understanding of the influence of dietary components and patterns on the risk of endometriosis is crucial to developing population-based strategies to prevent this serious and common gynecological disease. Declarations Ethics approval and consent to participate The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Urmia University of Medical Sciences, Urmia, Iran (Ethics Code IR.UMSU.REC.1400.396) . The patients/participants provided their written informed consent to participate in this study Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This work was supported by Urmia University Of Medical Sience (December 2021 to March 2022). Acknowledgements The authors would like to thank all patients who participate in this study. Aouther Contributions Dr Behrouzi Lak: Conceptualisation, Resources, Methodology. Dr Daneghian: Conceptualisation, Methodology, Visualization, Formal analysis, Writing - Review & Editing. Ahmadi: Conceptualisation, Methodology, Formal analysis, Investigation, Data Curation. Aminian: Investigation, Data Curation, Writing - Original Draft, Formal analysis. 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Cutting edge: Toll-like receptor 4 (TLR4)-deficient mice are hyporesponsive to lipopolysaccharide: evidence for TLR4 as the Lps gene product. J Immunol. 1999;162(7):3749–52. Marcinkowska A, Górnicka M. The role of dietary fats in the development and treatment of endometriosis. Life. 2023;13(3):654. Takeda K, Kaisho T, Akira S. Toll-like receptors. Annu Rev Immunol. 2003;21(1):335–76. Lee JY, Sohn KH, Rhee SH, Hwang D. Saturated fatty acids, but not unsaturated fatty acids, induce the expression of cyclooxygenase-2 mediated through Toll-like receptor 4. J Biol Chem. 2001;276(20):16683–9. Vergnaud A-C, Norat T, Mouw T, Romaguera D, May AM, Bueno-de-Mesquita HB, et al. Macronutrient composition of the diet and prospective weight change in participants of the EPIC-PANACEA study. PLoS ONE. 2013;8(3):e57300. Seli E, Berkkanoglu M, Arici A. Pathogenesis of endometriosis. Obstet Gynecol Clin. 2003;30(1):41–61. Andersson A-M, Skakkebaek NE. Exposure to exogenous estrogens in food: possible impact on human development and health. Eur J Endocrinol. 1999;140(6):477–85. Brinkman M, Baglietto L, Krishnan K, English D, Severi G, Morris H, et al. Consumption of animal products, their nutrient components and postmenopausal circulating steroid hormone concentrations. Eur J Clin Nutr. 2010;64(2):176–83. Samaneh Y, ShahidehJahanian S, Azadeh M, Anoshirvan K. The association of food consumption and nutrient intake with endometriosis risk in Iranian women: A case-control study. Int J reproductive Biomed. 2019;17(9):661. Heilier J-F, Donnez J, Nackers F, Rousseau R, Verougstraete V, Rosenkranz K, et al. Environmental and host-associated risk factors in endometriosis and deep endometriotic nodules: a matched case–control study. Environ Res. 2007;103(1):121–9. Trabert B, Peters U, De Roos AJ, Scholes D, Holt VL. Diet and risk of endometriosis in a population-based case–control study. Br J Nutr. 2011;105(3):459–67. Riccio LGC, Santulli P, Marcellin L, Abrão MS, Batteux F, Chapron C. Immunology of endometriosis. Best practice & research Clinical obstetrics & gynaecology. 2018;50:39–49. Zemel MB, Sun X. Dietary calcium and dairy products modulate oxidative and inflammatory stress in mice and humans. J Nutr. 2008;138(6):1047–52. Mazza E, Troiano E, Mazza S, Ferro Y, Abbinante A, Agneta MT, et al. The impact of endometriosis on dietary choices and activities of everyday life: a cross-sectional study. Front Nutr. 2023;10:1273976. Schwartz NR, Afeiche MC, Terry KL, Farland LV, Chavarro JE, Missmer SA, et al. Glycemic index, glycemic load, fiber, and gluten intake and risk of laparoscopically confirmed endometriosis in premenopausal women. J Nutr. 2022;152(9):2088–96. Sadeghi A, Sadeghian M, Nasiri M, Rahmani J, Khodadost M, Pirouzi A, et al. Carbohydrate quantity and quality affect the risk of endometrial cancer: a systematic review and dose-response meta-analysis. Clin Nutr. 2020;39(6):1681–91. Florova MS, Yarmolinskaya MI, Tkachenko NN, Tolibova GK, Tral TG. Role of insulin and insulin-like growth factor I receptor expression in the pathogenesis of genital endometriosis. J Obstet women's Dis. 2021;70(3):65–74. Ballard K, Seaman H, De Vries CS, Wright J. Can symptomatology help in the diagnosis of endometriosis? Findings from a national case–control study—part 1. BJOG: Int J Obstet Gynecol. 2008;115(11):1382–91. Bektaş H, Bilsel Y, Sarı YS, Ersöz F, Koç O, Deniz M, et al. Abdominal wall endometrioma; a 10-year experience and brief review of the literature. J Surg Res. 2010;164(1):e77–81. Hirsch M, Begum MR, Paniz É, Barker C, Davis CJ, Duffy JM. Diagnosis and management of endometriosis: a systematic review of international and national guidelines. BJOG: Int J Obstet Gynecol. 2018;125(5):556–64. Gaete L, Tchernitchin AN, Bustamante R, Villena J, Ferrada K, Erazo S, et al. Biological activity of genistein and soy extracts: selective induction of some but not all estrogenic responses in the prepubertal rat uterus. Boletín Latinoamericano y del Caribe de Plantas Medicinales y Aromáticas. 2010;9(4):302–11. Gaete L, Tchernitchin AN, Bustamante R, Villena J, Lemus I, Gidekel M, et al. Genistein selectively inhibits estrogen-induced cell proliferation and other responses to hormone stimulation in the prepubertal rat uterus. J Med Food. 2011;14(12):1597–603. Mvondo MA, Ekenfack JD, Minko Essono S, Saah Namekong H, Awounfack CF, Laschke MW, et al. Soy intake since the prepubertal age may contribute to the pathogenesis of endometriosis in adulthood. J Med Food. 2019;22(6):631–8. Gaete L, Tchernitchin AN, Bustamante R, Villena J, Lemus I, Gidekel M, et al. Daidzein–estrogen interaction in the rat uterus and its effect on human breast cancer cell growth. J Med Food. 2012;15(12):1081–90. Tsuchiya M, Miura T, Hanaoka T, Iwasaki M, Sasaki H, Tanaka T, et al. Effect of soy isoflavones on endometriosis: interaction with estrogen receptor 2 gene polymorphism. Epidemiology. 2007;18(3):402–8. Wang TT, Sathyamoorthy N, Phang JM. Molecular effects of genistein on estrogen receptor mediated pathways. Carcinogenesis. 1996;17(2):271–5. Harris H, Eke A, Chavarro J, Missmer S. Fruit and vegetable consumption and risk of endometriosis. Hum Reprod. 2018;33(4):715–27. Eswaran SL, Chey WD, Han-Markey T, Ball S, Jackson K. A randomized controlled trial comparing the low FODMAP diet vs. modified NICE guidelines in US adults with IBS-D. Official J Am Coll Gastroenterology| ACG. 2016;111(12):1824–32. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Feb, 2026 Read the published version in BMC Nutrition → Version 1 posted Editorial decision: Revision requested 10 Oct, 2025 Reviews received at journal 30 Sep, 2025 Reviews received at journal 23 Sep, 2025 Reviews received at journal 21 Sep, 2025 Reviewers agreed at journal 21 Sep, 2025 Reviewers agreed at journal 21 Sep, 2025 Reviewers agreed at journal 21 Sep, 2025 Reviewers invited by journal 21 Sep, 2025 Editor assigned by journal 23 Aug, 2025 Editor invited by journal 11 Aug, 2025 Submission checks completed at journal 06 Aug, 2025 First submitted to journal 06 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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01:07:14","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":144496,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7168622/v1/69323d1a309299f282a85a4c.html"},{"id":92682414,"identity":"687d6e7b-e5ca-4a31-92c2-b06cb757dd35","added_by":"auto","created_at":"2025-10-03 01:15:14","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107727,"visible":true,"origin":"","legend":"\u003cp\u003eScree plot (Eigenvalues of the factors) used for decision-making and selecting the appropriate number of factors.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7168622/v1/50f14cf0ce8a0c0eef05715a.jpeg"},{"id":102785848,"identity":"320b652b-9303-4933-8fae-c715ad1e5bfb","added_by":"auto","created_at":"2026-02-16 16:10:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":974435,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7168622/v1/76ea76f1-444e-4b20-bdea-50b4faf3cabe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Association between dominant food patterns and intake of energy and macronutrients with endometriosis in women aged 15-45","fulltext":[{"header":"Background","content":"\u003cp\u003eEndometriosis is a hormone-dependent inflammatory disease marked by the presence of endometrial tissue outside the uterus (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), typically starting in adolescence (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It is associated with pelvic pain (dysmenorrhea, dyspareunia, dyschezia) and infertility (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), which can greatly affect the physical, mental, sexual and social wellbeing, while also causing high societal costs (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), which is similar to the costs for other chronic conditions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Symptoms often appear up to 10 years before diagnosis, adding to these costs (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Endometriosis affects about 10% of reproductive-age women worldwide(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eEndometriosis has a multifactorial etiology, with retrograde menstruation being the most widely accepted theory(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Treatments include painkillers, hormonal therapies to lower or counter estrogen, and surgeries to remove affected organs. However, these options often fail, are costly, have side effects, and pain may recur(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDietary factors may contribute to the development and severity of endometriosis by affecting estrogen, inflammation, prostaglandin metabolism, or muscle contractility. However the impact of specific food groups remains unclear.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMany women with endometriosis use self-management strategies like nutrition, exercise, and meditation to manage symptoms and improve quality of life. Dietary interventions, particularly those rich in anti-inflammatory and anti-estrogen nutrients like antioxidants and omega-3 fatty acids, have shown promise in reducing symptoms.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRecent studies has shown high-carbohydrate diets exacerbating endometriosis symptoms, as insulin may stimulate endometrial cell growth and increase estrogen levels.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLarge cohort studies also found a significant association between red meat consumption and endometriosis risk, while no link was observed for fish, poultry, eggs, or total fat(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDietary pattern analysis has become a popular method for examining the link between diet and chronic diseases. Unlike examining individual nutrients or foods, pattern analysis evaluates the effects of overall diet(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This approach offers several advantages, including investigating the interactive or synergistic effects of foods when consumed together, as opposed to evaluating individual food intakes. Thus, the aim of this study was to investigating between dominant food patterns and intake of energy and macronutrients with endometriosis in women in reproductive age.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy population\u003c/p\u003e\u003cp\u003eThis case-control study was conducted from December 2021 to March 2022 at the Kosar Women's Educational-Therapy Center in Urmia, Iran. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Urmia University of Medical Sciences, Urmia, Iran (Ethics Code IR.UMSU.REC.1400.396). The patients/participants provided their written informed consent to participate in this study. The study involved 180 women aged 15\u0026ndash;45, including 60 diagnosed with endometriosis confirmed by laparoscopy in the case group and 120 healthy women in the control group. Inclusion criteria included being aged 15\u0026ndash;45 and newly diagnosed with endometriosis. Exclusion criteria included a history of chronic diseases, dieting in the past three months, and mental or cognitive disorders affecting participation. Participants with implausible daily caloric intake based on the food frequency questionnaire (FFQ) (e.g., \u0026lt;\u0026thinsp;500 or \u0026gt;\u0026thinsp;5000 kcal) or those who left more than 70 items unanswered were also excluded. Controls were selected from relatives or friends of the cases to account for potential confounders such as home environment and socio-economic status, and they had no endometriosis or related conditions based on self-reporting. Demographic data collected included age, marital status, occupation, education level, and family history of endometriosis in mothers and sisters. Menstrual pattern factors most related to endometriosis, including menstrual cycle sequence, duration, and intensity, were gathered through interviews. The Metabolic Equivalent of Task (MET) questionnaire was used to assess participants' physical activity levels(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDietary assessment\u003c/p\u003e\u003cp\u003eA validated 146-item semi-quantitative food frequency questionnaire (FFQ) was used to assess dietary intake(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Participant reported the frequency of consumption of each food item over the past year, using daily (e.g., bread), weekly (e.g., meat), or monthly (e.g., fish) units. We calculated daily intake from the FFQ and converted food amounts into grams/day. The 146 food items were categorized into 30 groups based on nutrient similarity, with some items classified as single foods (e.g., egg, poultry)(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCompleted FFQ data were entered into modified Nutritionist IV software, which calculated total energy and macronutrient intake for each participant.\u003c/p\u003e\u003cp\u003eThe reliability and validity of the questionnaire for the Iranian adult population were confirmed in previous studies using 24-hour dietary recalls for comparison. To ensure accuracy, we piloted the FFQ with 10% of our sample size and used 24-hour dietary recalls (two weekdays and one weekend day) to gather additional data, conducted by the researcher following a standardized protocol lasting about 20 minutes (supplementary file). Interviewers used a booklet with portion size images to enhance assessment accuracy.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe sample size was calculated according to prevalence of endometriosis (15%) and using the OR ratio equal to 3.42 for vegetable and animal oils in a previous study(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), with the power of 90% and 95% confidence interval using the following formulas:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:{P}_{2}=\\:\\frac{{\\text{P}}_{1}\\text{}\\times\\:\\text{O}\\text{R}}{1\\:+\\:{\\text{P}}_{1}\\:(\\text{O}\\text{R}\\:-\\:1)}$$\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:p=\\frac{{p}_{1+}\\:{p}_{2}}{2}$$\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Equc\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equc\" name=\"EquationSource\"\u003e\n$$\\:C=\\frac{control}{case}=\\:\\frac{2}{1}$$\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Equd\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equd\" name=\"EquationSource\"\u003e\n$$\\:n=\\:\\frac{\\left(1+\\frac{1}{c}\\right)\\text{*}{\\left({Z}_{1-\\frac{{\\alpha\\:}}{2}}+{Z}_{1-{\\beta\\:}\\text{}}\\text{}\\right)}^{2}\\text{*}P(1-P)}{{\\left({P}_{1}-{P}_{2}\\right)}^{2}}$$\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Eque\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Eque\" name=\"EquationSource\"\u003e\n$$\\:n=\\:\\frac{\\left(1+\\frac{1}{2}\\right)\\text{*}\\left({1.96+1.28)}^{2}\\text{*}0.26\\right(0.74)}{({0.15-0.38)}^{2}}\\cong\\:60$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e(Z1-α/2\u0026thinsp;=\u0026thinsp;1.96, Z1-β\u0026thinsp;=\u0026thinsp;1.28, P1\u0026thinsp;=\u0026thinsp;0.15, P2\u0026thinsp;\u0026cong;\u0026thinsp;0.38, OR\u0026thinsp;=\u0026thinsp;3.42, P\u0026thinsp;\u0026cong;\u0026thinsp;0.26)\u003c/p\u003e\u003cp\u003eContinuous and categorical variables were summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or number (%), respectively (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Categorical demographic variables were compared using Pearson\u0026rsquo;s Chi-square Test, while independent t-tests were used for continuous variables between groups.\u003c/p\u003e\u003cp\u003eThirty food groups were included in the analysis based on food similarity (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Principal component analysis (PCA) and Kaiser-Meyer-Olkin (KMO) and Bartlett\u0026rsquo;s tests were used to find major dietary patterns and to assess factor analysis suitability, respectively. KMO ranges between 0 and 1, and the minimum value for proper factor analysis is 0.6. Besides, Bartlett\u0026rsquo;s test should be significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The sampling sufficiency of components was approved by the KMO test (value: 0.78). Moreover, the inter-correlation of components was confirmed using Bartlett\u0026rsquo;s test of sphericity\u0026thinsp;\u0026lt;\u0026thinsp;0.001. We used a factor eigenvalue to decide several factors to retain. Besides, we used the scree plot which involves plotting each value. Dietary patterns were determined due to eigenvalue\u0026thinsp;\u0026gt;\u0026thinsp;1.5 and scree plot examination (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). To simplify the interpretation of data orthogonal rotation (varimax) was used. Food groups with absolute factor loadings of more than 0.3 were considered to have a significant contribution to the pattern. To name each dietary pattern, the principal food groups were considered. A score was assigned to all participants considering adherence to each dietary pattern.\u003c/p\u003e\u003cp\u003eOdds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression to examine the relationship between dietary pattern scores and endometriosis. Factor scores were treated as independent and dependent variables, respectively. In addition to the crude model, three models were used including a model adjusted for previous pregnancy, sequence of the menstrual cycle, duration of menstruation, and menstrual volume (model 1); and adjusted for BMI, level of physical activity, and education, in addition to first model variables (model 2); and adjusted for mean energy, carbohydrate and lipid intake in addition to second model variable (model 3).\u003c/p\u003e\u003cp\u003eData were analyzed using SPSS software version 22 (IBM Corp. IBM SPSS Statistics for Windows, Armonk, NY), and p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study was started from December 2021 and completed in March 2022 and was performed on 180 participants, 60 case and 120 healthy control.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1and Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the general characteristics of study participants in case and control groups. When the demographic characteristics of the women with endometriosis were compared with the control group, there were no significant differences detected in the marital status, occupation, family history of endometriosis, underlying disease and cigarette smoking. However, there was significant difference in weight, physical activity, BMI, education level, successful pregnancy, sequence of menstrual cycle, duration of menstruation, intensity of menstrual volume (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Significant differences were also observed in terms of energy, carbohydrate, and lipid intake, with higher intake among case group (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). According to the results, participants in the case group had a significantly higher weight, BMI, energy intake, dietary carbohydrate and lipid intake (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, those in the control group had a higher physical activity, and educational status (11.7% in case versus 71.7% in control group). In addition, in control group menstrual pattern factors, including sequence of menstrual cycle (3.3% in case versus 90.8% in control group), duration of menstruation (65% of subjects had normal duration in case versus 94.2% in control group), and intensity of menstrual volume (53.3% of subjects had normal volume in case versus 94.2% in control group), were normal and had higher successful pregnancy history compare to case group. Among control group 68.3% of subjects had successful pregnancy, however this was 50% among case group.\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eComparison of baseline qualitative characteristics between the endometriosis and control groups\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCase\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eControl\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;120)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP*\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNumber of successful pregnancy\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e30 (50)\u003c/p\u003e\n\u003cp\u003e30 (50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e82 (68.3)\u003c/p\u003e\n\u003cp\u003e38 (31.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLevel of education\u003c/p\u003e\n\u003cp\u003eUniversity\u003c/p\u003e\n\u003cp\u003eHigh school\u003c/p\u003e\n\u003cp\u003eSecondary school and less\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e7 (11.7)\u003c/p\u003e\n\u003cp\u003e28 (46.7)\u003c/p\u003e\n\u003cp\u003e25 (41.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e86 (71.7)\u003c/p\u003e\n\u003cp\u003e31 (25.8)\u003c/p\u003e\n\u003cp\u003e86 (71.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarital status\u003c/p\u003e\n\u003cp\u003eSingle\u003c/p\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e11 (18.3)\u003c/p\u003e\n\u003cp\u003e49 (81.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e35 (29.2)\u003c/p\u003e\n\u003cp\u003e85 (60.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.12\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOccupation\u003c/p\u003e\n\u003cp\u003eHousewife\u003c/p\u003e\n\u003cp\u003eEmployed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e41 (68.3)\u003c/p\u003e\n\u003cp\u003e19 (31.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e66 (55)\u003c/p\u003e\n\u003cp\u003e54 (\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.08\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFamily history of Endometriosis\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9 (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003e51 (85)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9 (7.5)\u003c/p\u003e\n\u003cp\u003e111 (92.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.11\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnderlying disease\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9 (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003e51 (85)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e13 (10.8)\u003c/p\u003e\n\u003cp\u003e107 (89.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.42\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSmoking\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1 (1.7)\u003c/p\u003e\n\u003cp\u003e59 (98.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3 (2.5)\u003c/p\u003e\n\u003cp\u003e117 (97.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0.72\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSequence of menstrual cycle\u003c/p\u003e\n\u003cp\u003eLow\u003c/p\u003e\n\u003cp\u003eNormal\u003c/p\u003e\n\u003cp\u003eMore\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e36 (60)\u003c/p\u003e\n\u003cp\u003e2 (3.3)\u003c/p\u003e\n\u003cp\u003e22 (36.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3 (2.5)\u003c/p\u003e\n\u003cp\u003e109 (90.8)\u003c/p\u003e\n\u003cp\u003e8 (6.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDuration of menstruation\u003c/p\u003e\n\u003cp\u003eLow\u003c/p\u003e\n\u003cp\u003eNormal\u003c/p\u003e\n\u003cp\u003eMore\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e21 (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003e39 (65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e7 (5.8)\u003c/p\u003e\n\u003cp\u003e113 (94.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntensity of menstrual volume\u003c/p\u003e\n\u003cp\u003eLow\u003c/p\u003e\n\u003cp\u003eNormal\u003c/p\u003e\n\u003cp\u003eMore\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e20 (33.3)\u003c/p\u003e\n\u003cp\u003e32 (53.3)\u003c/p\u003e\n\u003cp\u003e8 (13.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e6 (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003e113 (94.2)\u003c/p\u003e\n\u003cp\u003e1 (0.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*p values were computed by the Person\u0026rsquo;s Chi-square Test.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eGeneral characteristics of participants with endometriosis and controls.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eendometriosis\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eControl\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;120)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP*\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMin-Max\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMin-Max\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge (y)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.38\u0026thinsp;\u0026plusmn;\u0026thinsp;5.36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21\u0026ndash;40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28.88\u0026thinsp;\u0026plusmn;\u0026thinsp;5.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20\u0026ndash;44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.07*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHeight (cm)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e162.08\u0026thinsp;\u0026plusmn;\u0026thinsp;4.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e153\u0026ndash;171\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e161.88\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e151\u0026ndash;175\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.83*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWeight (kg)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53\u0026ndash;96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64.37\u0026thinsp;\u0026plusmn;\u0026thinsp;7.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e47\u0026ndash;83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.008*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBMI (kg/m2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.77\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21.4\u0026ndash;36.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.62\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19.7\u0026ndash;30.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.001**\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical activity (MET.min/week)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1745.37\u0026thinsp;\u0026plusmn;\u0026thinsp;499.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e939\u0026ndash;2870\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1951.67\u0026thinsp;\u0026plusmn;\u0026thinsp;545.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1002\u0026ndash;3360\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.01*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEnergy (Kcal)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2452.59\u0026thinsp;\u0026plusmn;\u0026thinsp;394.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1686\u0026ndash;3592\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2161.2\u0026thinsp;\u0026plusmn;\u0026thinsp;265.09\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1472\u0026ndash;2950\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCarbohydrate(gr)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e318.04\u0026thinsp;\u0026plusmn;\u0026thinsp;55.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e204\u0026ndash;451\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e296.66\u0026thinsp;\u0026plusmn;\u0026thinsp;49.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e182\u0026ndash;447\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.009**\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eProtein(gr)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87.52\u0026thinsp;\u0026plusmn;\u0026thinsp;14.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51.6-113.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87.11\u0026thinsp;\u0026plusmn;\u0026thinsp;12.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e59\u0026ndash;118\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.85**\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLipid(gr)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89.93\u0026thinsp;\u0026plusmn;\u0026thinsp;18.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54.6\u0026ndash;143\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e74.43\u0026thinsp;\u0026plusmn;\u0026thinsp;85.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e47.6\u0026ndash;121\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*p values were computed by the Mann\u0026ndash;Whitney\u0026rsquo;s test.\u003c/p\u003e\n\u003cp\u003e**p values were computed by the independent t test.\u003c/p\u003e\n\u003cp\u003eMajor dietary patterns and endometriosis\u003c/p\u003e\n\u003cp\u003eBy the use of factor analysis, 3 major dietary patterns were extracted. Totally, these factors explained 28.72% of the whole variance. We labeled these factors as following; 1. Dietary pattern 1 (high in red meat, hydrogenated fats, fast foods, Sweet dried fruit, soy, tea, nuts, Viscera), which explained 16.74% of the whole variance. 2. Dietary pattern 2 (high in vegetables, potato, egg, grains and coffee) which explained 6.19% of the whole variance. 3. Dietary pattern 3 (high in sugar, grain, fruit juice, jam, honey and hydrogenated fat) which explained 5.78% of the whole variance.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eFood groups and factor-loading matrix for major dietary patterns, explored by factor analysis\u0026beta;.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eFood groups\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eFood items\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eDietary patterns*\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003egrains\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhite bread (lavash, baguette, sangak, barbari), noodles, pasta, starch, Buckwheat and oats, rice, wheat flour\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.382\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.347\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSoybean\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSoybean\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.439\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBeans\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBeans, chickpeas, lentils, mung beans, green beans\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.504\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLow fat dairies\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSkim or low-fat milk, low-fat yogurt, cheese, curd and dough\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.405\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigh fat dairies\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigh-fat milk, whole milk, chocolate milk, high-fat yogurt, cream yogurt, cream cheese, ice cream\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.502\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRed meat\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBeef, lamb, ground meat, types of Kabab\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.680\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePoultry\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChicken\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.314\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.421\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFish\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFish\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.266\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.467\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEggs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEggs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.431\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eViscera\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHeart, liver and intestines, head, stomach, tongue, brain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.218\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.372\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSolid oils\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esolid oil, animal oil, butter, margarine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.653\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.431\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLiquid oil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLiquid oil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.360\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.265\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOlive oil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOlive oil, olive\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.594\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eProcessed meat and fast foods\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSausage, pizza, hamburger\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.474\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.251\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFatty Foods\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFried potatoes, fried onions, tuna fish, Potato and vegetable omelet (kookoo in persian), halva, mayonnaise sauce, Oily bread, cake, cream, creamy sweets,\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.613\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDried fruits\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDried figs, raisin, dried mulberries, dates and other dried fruits\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.518\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSnack\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePotato chips, corn puffs, crackers, popcorn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.475\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.235\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHoney and jam\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHoney and jam\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.235\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eSweets and\u003c/p\u003e\n\u003cp\u003esugars\u003c/p\u003e\n\u003cp\u003eVegetables\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBiscuit, cookies, confections, pastries, sugars, sugar cube, candies, gaz (an Iranian confectionery made of sugar, nuts, and tamarisk), chocolate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.711\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSpinach, lettuce, mixed vegetable, stew vegetables, local vegetables, kinds of cabbage, celery, carrots,, green squash, pepper,, tomato, green peas\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.723\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.211\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther vegetables\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecucumber,, mixed vegetable, stew vegetables, local vegetables, Eggplant, onion, mushroom, garlic, pumpkin, corn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.722\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.220\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFruits\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eApple, banana, strawberry, white berry, cherry, apricot, peach, plum, fig, pear, grape, watermelon, cantaloupe, melon, persimmon, pomegranate, kiwi, pineapple, mango\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.358\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCitrus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLemon, lime, tangerine, orange, grapefruit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.408\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.279\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSoft drinks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSoda, soft drinks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.588\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFruit juices\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFruit (apple, orange, cantaloupe, \u0026hellip;) juices\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.420\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.397\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCoffee\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCoffee\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.318\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePickle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePickles, brine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.555\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLemon juice\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLemon juice\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epotato\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.659\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*Absolute factor loading values\u0026thinsp;\u0026lt;\u0026thinsp;0.20 for all patterns were excluded for simplicity.\u003c/p\u003e\n\u003cp\u003e\u0026Beta; Bartlett\u0026rsquo;s test of sphericity\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Kaiser_Meyer_Olkin\u0026thinsp;=\u0026thinsp;0.778; total variance\u0026thinsp;=\u0026thinsp;28.72%.\u003c/p\u003e\n\u003cp\u003eThe logistic regression analysis of dietary pattern scores is presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. Among the three identified patterns, the 1st and 3rd showed significant associations with endometriosis (OR\u0026thinsp;=\u0026thinsp;29.73, 95% CI\u0026thinsp;=\u0026thinsp;11.09\u0026ndash;79.7, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001, and OR\u0026thinsp;=\u0026thinsp;1.84, 95% CI\u0026thinsp;=\u0026thinsp;1.29\u0026ndash;2.61, p\u0026thinsp;=\u0026thinsp;0.001, respectively). This association remained significant after adjusting for confounders in model one (OR\u0026thinsp;=\u0026thinsp;24.5, 95% CI\u0026thinsp;=\u0026thinsp;8.68\u0026ndash;69.15, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001, and OR\u0026thinsp;=\u0026thinsp;1.57, 95% CI\u0026thinsp;=\u0026thinsp;1.06\u0026ndash;2.33, p\u0026thinsp;=\u0026thinsp;0.02, respectively), model two (OR\u0026thinsp;=\u0026thinsp;29.44, 95% CI\u0026thinsp;=\u0026thinsp;7.46-116.12, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001, and OR\u0026thinsp;=\u0026thinsp;1.57, 95% CI\u0026thinsp;=\u0026thinsp;1.05\u0026ndash;2.35, p\u0026thinsp;=\u0026thinsp;0.03, respectively), and model three (OR\u0026thinsp;=\u0026thinsp;25.54, 95% CI\u0026thinsp;=\u0026thinsp;5.84-111.72, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001, and OR\u0026thinsp;=\u0026thinsp;1.86, 95% CI\u0026thinsp;=\u0026thinsp;1.14\u0026ndash;3.04, p\u0026thinsp;=\u0026thinsp;0.01). In contrast, no significant correlation was found for the second dietary pattern across crude or adjusted models (OR\u0026thinsp;=\u0026thinsp;1.07, 95% CI\u0026thinsp;=\u0026thinsp;0.79\u0026ndash;1.47, p-value\u0026thinsp;=\u0026thinsp;0.64, and OR\u0026thinsp;=\u0026thinsp;0.87, 95% CI\u0026thinsp;=\u0026thinsp;0.59\u0026ndash;1.28, p\u0026thinsp;=\u0026thinsp;0.47, OR\u0026thinsp;=\u0026thinsp;0.86, 95% CI\u0026thinsp;=\u0026thinsp;0.58\u0026ndash;1.29, p-value\u0026thinsp;=\u0026thinsp;0.48, OR\u0026thinsp;=\u0026thinsp;0.89, 95% CI\u0026thinsp;=\u0026thinsp;0.55\u0026ndash;1.44, p-value\u0026thinsp;=\u0026thinsp;0.63, respectively). Additionally, Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e shows that the case group had significantly higher mean scores for dietary patterns 1 and 3 compared to the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). These results suggest a potential link between high-fat and high-sugar food consumption and an increased risk of endometriosis.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eOdds ratios and 95% confidence intervals for dietary patterns and endometriosis\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDietary pattern\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eModel\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOR\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e95% CI\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDietary pattern 1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCrude model\u003c/p\u003e\n\u003cp\u003eModel 1a\u003c/p\u003e\n\u003cp\u003eModel 2b\u003c/p\u003e\n\u003cp\u003eModel 3c\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29.73\u003c/p\u003e\n\u003cp\u003e24.5\u003c/p\u003e\n\u003cp\u003e29.44\u003c/p\u003e\n\u003cp\u003e25.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.09\u0026ndash;79.7\u003c/p\u003e\n\u003cp\u003e8.68\u0026ndash;69.15\u003c/p\u003e\n\u003cp\u003e7.46-116.12\u003c/p\u003e\n\u003cp\u003e5.84-111.72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDietary pattern 2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCrude model\u003c/p\u003e\n\u003cp\u003eModel 1a\u003c/p\u003e\n\u003cp\u003eModel 2b\u003c/p\u003e\n\u003cp\u003eModel 3c\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.07\u003c/p\u003e\n\u003cp\u003e0.87\u003c/p\u003e\n\u003cp\u003e0.86\u003c/p\u003e\n\u003cp\u003e0.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.79\u0026ndash;1.47\u003c/p\u003e\n\u003cp\u003e0.59\u0026ndash;1.28\u003c/p\u003e\n\u003cp\u003e0.58\u0026ndash;1.29\u003c/p\u003e\n\u003cp\u003e0.55\u0026ndash;1.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.64\u003c/p\u003e\n\u003cp\u003e0.47\u003c/p\u003e\n\u003cp\u003e0.48\u003c/p\u003e\n\u003cp\u003e0.63\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDietary pattern 3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCrude model\u003c/p\u003e\n\u003cp\u003eModel 1a\u003c/p\u003e\n\u003cp\u003eModel 2b\u003c/p\u003e\n\u003cp\u003eModel 3c\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.84\u003c/p\u003e\n\u003cp\u003e1.57\u003c/p\u003e\n\u003cp\u003e1.57\u003c/p\u003e\n\u003cp\u003e1.86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.29\u0026ndash;2.61\u003c/p\u003e\n\u003cp\u003e1.06\u0026ndash;2.33\u003c/p\u003e\n\u003cp\u003e1.05\u0026ndash;2.35\u003c/p\u003e\n\u003cp\u003e1.14\u0026ndash;3.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e0.01\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eOR, odds ratio; CI, confidence interval.\u003c/p\u003e\n\u003cp\u003ea Adjusted for previous pregnancy, sequence of menstrual cycle, duration of menstruation, and menstrual volume.\u003c/p\u003e\n\u003cp\u003eb Adjusted for variables in model 1 and BMI, level of physical activity, and education.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eComparison of mean and standard error of factor scores of dietary patterns in endometriosis and control groups\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDietary pattern 1\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDietary pattern 2\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDietary pattern 3\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SE\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SE\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCase\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.068\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eControl\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.060\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*p values were computed by the independent t test.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this case-control study, we explored the relationship between dietary patterns and endometriosis in women. We found that dietary patterns 1 and 3 were significantly associated with higher odds of endometriosis, even after adjusting for confounders, while no association was found with dietary pattern 2. Dietary pattern 1 included high intake of red meat, hydrogenated fats, fatty and fast foods, dried fruit, soy, tea, nuts, viscera, fruits, low and high-fat dairy, and olive oil. Dietary pattern 3 was rich in sugar, grains, fruit juice, soft drinks, jam, honey, hydrogenated fat, poultry, and beans.\u003c/p\u003e\u003cp\u003eOne of the components of the first dietary pattern is meat. According to our study, a diet rich in meat was associated with higher odds of endometriosis. Our study showed that a diet rich in meat is associated with higher odds of endometriosis, aligning with previous findings, Parazzini et al. and a meta-analysis conducted in 2022, which reported a 17% increased risk with higher red meat consumption (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This may be due to saturated fatty acids (SFAs) in animal protein(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Saturated fatty acids have the ability to trigger a pro inflammatory molecule known as LPS. Certain immune system cells, such as macrophages, possess a receptor named TLR4 that detects LPS(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Upon binding to TLR4, LPS initiates a signaling pathway that activates a transcription factor called NF-κB. NF-κB then prompts the expression of pro-inflammatory cytokines(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In vitro studies have shown that SFAs can directly induce the expression of inflammatory genes by binding to TLR4(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). SFAs can cause inflammation in the body by imitating the effects of LPS. For instance, palmitic acid (PA), a common SFA, has been demonstrated to activate TLR4 receptors in hypothalamic microglia and promote the release of cytokines(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). PA might also heighten the risk of endometriosis by generating estrogen, which can elicit inflammation in endometriosis by activating specific prostaglandins(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Another possible mechanism which contribute to the endometriosis, is the effect of red meat on steroid hormones(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). red meat consumption may lower sex hormone-binding globulin (SHBG) and raise estradiol levels(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), while its high iron content can induce oxidative stress and inflammation(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn contrast to our result, Samaneh et al. found that the consumption of red meat in the highest quartile was associated with a lower risk for endometriosis, It is argued due to the rich nutrient content, including protein, iron, and vitamin. However, no relationship was observed in the lower quartiles(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Other studies, such as those by Heilier and Trabert, found no significant association, which could be due to differences in the classifications servings/week(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMarcinkowska et al. also noted that the risk may increase with higher consumption of saturated fats, particularly palmitic acid and trans-unsaturated fatty acids(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Missmer et al. showed that increased trans fats intake is linked to a higher risk of endometriosis(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). It is argued that, by consuming a high-fat diet, the inflammatory response in endometriosis is triggered due to the production of trans fatty acids during food processing. This diet leads to elevated levels of systemic inflammation markers such as CRP, IL-6, and TNF and promotes endogenous estrogen production. Additionally, this dietary pattern impacts the immune system, reduces phagocytosis ability, increases active macrophages, and activates the inflammatory pathway ROS NF-κB resulting in heightened endometriosis lesions(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In contrast to our result, Ghasemisedaghat et al. discovered that the association of fat consumption with endometriosis was not statistically significant, nonetheless individuals with a high MUFA/TFA ratio had lower odds of developing endometriosis(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The analysis of fat subgroups revealed no direct link between SFA and TFA with endometriosis, nor an inverse relationship between MUFA and PUFA(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Trabert et al. did not find a significant impact of trans fat consumption on the risk of endometriosis(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur study's findings indicated a positive correlation between endometriosis and the consumption of dairy rich dietary pattern. Surprisingly, this differs from many previous studies.\u003c/p\u003e\u003cp\u003eA meta-analysis showed that higher dairy intake is linked to a lower risk of endometriosis(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Possibly due to calcium and vitamin D in dairy products and their role in reducing growth factors like Insulin-like growth factor 1 IGF-I and increasing regulators like transforming growth factor β (TGF-β)(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Dairy consumption and higher calcium may also lower inflammation (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The disagreement between our findings and others may stem from our focus on dietary patterns that include dairy alongside other foods, rather than isolating individual items or nutrients. This approach offers a different perspective on the dairy-endometriosis relationship(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs it has been shown in the present study, the consumption of foods with high glycemic index is predominant in food pattern 3 and is directly related to the increased risk of endometriosis. Similar to our study, Ghasemisedaghat et al. also found a significant positive association between glycemic load and endometriosis, they argued that this association might be due to the low levels of complex carbohydrates and fiber consumption in women with endometriosis, who followed a high glycemic diet(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). High consumption of juice, soft drinks, jam, and generally simple carbohydrates in this pattern was associated with an increased levels of estrogen. High consumption of simple carbohydrates in the diet causes hyperinsulinemia, which increases the level of endogenous estrogen through the reduction of SHBG and the increase of IGF-1 in endometrial cells(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). In contrast to our study, Schwartz et al. have not observed any correlation between glycemic load (GL) And laparoscopically confirmed endometriosis diagnosis, among premenopausal women(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSoy isoflavones may contribute to the development of estrogen-related diseases, and research on soy isoflavones has been complex and inconclusive(\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). This may be due to the agonistic and antagonistic properties of genistein and daidzein(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our research, we discovered that high soy intake, when combined with other foods in food pattern one, is linked to a higher risk of endometriosis. Consistent with our results, Mvondo et al. showed that consuming over 10% soy during the prepubertal stage in rats could enhance the growth and survival of ectopic endometrial cells and worsen endometriosis-related pain in adulthood(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). This was achieved by stimulating cell proliferation with daidzein(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) and cell hypertrophy with genistein(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Contrary to our findings, Tsuchiya et al. showed that higher urinary isoflavones are inversely associated with advanced endometriosis, but not correlated with early-stage endometriosis(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Previous study also indicated that long-term genistein consumption can reduce estradiol response levels and estrogen receptor mRNA(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our study, we found no significant link between the second dietary pattern, comprising high-fat snacks, Viscera, cereals, chicken, potatoes, eggs, vegetables, and coffee, and the risk of endometriosis. Previous research did not explore this specific dietary pattern, but a meta-analysis conducted by Arab and et al. on food groups and their components, such as vegetables yielded similar results to ours. While overall vegetable consumption appeared to decrease the risk of endometriosis, the change was not statistically significant(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). However, the meta-analysis outcome was influenced by Harris et al.'s study, which demonstrated no association between total vegetable intake and endometriosis risk. Interestingly, women who consumed\u0026thinsp;\u0026ge;\u0026thinsp;1 serving of cruciferous vegetables (broccoli, cauliflower, cabbage and Brussel sprouts) daily had a 13% higher risk of endometriosis compared to those consuming\u0026thinsp;\u0026lt;\u0026thinsp;1 serving per week(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). This finding may suggest a link between gastrointestinal symptoms and the development and worsening of endometriosis-related pain(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur study had some limitations, but we took steps to minimize biases, such as selecting newly diagnosed participants to reduce recall bias. Dietary patterns were assessed using a 12-month FFQ reflecting food intake over the year before the study. While the occurrence of disease might take place many years before. Thus, this assessment may not reflect eating patterns prior to the date of diagnosis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003edietary patterns high in red meat, hydrogenated fats, fatty and fast foods, sweet dried fruit, soy, tea, nuts, viscera, fruits, citrus, low and high-fat dairy, olive oil, and a pattern with higher amounts of sugar, grains, fruit juice, soft drinks, jam, honey, hydrogenated fat, poultry, and beans, as well, may increase the risk of endometriosis. More research is needed to understand the role of diet in endometriosis development and progression. Also more comprehensive understanding of the influence of dietary components and patterns on the risk of endometriosis is crucial to developing population-based strategies to prevent this serious and common gynecological disease.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Urmia University of Medical\u003cbr\u003e\u0026nbsp;Sciences, Urmia, Iran (Ethics Code IR.UMSU.REC.1400.396) .\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe patients/participants provided their written informed consent to participate in this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Urmia University Of Medical Sience (December 2021 to March 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all patients who participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAouther Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr Behrouzi Lak: Conceptualisation, Resources, Methodology. Dr Daneghian: Conceptualisation, Methodology, Visualization, Formal analysis, Writing - Review \u0026amp; Editing. Ahmadi: Conceptualisation, Methodology, \u0026nbsp;Formal analysis, Investigation, Data Curation. Aminian: Investigation, Data Curation, Writing - Original Draft, Formal analysis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJurkiewicz-Przondziono J, Lemm M, Kwiatkowska-Pamuła A, Zi\u0026oacute;łko E, W\u0026oacute;jtowicz MK. Influence of diet on the risk of developing endometriosis. Ginekologia polska. 2017;88(2):96\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiVasta AD, Stamoulis C, Gallagher JS, Laufer MR, Anchan R, Hornstein MD. Nonhormonal therapy for endometriosis: a randomized, placebo-controlled, pilot study of cabergoline versus norethindrone acetate. 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J Med Food. 2012;15(12):1081\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsuchiya M, Miura T, Hanaoka T, Iwasaki M, Sasaki H, Tanaka T, et al. Effect of soy isoflavones on endometriosis: interaction with estrogen receptor 2 gene polymorphism. Epidemiology. 2007;18(3):402\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang TT, Sathyamoorthy N, Phang JM. Molecular effects of genistein on estrogen receptor mediated pathways. Carcinogenesis. 1996;17(2):271\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarris H, Eke A, Chavarro J, Missmer S. Fruit and vegetable consumption and risk of endometriosis. Hum Reprod. 2018;33(4):715\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEswaran SL, Chey WD, Han-Markey T, Ball S, Jackson K. A randomized controlled trial comparing the low FODMAP diet vs. modified NICE guidelines in US adults with IBS-D. Official J Am Coll Gastroenterology| ACG. 2016;111(12):1824\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Carbohydrate, Dietary Patterns, Endometriosis, Inflammation, Lipids","lastPublishedDoi":"10.21203/rs.3.rs-7168622/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7168622/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003cbr\u003e\n \u003c/strong\u003eEndometriosis is a chronic, inflammatory condition affecting women, characterized by the presence of endometrial tissue outside the uterus. This study aimed to explore the relationship between dominant food patterns and the incidence of endometriosis in women aged 15-45 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nThis case-control study involved 180 women, with 60 participants in the case group (with endometriosis) and 120 in the control group. Participants, aged 15-45, were recruited from the Kosar Educational and Therapeutic Center. Endometriosis diagnosis was confirmed via ultrasound or laparoscopy by a gynecologist. Dietary intake was assessed using a 146-item food frequency questionnaire. Factor analysis was used to identify dominant dietary patterns, and statistical tests (Chi-squared, Mann-Whitney U, T-tests) alongside logistic regression were used to assess the relationship between dietary patterns and endometriosis, adjusting for confounding factors (e.g., BMI, menstrual cycle characteristics, physical activity, education level).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nThree dominant dietary patterns were identified. Pattern one was high in red meat, solid oils, high-fat snacks, and processed foods. Pattern two featured vegetables, grains, and coffee, while pattern three included sugar, cereals, and jam. Significant associations were found between food pattern one (OR = 25.54, 95% CI: 111.72–5.84, P \u0026lt; 0.001) and food pattern three (OR = 1.86, 95% CI: 1.14–3.04, P = 0.01) with increased risk of endometriosis. Higher energy, lipid, and carbohydrate intake were significantly associated with endometriosis (P \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003cbr\u003e\n \u003c/strong\u003eFood patterns high in processed meats, oils, and sugars may increase the risk of endometriosis in women.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Urmia University of Medical\u003cbr\u003e\nSciences, Urmia, Iran (Ethics Code IR.UMSU.REC.1400.396) .\u003c/p\u003e","manuscriptTitle":"The Association between dominant food patterns and intake of energy and macronutrients with endometriosis in women aged 15-45","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-03 01:07:09","doi":"10.21203/rs.3.rs-7168622/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-10T09:50:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-01T02:38:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-23T13:44:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-21T10:31:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102185014207593892903068746222167489158","date":"2025-09-21T10:23:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204218641649548435801146827123295739096","date":"2025-09-21T07:03:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121259686337634394471489014344741894811","date":"2025-09-21T05:42:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-21T05:29:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-23T21:39:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-11T08:13:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-06T08:41:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2025-08-06T08:37:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a6f0797f-67ef-4931-a52b-24d96033333a","owner":[],"postedDate":"October 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:08:56+00:00","versionOfRecord":{"articleIdentity":"rs-7168622","link":"https://doi.org/10.1186/s40795-026-01268-6","journal":{"identity":"bmc-nutrition","isVorOnly":false,"title":"BMC Nutrition"},"publishedOn":"2026-02-10 15:58:57","publishedOnDateReadable":"February 10th, 2026"},"versionCreatedAt":"2025-10-03 01:07:09","video":"","vorDoi":"10.1186/s40795-026-01268-6","vorDoiUrl":"https://doi.org/10.1186/s40795-026-01268-6","workflowStages":[]},"version":"v1","identity":"rs-7168622","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7168622","identity":"rs-7168622","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}