Mediterranean diet adherence among women attending mobile breast cancer prevention program: results of a cross-sectional study in Italy

Mediterranean diet adherence among women attending mobile breast cancer prevention program: results of a cross-sectional study in Italy | 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 Mediterranean diet adherence among women attending mobile breast cancer prevention program: results of a cross-sectional study in Italy Alessandra Maio, Alba Di Leone, Salvatore Di Grande, Gianluca Franceschini, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8099766/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background. The Mediterranean Diet (MedDiet) has been linked to lower breast cancer incidence through anti-inflammatory and antioxidant effects. This study evaluated adherence to the MedDiet among women undergoing mammographic screening provided by mobile units in Italy and explored its association with breast cancer risk factors. Methods. A cross-sectional study was carried out between January and December 2023 as part of the “Prevention Caravan” mobile health program. Eligible participants included women aged 18 years or older who underwent breast ultrasound or mammography and completed the 14-item Mediterranean Diet Adherence Screener (MEDAS). Descriptive analyses and differences across groups defined by known breast cancer risk factors, stratified by MedDiet adherence levels, were performed. Results. A total of 7,492 women were included, most of whom were < 45 years of age (69%) and from Central Italy (59%). The mean MEDAS score was 7.0 (SD 1.6), with 62% categorized as having low adherence to the MedDiet. Excellent adherence was more prevalent in women from Southern Italy (34%, p = 0.002). MEDAS score increased by increasing age (p = 0.036), with excellent adherence being more common among women aged 46–74 years (37%, p = 0.022) and postmenopausal women (27%, p < 0.001). A significant association emerged with family history of breast conditions (p < 0.001), particularly benign lesions, who showed lower adherence. Conclusion. Mobile programs like the “Prevention Caravan” may help promote healthy lifestyles and reduce inequalities. Future studies should confirm these results in larger, more diverse populations and explore associations with lesion type and severity. mediterranean diet dietary adherence women’s health health promotion breast cancer Introduction As a leading cause of morbidity and mortality worldwide, cancer places a substantial burden on public health, profoundly affecting individuals and communities. The World Health Organization (WHO) predicts that by 2050 the number of new cancer cases will exceed 35 million, marking a dramatic 77 percent increase from the approximately 20 million cases recorded in 2022. Among the various forms of cancer, breast cancer is the most commonly diagnosed malignancy in women and a major health concern. Its high prevalence makes it the leading cause of cancer-related mortality among females [ 1 ]. Early detection through screening programs, coupled with effective prevention strategies, is critical—not only to reduce mortality, but also to improve quality of life and reduce healthcare costs associated with treatment and long-term management [ 2 ]. Primary prevention, particularly through dietary and lifestyle interventions, plays a crucial role in mitigating breast cancer risk. According to the American Institute for Cancer Research, up to 38% of breast cancer cases may be preventable through a balanced diet and healthy lifestyle choices [ 3 ]. Among healthy dietary patterns, the Mediterranean Diet (MedDiet) stands out for its well-documented protective effects against several chronic diseases, including cancer. This dietary model—characterized bynsumption of fruits, vegetables, legumes, whole grains, fish, and extra virgin olive oil—has been associated with a significantly reduced risk of breast cancer. The MedDiet’s protective effects are primarily attributed to its anti-inflammatory and antioxidant properties, as well as the presence of beneficial nutrients such as monounsaturated and polyunsaturated fatty acids, dietary fiber, and bioactive phytochemicals. These components are known to influence molecular and cellular mechanisms involved in carcinogenesis, thereby reducing the risk of breast cancer development and progression, while also supporting overall health and well-being [ 4 , 5 ]. Although women generally exhibit higher adherence to the MedDiet than men, lower adherence is often observed among younger women and those with lower socioeconomic status. This trend—shaped by factors such as education, lifestyle behaviours, and household conditions—combined with declining adherence in certain age groups, highlights the need for targeted public health interventions [ 6 ] In this context, the National Itinerant Program for Women’s Health Promotion, known as the “Prevention Caravan” and organized by Komen Italy, offers free mammographic screenings and health promotion services to women across the country. Since its launch, the initiative has conducted over 918 health promotion days across 17 Italian regions, reaching more than 250,000 women. By facilitating access to screenings and health information, the program aims not only to improve early detection of breast cancer but also to potentially influence participants’ dietary habits, thereby enhancing their overall health [ 7 ]. The aim was to evaluate adherence to the MedDiet among women undergoing mammographic screening as part of the “Prevention Caravan” program. Methods Objectives and endpoints The primary objective of the study was to assess adherence to the MedDiet using the Mediterranean Diet Adherence Screener (MEDAS) questionnaire [ 8 ]; the corresponding primary endpoint was the mean total MEDAS score observed in the study population. Secondary objectives were twofold: (i) to explore how the frequency of MedDiet adherence varied across different categories of known breast cancer risk factors [ 9 ]; and (ii) to investigate the presence of malignant breast lesions among a subset of screened participants. The secondary endpoints were: (i) the percentage of the MEDAS score categorized by the different known breast cancer risk factors and (ii) the prevalence of malignant breast lesion in a subgroup of 10% of participants. Study design, setting, and population This study adopted a cross-sectional design, with interviews conducted between January and December 2023, as part of a national initiative promoted by Komen Italy, known as the “Prevention Caravan”. The program aims to improve women’s health by offering free prevention activities focused primarily on cancer, especially breast cancer [ 7 ]. Mobile units equipped with diagnostic technologies provide mammography, breast ultrasounds, and clinical visits for early diagnosis. These services are delivered by healthcare professionals from the “Fondazione Policlinico Universitario A. Gemelli” and by Komen Italy volunteers, in collaboration with local health units. In addition, the program offers consultations for women’s health conditions not covered by National Health Service (NHS) screening and educational workshops on physical activity, wellness, and nutrition. The study population included women ≥ 18 years who participated in mammographic screening through the “Prevention Caravan” in 2023 and who, due to age or other criteria, were not eligible for NHS breast cancer screening programs. The program primarily targets women in social or economic hardship—such as those in suburban areas, detention, or shelters—but is open to all women beyond NHS age limits. Awareness was promoted through communication campaigns, and participation facilitated via an online platform. Women were eligible if they participated in the “Prevention Caravan” program during the study period, underwent mammographic screening (mammography or breast ultrasound), and completed the MEDAS questionnaire. Women were excluded if they did not take part in the program, underwent only non-breast-related screenings or consultations (e.g., for gynecological cancers, thyroid, or dermatological issues), or failed to complete the MEDAS questionnaire. At a later stage, participants were contacted by phone to collect follow-up information on the outcomes of their breast screening. A subset of 743 women responded, providing details on whether any lesions had been detected. Data collection Adherence to the MedDiet was evaluated using the 14-item MEDAS questionnaire (Additional File 1), a validated tool designed to assess specific dietary behaviours—including the consumption of olive oil, fruits, vegetables, legumes, fish, white meat, and wine—as well as the intake of foods considered inconsistent with the Mediterranean dietary pattern, such as red meat, butter, and sugar-sweetened beverages. Each item is scored as 0 or 1 based on the participant’s response, resulting in a total score ranging from 0 to 14. Higher scores indicate greater adherence: scores above 10 are classified as excellent, scores between 8 and 10 as good, and scores below 8 as poor adherence to the MedDiet [ 8 ]. Key breast cancer risk factors were investigated through a structured medical history questionnaire (Additional File 2), which collected information on participants’ age, age at menarche, menopausal status, use of hormonal therapies, reproductive history (including number of pregnancies and duration of breastfeeding), and personal or familial history of breast conditions. Data on the result of the screening conducted as part of the “Prevention Caravan” program was available for a non-randomized subset of 743 women who completed a follow-up telephone interview. Statistical Analysis Plan All analyses were performed using Stata software with a statistical significance level set at p < 0.05. The MEDAS score was treated as a continuous variable but will also be categorized into three groups: poor adherence (score 11) [ 8 ]. Breast cancer risk factors were treated as follows: Age: continuous variable, and categorized as “≤45 years”, “46–74 years”, and” ≥75 years” [ 10 ]; Menarche age: continuous variable, and categorized as “early menarche (≤ 10 years)”, “normal menarche (11–15 years)”, and “late menarche (≥ 16 years)” [ 11 ]; Menopausal status: categorized as “premenopausal (no continuous amenorrhea)”, “perimenopausal (≤12 months of continuous amenorrhea)”, and “postmenopausal (> 12 months of continuous amenorrhea)” [ 11 ]; Hormonal therapies: categorized as “never”, “in the past”, and “ongoing”; Pregnancies: categorized as “none” and “yes”; Breastfeeding time: categorized as “0 months”, “12 months” [ 12 ]; Previous personal breast lesion: categorized as “none”, “benign”, and “malignant”; Previous familial breast lesion: categorized as “none”, “benign”, and “malignant”; Previous breast malignant lesion in a first-degree relative (parents, brothers, sons) [ 13 ]: categorized as “none” and “yes”; Screening result “Prevention Caravan”: categorized as “no malignant lesion” and “malignant lesion”. Descriptive analyses were initially conducted to characterize the study population. The mean MEDAS score was then calculated for the entire population, and the distribution across the three adherence levels of the categorical MEDAS variable was reported as percentages. Subsequently, the mean values and percentages for the different categories of known breast cancer risk factors were calculated, stratified by adherence level to the MedDiet. Differences across adherence levels were evaluated using the chi-square test or Fisher's exact test for categorical variables, as appropriate, and the Kruskal-Wallis test for numerical variables, given their non-normal distribution. Also, for the subset of woman with available data, the prevalence of malignant breast lesion was calculated, along with percentages and mean for screening results from the “Prevention Caravan” program, stratified by the categorical MEDAS variable, breast cancer risk factor categories, and other information collected from the medical history questionnaire. Results Characteristics study population The study comprised a total of 7,492 women, of whom 55.02% had undergone breast ultrasound and 44.98% had undergone mammography as part of the “Prevention Caravan” program. Participants were predominantly from Central Italy (59.15%), followed by Southern Italy (22.83%), Northern Italy (17.75%), and the Islands (0.27%). The mean age of the participants was 41.55 years (± 10.08 SD), with the majority (68.85%) aged ≤ 45 years. Most participants experienced normal menarche (87.33%), while 10.25% had early menarche and 2.41% had late menarche. Menstrual cycles were regular in the majority of cases (80.90%). About menopausal status, the population was predominantly premenopausal (85.74%), whereas only 11.66% were postmenopausal and 2.60% perimenopausal. The use of hormonal therapies was generally limited: 70.48% of participants had never used them, 19.47% had used them in the past, and 10.04% were undergoing treatment at the time of the study. In terms of pregnancy history, 56.68% of participants reported having been pregnant. As for breastfeeding, 86.76% of participants had breastfed, with 3.68% currently breastfeeding. Regarding breastfeeding duration, 40.33% breastfed for 6–12 months, 31.56% for more than 12 months, and 28.12% for less than 6 months. The vast majority of participants had no previous breast lesions (93.46%), while 5.90% had benign lesions and 0.64% had malignant lesions. Regarding familial breast health history, 70.52% of participants reported no family history of breast lesions, 9.35% had a history of benign lesions, and 20.13% had a history of malignant breast lesions. Further detailed information is provided in Table 1 . Table 1 Description of the study population. Total (N = 7,492) N (%) or Mean ± SD Mammographic screening Breast ultrasound 4,122 (55.02) Mammography 3,370 (44.98) Missing 0 Demographic characteristics Geographical area Northern Italy 1,305 (17.75) Central Italy 4,350 (59.15) Southern Italy 1,679 (22.83) Islands Italy 20 (0.27) Missing 138 (1.84) Age (continuous) 41.55 ± 10.08 Age (categorical) ≤45 years 5,001 (68.85) 46–74 years 2,207 (30.38) ≥75 years 56 (0.77) Missing 228 (3.04) Gynecological history Menarche age (continuous) 12.35 ± 1.51 Menarche age (categorical) Early menarche (≤ 10 years) 629 (10.25) Normal menarche (11–15 years) 5,358 (87.33) Late menarche (≥ 16 years) 148 (2.41) Missing 1,357 (18.11) Menstrual cycle Regular 6,033 (80.90) Irregular 1,424 (19.10) Missing 35 (0.46) Menopausal status Premenopausal (no continuous amenorrhea) 6,065 (85.74) Perimenopausal (≤12 months of continuous amenorrhea) 184 (2.60) Postmenopausal (> 12 months of continuous amenorrhea) 825 (11.66) Missing 418 (5.48) Hormonal therapies Never 5,277 (70.48) In the past 1,458 (19.47) Ongoing 752 (10.04) Missing 5 (0.06) Pregnancy None 3,180 (43.32) Yes 4,161 (56.68) Missing 151 (2.01) Breastfeeding None 551 (13.24) Yes 3,610 (86.76) Missing 0 Breastfeeding ongoing None 3,477 (96.32) Yes 133 (3.68) Missing 0 Breastfeeding time 12 months 1,101 (31.56) Missing 121 (1.61) Previous personal breast lesion None 7,002 (93.46) Benign 442 (5.90) Malignant 48 (0.64) Missing 0 Previous familial breast lesion None 5,270 (70.52) Benign 699 (9.35) Malignant 1,504 (20.13) Missing 19 (0.25) Adherence to the MedDiet MEDAS score (continuous) 6.99 ± 1.65 MEDAS score (categorical) Low adherence 4,617 (61.63) Good adherence 2,784 (37.16) Excellent adherence 91 (1.21) Missing 0 Abbreviations MEDAS = Mediterranean Diet Adherence Screener MedDiet = Mediterranean Diet Adherence to the Mediterranean diet The MEDAS score indicated a mean of 6.99 (SD 1.65), reflecting generally low adherence to the MedDiet among the participants. This finding was further supported by categorical analysis, which revealed that 61.63% (n = 4,617) of participants exhibited low adherence, 37.16% (n = 2,784) demonstrated good adherence, and only 1.21% (n = 91) achieved excellent adherence (Table 1 ). The geographical distribution, stratified by adherence levels to the MedDiet, showed that the MEDAS score was generally consistent across regions. However, a significantly higher proportion of participants with “excellent” adherence was observed in Southern Italy, reaching 34.07% (p = 0.002) (Table 2 ). Table 2 Distribution of Mediterranean diet adherence across geographical area and breast cancer risk factor categories. MEDAS score p-value Low Adherence (N = 4,617) Good Adherence (N = 2,784) Excellent Adherence (N = 91) N (%) or Mean ± SD N (%) or Mean ± SD N (%) or Mean ± SD Geographical area 0.002 Northern Italy 842 (18.69) 450 (16.32) 13 (14.29) Central Italy 2,634 (58.47) 1,669 (60.51) 47 (51.65) Southern Italy 1,011 (22.44) 637 (23.10) 31 (34.07) Islands Italy 18 (0.40) 2 (0.07) 0 Missing 112 (1.49) 26 (0.34) 0 Breast Cancer Risk factors Age (continuous) 41.29 ± 9.96 41.91 ± 10.13 43.67 ± 13.14 0.036 Age (categorical) 0.022 ≤45 years 3,117 (70.00) 1,829 (67.24) 55 (60.44) 46–74 years 1,303 (29.26) 870 (31.99) 34 (37.36) ≥75 years 33 (0.74) 21 (0.77) 2 (2.20) Missing 164 (2.19) 64 (0.85) 0 Menarche age (continuous) 12.34 ± 1.50 12.37 ± 1.53 12.60 ± 1.35 0.287 Menarche age (categorical) 0.195 Early menarche (≤ 10 years) 405 (10.73) 219 (9.58) 5 (6.94) Normal menarche (11–15 years) 3,289 (87.10) 2,005 (87.67) 64 (88.89) Late menarche (≥ 16 years) 82 (2.17) 63 (2.75) 3 (4.17) Missing 841 (11.22) 497 (6.63) 19 (0.25) Menopausal status 12 months of continuous amenorrhea) 462 (10.61) 339 (12.89) 24 (26.97) Missing 262 (3.50) 154 (2.05) 2 (0.27) Hormonal therapies 0.643 Never 3,243 (70.29) 1,976 (71.03) 58 (63.74) In the past 906 (19.64) 530 (19.05) 22 (24.18) Ongoing 465 (10.08) 276 (9.92) 11 (12.09) Missing 3 (0.04) 2 (0.02) 0 Pregnancy 0.448 None 1,936 (42.76) 1,206 (44.27) 38 (42.70) Yes 2,592 (57.24) 1,518 (55.73) 51 (57.30) Missing 89 (1.19) 60 (0.80) 2 (0.02) Breastfeeding time 0.732 12 months 660 (30.81) 425 (32.59) 16 (37.21) Missing 80 (1.07) 37 (0.49) 4 (0.05) Previous personal breast lesion 0.276 None 4,295 (93.03) 2,623 (94.22) 84 (92.31) Benign 291 (6.30) 144 (5.17) 7 (7.69) Malignant 31 (0.67) 17 (0.61) 0 Missing 0 0 0 Previous familial breast lesion < 0.001 None 3,215 (69.80) 1,987 (71.58) 68 (74.73) Benign 495 (10.75) 202 (7.28) 2 (2.20) Malignant 896 (19.45) 587 (21.15) 21 (23.08) Missing 11 (0.15) 8 (0.11) 0 Previous breast malignant lesion in a first-degree relative (parents, brothers, sons) 0.674 None 263 (69.39) 161 (66.26) 7 (63.64) Yes 116 (30.61) 82 (33.74) 4 (36.36) Missing 10 (0.13) 4 (0.05) 0 Abbreviations MEDAS = Mediterranean Diet Adherence Screener Regarding breast cancer risk factors, the mean age increased significantly with higher levels of adherence to the MedDiet (p = 0.036). Specifically, the mean age was 41.29 years (SD 9.96) in the low adherence group, 41.91 years (SD 10.13) in the good adherence group, and 43.67 years (SD 13.14) in the excellent adherence group. Analysis by age group revealed a significant increase in adherence to the MedDiet among participants aged 46–74 years (p = 0.022). In this age range, 29.26% of participants were in the low adherence group, 31.99% in the good adherence group, and 37.36% in the excellent adherence group. Menarche age did not differ significantly across the adherence groups (p = 0.287 for continuous data, p = 0.195 for categorical data). In contrast, menopausal status was significantly associated with levels of adherence to the MedDiet (p < 0.001). In particular, adherence increased substantially among postmenopausal women, with 10.61% showing low adherence, 12.89% good adherence, and 26.97% excellent adherence. There was no significant difference between adherence and the use of hormonal therapies (p = 0.643), pregnancy history (p = 0.448), or breastfeeding duration (p = 0.732). Regarding the history of breast diseases, no significant difference was found between personal history and adherence to the MedDiet, whereas a significant difference was observed with family history (p < 0.001). Specifically, among individuals with a family history of benign breast lesions, adherence to the MedDiet decreased significantly, with only 2.20% reporting high adherence. When considering the presence of a previous breast malignant lesion in a first-degree relative (parents, brothers, or sons), the difference between the various MedDiet adherence groups was not significant (p = 0.674). Screening result in the “Prevention Caravan” The prevalence of malignant breast lesions diagnosed through screening was evaluated in a subgroup of 743 women from the original cohort of 7,492 participants, representing those who responded to follow-up contact. The results showed that 1.08% (n = 8) of these women had malignant lesions (95% CI: 0.0054–0.0214). Low adherence to the MedDiet, ad indicated by the MEDAS score, was predominant in both groups: 82.31% among women without malignant lesions and 87.50% among those with malignant lesions (Additional File 3). A smaller proportion demonstrated good adherence (17.69% and 12.50%, respectively), while no participants in either group exhibited excellent adherence. The majority of women with malignant lesions were from Central Italy (57.14%), followed by Islands Italy (28.57%), and Southern Italy (14.29%), with no representation from Northern Italy. The mean age was higher in women with malignant lesions (47.75 years, SD 4.33) compared to those without malignant lesions (41.10 years, SD 8.65). When categorizing by age, most women without malignant lesions were ≤ 45 years (71.41%), while the majority with malignant lesions were aged 46–74 years (75.00%). Among women with malignant breast lesions, 25.00% had experienced early menarche (≤ 10 years), while none reported late menarche (≥ 16 years). Half had never used hormonal therapies, 12.50% had used them in the past, and 37.50% were undergoing treatment at the time of data collection. Regarding reproductive history, 87.50% had been pregnant at least once, and all had breastfed. The majority breastfed for 6–12 months (57.14%), while 28.57% did so for over 12 months. In terms of previous breast conditions, 37.50% reported no prior lesions, 12.50% had a history of benign lesions, and 50.00% had previously been diagnosed with a malignant lesion. Additionally, 50.00% reported a family history of benign breast conditions. Further detailed information can be found in Additional File 3. Discussion The aim of this study was to assess adherence to the MedDiet among women who participated in the national free mammography screening program known as the “Prevention Caravan”. This population primarily includes women who, due to age or socio-economic conditions, are not eligible for organized screening programs offered by the NHS and may therefore be more vulnerable or less likely to be reached by conventional prevention initiatives. Assessing their dietary behaviours represents a crucial first step in identifying specific needs and developing targeted, integrated health promotion strategies. In this context, incorporating food insecurity screening tools may help identify individuals at greater risk and support the implementation of tailored interventions to improve participation in breast cancer screening [ 14 , 15 ]. The results showed generally a low adherence to the MedDiet, with only 1.2% of participants achieving an “excellent” score. Similar findings have been reported in studies conducted in Italy and other Mediterranean countries, documenting a steady decline in adherence to this dietary pattern, particularly among younger adults and socioeconomically disadvantaged groups [ 16 – 18 ]. Factors such as education level, income, and the perception of the diet as healthy and sustainable are positively associated with adherence [ 19 , 20 ]. In particular, findings from the Moli-sani cohort showed a marked reduction in adherence among lower-income groups following the economic crisis, highlighting the influence of social inequalities on dietary choices [ 21 ]. Despite this evidence, our analysis showed a higher prevalence of “excellent” adherence among women from Southern Italy compared to those from Central and Northern regions. This geographical pattern likely reflects the persistence of traditional eating habits in Southern areas, where access to typical Mediterranean foods remains more widespread [ 22 ]. However, this cultural advantage does not necessarily translate into better health outcomes: Southern Italy continues to report higher rates of obesity, diabetes, and sedentary behaviour [ 23 ]. These contradictions may be due to a progressive erosion of the Mediterranean Diet, especially among younger generations, and the growing consumption of ultra-processed foods, sugary drinks, and low-cost industrial products [ 24 ]. Additionally, adverse social conditions—such as low education levels, family-related stress, and limited access to health resources—contribute to poorer dietary quality and physical inactivity, even in regions where the Mediterranean model remains culturally relevant [ 19 , 25 ]. Adherence to the MedDiet was significantly higher among older women and those who were postmenopausal. This result is consistent with national studies showing that adherence increases progressively with age and is highest among adults over 75. Among postmenopausal women, higher adherence has been associated with lower BMI, reduced fat mass, and smaller waist circumference—indicators of greater health awareness and more stable, prevention-oriented dietary patterns [ 26 , 27 ]. No significant association was found between adherence to the MedDiet and family history of breast conditions. Specifically, women with a family history of benign breast disease did not report healthier eating behaviours. This finding is supported by existing literature showing that, although individuals with a family history of breast disease may perceive a higher personal risk, they do not consistently adopt healthier lifestyle behaviours [ 28 , 29 ]. The only preventive behaviour more frequently observed in this group is greater participation in screening programs [ 30 ]. Similarly, no associations were observed between dietary adherence and hormonal or reproductive factors such as age at menarche, pregnancy, breastfeeding, or hormone therapy use. Some studies have suggested a link between adherence to the MedDiet and later menarche, although the evidence remains limited and inconclusive [ 31 ]. While adherence tends to be lower during pregnancy [ 32 ], it generally improves in the postmenopausal period, likely reflecting increased health consciousness and more consistent lifestyle habits [ 33 ]. The prevalence of malignant breast lesions in the limited follow-up sample was small, preventing any reliable conclusions about the association between MedDiet and breast cancer outcomes. Adherence to the MedDiet was low in both women with and without malignant lesions. While this may partly reflect the limited sample size, it also highlights the complexity of behavioural change after a cancer diagnosis. Several cohort studies and meta-analyses have shown that higher adherence to the MedDiet among breast cancer survivors is associated with reduced overall mortality and, to a lesser extent, lower risk of recurrence—especially in postmenopausal women and those with receptor-negative tumors [ 34 – 36 ]. Although the DIANA-5 randomized controlled trial did not find a statistically significant difference in recurrence between intervention and control groups, it did show that women who closely followed dietary recommendations had a lower risk of recurrence (HR 0.59) [ 37 ]. Although many patients report positive lifestyle changes following a cancer diagnosis, a substantial proportion do not significantly modify their habits. According to the American Society of Clinical Oncology, about 75% of patients report changes in diet or physical activity, but evidence also highlights marked individual variability [ 38 , 39 ]. Multinational studies confirm that adopting healthy behaviours after diagnosis is associated with reduced cancer-specific and all-cause mortality, underscoring the need to support survivors in maintaining long-term lifestyle improvements [ 40 ]. This study has several limitations that must be considered when interpreting the findings. The cross-sectional design limits the ability to establish causal relationships between adherence to the MedDiet and breast cancer risk factors. Additionally, the study population consisted primarily of women who voluntarily participated in a free screening program, potentially introducing selection bias, as these women may differ from the general population in terms of socioeconomic status, health awareness, or access to healthcare. The lack of detailed data on some relevant variables—such as the duration of hormone therapy—may affect the accuracy of risk factor assessment. The use of self-reported data for dietary adherence and medical history could introduce recall bias. Objective dietary assessments and clinical verification of risk factors would enhance the reliability of the findings. The absence of longitudinal follow-up further limits our understanding of how dietary patterns evolve over time and their potential impact on long-term health outcomes. Finally, the small number of malignant lesions detected precluded statistically robust analyses between groups. In conclusion, this study highlights a generally low adherence to the MedDiet among women participating in the “Prevention Caravan” initiative in Italy. These findings emphasize the need to incorporate targeted nutritional education into public health strategies aimed at Italian women, particularly younger age groups. Leveraging the reach and accessibility of mobile screening programs such as the “Prevention Caravan” may offer an innovative public health opportunity to promote healthy lifestyles and reduce disparities in cancer prevention among underserved populations. However, considering the limitations of this study, future research should aim to confirm these findings in larger and more diverse samples, in order to assess whether they accurately reflect dietary habits across different regions of Italy. Additionally, further investigation is needed to explore whether dietary adherence varies not only with a greater number of malignant lesions, but also in relation to the specific type of lesion detected. Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of Policlinico Universitario A. Gemelli – IRCCS (protocol ID7535) and was conducted in accordance with the Declaration of Helsinki. Participation was voluntary and unpaid. All participants provided written informed consent, including authorization for anonymous publication of findings. Consent for publication Not applicable. The study used anonymized data collected from participants who provided written informed consent to take part in the research. Competing interests The authors declare that they have no competing interests. Funding The authors declare that they received no specific funding for this work. Author Contribution SB, RP, and AM conceived and designed the study. ADL and RM were responsible for data collection. AM and RP performed the data analysis. AM and SDG drafted the manuscript, and SB and RP critically revised it for important intellectual content. All authors have read and approved the final version of the manuscript. They agree to be personally accountable for their own contributions and to ensure that any questions related to the accuracy or integrity of any part of the work, even those in which they were not directly involved, are appropriately investigated and resolved. Acknowledgement The authors thank Komen Italia for promoting and organizing the “Prevention Caravan” initiative, which made this study possible. Data Availability The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Breast cancer. https://www.who.int/news-room/fact-sheets/detail/breast-cancer . Accessed 14 Jul 2025. PDQ Screening and Prevention Editorial Board. Breast Cancer Screening (PDQ®): Health Professional Version. PDQ Cancer Information Summaries; 2002. Aicr WCRF, Diet. Nutrition, Physical Activity and Cancer: a Global Perspective A summary of the Third Expert Report. 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Front Endocrinol (Lausanne). 2022;13. https://doi.org/10.3389/FENDO.2022.886824 . McTiernan A. Diet Matters in Breast Cancer Prognosis: Clinical Trial Evidence and Questions. Clin Cancer Res. 2024;30:931–3. https://doi.org/10.1158/1078-0432.CCR-23-3195 . Berrino F, Villarini A, Gargano G, Krogh V, Grioni S, Bellegotti M, et al. The Effect of Diet on Breast Cancer Recurrence: The DIANA-5 Randomized Trial. Clin Cancer Res. 2024;30:965–74. https://doi.org/10.1158/1078-0432.CCR-23-1615 . Chen G, Leary S, Niu J, Perry R, Papadaki A. The Role of the Mediterranean Diet in Breast Cancer Survivorship: A Systematic Review and Meta-Analysis of Observational Studies and Randomised Controlled Trials. Nutrients. 2023;15. https://doi.org/10.3390/NU15092099 . Berrino F, Villarini A, Gargano G, Krogh V, Grioni S, Bellegotti M, et al. The Effect of Diet on Breast Cancer Recurrence: The DIANA-5 Randomized Trial. Clin Cancer Res. 2024;30:965–74. https://doi.org/10.1158/1078-0432.CCR-23-1615 . Ligibel JA, Bohlke K, May AM, Clinton SK, Demark-Wahnefried W, Gilchrist SC, et al. Exercise, Diet, and Weight Management during Cancer Treatment: ASCO Guideline. J Clin Oncol. 2022;348. https://doi.org/10.1200/JCO.22.00687 . Hoedjes M, Nijman I, Hinnen C. Psychosocial Determinants of Lifestyle Change after a Cancer Diagnosis: A Systematic Review of the Literature. Cancers (Basel). 2022;14. https://doi.org/10.3390/CANCERS14082026 . Bian Z, Zhang R, Yuan S, Fan R, Wang L, Larsson SC, et al. Healthy lifestyle and cancer survival: A multinational cohort study. Int J Cancer. 2024;154:1709–18. https://doi.org/10.1002/IJC.34846 . Additional Declarations No competing interests reported. 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The World Health Organization (WHO) predicts that by 2050 the number of new cancer cases will exceed 35\u0026nbsp;million, marking a dramatic 77 percent increase from the approximately 20\u0026nbsp;million cases recorded in 2022. Among the various forms of cancer, breast cancer is the most commonly diagnosed malignancy in women and a major health concern. Its high prevalence makes it the leading cause of cancer-related mortality among females [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Early detection through screening programs, coupled with effective prevention strategies, is critical\u0026mdash;not only to reduce mortality, but also to improve quality of life and reduce healthcare costs associated with treatment and long-term management [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrimary prevention, particularly through dietary and lifestyle interventions, plays a crucial role in mitigating breast cancer risk. According to the American Institute for Cancer Research, up to 38% of breast cancer cases may be preventable through a balanced diet and healthy lifestyle choices [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong healthy dietary patterns, the Mediterranean Diet (MedDiet) stands out for its well-documented protective effects against several chronic diseases, including cancer. This dietary model\u0026mdash;characterized bynsumption of fruits, vegetables, legumes, whole grains, fish, and extra virgin olive oil\u0026mdash;has been associated with a significantly reduced risk of breast cancer. The MedDiet\u0026rsquo;s protective effects are primarily attributed to its anti-inflammatory and antioxidant properties, as well as the presence of beneficial nutrients such as monounsaturated and polyunsaturated fatty acids, dietary fiber, and bioactive phytochemicals. These components are known to influence molecular and cellular mechanisms involved in carcinogenesis, thereby reducing the risk of breast cancer development and progression, while also supporting overall health and well-being [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough women generally exhibit higher adherence to the MedDiet than men, lower adherence is often observed among younger women and those with lower socioeconomic status. This trend\u0026mdash;shaped by factors such as education, lifestyle behaviours, and household conditions\u0026mdash;combined with declining adherence in certain age groups, highlights the need for targeted public health interventions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn this context, the National Itinerant Program for Women\u0026rsquo;s Health Promotion, known as the \u0026ldquo;Prevention Caravan\u0026rdquo; and organized by Komen Italy, offers free mammographic screenings and health promotion services to women across the country. Since its launch, the initiative has conducted over 918 health promotion days across 17 Italian regions, reaching more than 250,000 women. By facilitating access to screenings and health information, the program aims not only to improve early detection of breast cancer but also to potentially influence participants\u0026rsquo; dietary habits, thereby enhancing their overall health [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aim was to evaluate adherence to the MedDiet among women undergoing mammographic screening as part of the \u0026ldquo;Prevention Caravan\u0026rdquo; program.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eObjectives and endpoints\u003c/h2\u003e \u003cp\u003eThe primary objective of the study was to assess adherence to the MedDiet using the Mediterranean Diet Adherence Screener (MEDAS) questionnaire [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; the corresponding primary endpoint was the mean total MEDAS score observed in the study population.\u003c/p\u003e \u003cp\u003eSecondary objectives were twofold: (i) to explore how the frequency of MedDiet adherence varied across different categories of known breast cancer risk factors [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; and (ii) to investigate the presence of malignant breast lesions among a subset of screened participants. The secondary endpoints were: (i) the percentage of the MEDAS score categorized by the different known breast cancer risk factors and (ii) the prevalence of malignant breast lesion in a subgroup of 10% of participants.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design, setting, and population\u003c/h3\u003e\n\u003cp\u003eThis study adopted a cross-sectional design, with interviews conducted between January and December 2023, as part of a national initiative promoted by Komen Italy, known as the \u0026ldquo;Prevention Caravan\u0026rdquo;. The program aims to improve women\u0026rsquo;s health by offering free prevention activities focused primarily on cancer, especially breast cancer [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMobile units equipped with diagnostic technologies provide mammography, breast ultrasounds, and clinical visits for early diagnosis. These services are delivered by healthcare professionals from the \u0026ldquo;Fondazione Policlinico Universitario A. Gemelli\u0026rdquo; and by Komen Italy volunteers, in collaboration with local health units. In addition, the program offers consultations for women\u0026rsquo;s health conditions not covered by National Health Service (NHS) screening and educational workshops on physical activity, wellness, and nutrition.\u003c/p\u003e \u003cp\u003eThe study population included women\u0026thinsp;\u0026ge;\u0026thinsp;18 years who participated in mammographic screening through the \u0026ldquo;Prevention Caravan\u0026rdquo; in 2023 and who, due to age or other criteria, were not eligible for NHS breast cancer screening programs. The program primarily targets women in social or economic hardship\u0026mdash;such as those in suburban areas, detention, or shelters\u0026mdash;but is open to all women beyond NHS age limits. Awareness was promoted through communication campaigns, and participation facilitated via an online platform.\u003c/p\u003e \u003cp\u003eWomen were eligible if they participated in the \u0026ldquo;Prevention Caravan\u0026rdquo; program during the study period, underwent mammographic screening (mammography or breast ultrasound), and completed the MEDAS questionnaire. Women were excluded if they did not take part in the program, underwent only non-breast-related screenings or consultations (e.g., for gynecological cancers, thyroid, or dermatological issues), or failed to complete the MEDAS questionnaire.\u003c/p\u003e \u003cp\u003eAt a later stage, participants were contacted by phone to collect follow-up information on the outcomes of their breast screening. A subset of 743 women responded, providing details on whether any lesions had been detected.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eAdherence to the MedDiet was evaluated using the 14-item MEDAS questionnaire (Additional File 1), a validated tool designed to assess specific dietary behaviours\u0026mdash;including the consumption of olive oil, fruits, vegetables, legumes, fish, white meat, and wine\u0026mdash;as well as the intake of foods considered inconsistent with the Mediterranean dietary pattern, such as red meat, butter, and sugar-sweetened beverages. Each item is scored as 0 or 1 based on the participant\u0026rsquo;s response, resulting in a total score ranging from 0 to 14. Higher scores indicate greater adherence: scores above 10 are classified as excellent, scores between 8 and 10 as good, and scores below 8 as poor adherence to the MedDiet [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKey breast cancer risk factors were investigated through a structured medical history questionnaire (Additional File 2), which collected information on participants\u0026rsquo; age, age at menarche, menopausal status, use of hormonal therapies, reproductive history (including number of pregnancies and duration of breastfeeding), and personal or familial history of breast conditions.\u003c/p\u003e \u003cp\u003eData on the result of the screening conducted as part of the \u0026ldquo;Prevention Caravan\u0026rdquo; program was available for a non-randomized subset of 743 women who completed a follow-up telephone interview.\u003c/p\u003e\n\u003ch3\u003eStatistical Analysis Plan\u003c/h3\u003e\n\u003cp\u003eAll analyses were performed using Stata software with a statistical significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eThe MEDAS score was treated as a continuous variable but will also be categorized into three groups: poor adherence (score\u0026thinsp;\u0026lt;\u0026thinsp;8), good adherence (score 8\u0026ndash;10), and excellent adherence (score\u0026thinsp;\u0026gt;\u0026thinsp;11) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBreast cancer risk factors were treated as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAge: continuous variable, and categorized as \u0026ldquo;\u0026le;45 years\u0026rdquo;, \u0026ldquo;46\u0026ndash;74 years\u0026rdquo;, and\u0026rdquo; \u0026ge;75 years\u0026rdquo; [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e];\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMenarche age: continuous variable, and categorized as \u0026ldquo;early menarche (\u0026le;\u0026thinsp;10 years)\u0026rdquo;, \u0026ldquo;normal menarche (11\u0026ndash;15 years)\u0026rdquo;, and \u0026ldquo;late menarche (\u0026ge;\u0026thinsp;16 years)\u0026rdquo; [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e];\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMenopausal status: categorized as \u0026ldquo;premenopausal (no continuous amenorrhea)\u0026rdquo;, \u0026ldquo;perimenopausal (\u0026le;12 months of continuous amenorrhea)\u0026rdquo;, and \u0026ldquo;postmenopausal (\u0026gt;\u0026thinsp;12 months of continuous amenorrhea)\u0026rdquo; [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e];\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHormonal therapies: categorized as \u0026ldquo;never\u0026rdquo;, \u0026ldquo;in the past\u0026rdquo;, and \u0026ldquo;ongoing\u0026rdquo;;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePregnancies: categorized as \u0026ldquo;none\u0026rdquo; and \u0026ldquo;yes\u0026rdquo;;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBreastfeeding time: categorized as \u0026ldquo;0 months\u0026rdquo;, \u0026ldquo;\u0026lt;6 months\u0026rdquo;, \u0026ldquo;6\u0026ndash;12 months\u0026rdquo;, and \u0026ldquo;\u0026gt;12 months\u0026rdquo; [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e];\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePrevious personal breast lesion: categorized as \u0026ldquo;none\u0026rdquo;, \u0026ldquo;benign\u0026rdquo;, and \u0026ldquo;malignant\u0026rdquo;;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePrevious familial breast lesion: categorized as \u0026ldquo;none\u0026rdquo;, \u0026ldquo;benign\u0026rdquo;, and \u0026ldquo;malignant\u0026rdquo;;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePrevious breast malignant lesion in a first-degree relative (parents, brothers, sons) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]: categorized as \u0026ldquo;none\u0026rdquo; and \u0026ldquo;yes\u0026rdquo;;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eScreening result \u0026ldquo;Prevention Caravan\u0026rdquo;: categorized as \u0026ldquo;no malignant lesion\u0026rdquo; and \u0026ldquo;malignant lesion\u0026rdquo;.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eDescriptive analyses were initially conducted to characterize the study population. The mean MEDAS score was then calculated for the entire population, and the distribution across the three adherence levels of the categorical MEDAS variable was reported as percentages. Subsequently, the mean values and percentages for the different categories of known breast cancer risk factors were calculated, stratified by adherence level to the MedDiet. Differences across adherence levels were evaluated using the chi-square test or Fisher's exact test for categorical variables, as appropriate, and the Kruskal-Wallis test for numerical variables, given their non-normal distribution.\u003c/p\u003e \u003cp\u003eAlso, for the subset of woman with available data, the prevalence of malignant breast lesion was calculated, along with percentages and mean for screening results from the \u0026ldquo;Prevention Caravan\u0026rdquo; program, stratified by the categorical MEDAS variable, breast cancer risk factor categories, and other information collected from the medical history questionnaire.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics study population\u003c/h2\u003e \u003cp\u003eThe study comprised a total of 7,492 women, of whom 55.02% had undergone breast ultrasound and 44.98% had undergone mammography as part of the \u0026ldquo;Prevention Caravan\u0026rdquo; program. Participants were predominantly from Central Italy (59.15%), followed by Southern Italy (22.83%), Northern Italy (17.75%), and the Islands (0.27%). The mean age of the participants was 41.55 years (\u0026plusmn;\u0026thinsp;10.08 SD), with the majority (68.85%) aged\u0026thinsp;\u0026le;\u0026thinsp;45 years.\u003c/p\u003e \u003cp\u003eMost participants experienced normal menarche (87.33%), while 10.25% had early menarche and 2.41% had late menarche. Menstrual cycles were regular in the majority of cases (80.90%). About menopausal status, the population was predominantly premenopausal (85.74%), whereas only 11.66% were postmenopausal and 2.60% perimenopausal. The use of hormonal therapies was generally limited: 70.48% of participants had never used them, 19.47% had used them in the past, and 10.04% were undergoing treatment at the time of the study.\u003c/p\u003e \u003cp\u003eIn terms of pregnancy history, 56.68% of participants reported having been pregnant. As for breastfeeding, 86.76% of participants had breastfed, with 3.68% currently breastfeeding. Regarding breastfeeding duration, 40.33% breastfed for 6\u0026ndash;12 months, 31.56% for more than 12 months, and 28.12% for less than 6 months.\u003c/p\u003e \u003cp\u003eThe vast majority of participants had no previous breast lesions (93.46%), while 5.90% had benign lesions and 0.64% had malignant lesions. Regarding familial breast health history, 70.52% of participants reported no family history of breast lesions, 9.35% had a history of benign lesions, and 20.13% had a history of malignant breast lesions. Further detailed information is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescription of the study population.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;7,492)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%) or\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMammographic screening\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,122 (55.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMammography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,370 (44.98)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDemographic characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographical area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthern Italy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,305 (17.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentral Italy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,350 (59.15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouthern Italy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,679 (22.83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIslands Italy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (0.27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e138 (1.84)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (continuous)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.55\u0026thinsp;\u0026plusmn;\u0026thinsp;10.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (categorical)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;45 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,001 (68.85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u0026ndash;74 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,207 (30.38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;75 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (0.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e228 (3.04)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGynecological history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenarche age (continuous)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenarche age (categorical)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly menarche (\u0026le;\u0026thinsp;10 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e629 (10.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal menarche (11\u0026ndash;15 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,358 (87.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLate menarche (\u0026ge;\u0026thinsp;16 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148 (2.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e1,357 (18.11)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenstrual cycle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,033 (80.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrregular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,424 (19.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e35 (0.46)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenopausal status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePremenopausal (no continuous amenorrhea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,065 (85.74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerimenopausal (\u0026le;12 months of continuous amenorrhea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e184 (2.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostmenopausal (\u0026gt;\u0026thinsp;12 months of continuous amenorrhea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e825 (11.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e418 (5.48)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHormonal therapies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,277 (70.48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn the past\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,458 (19.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOngoing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e752 (10.04)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e5 (0.06)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,180 (43.32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,161 (56.68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e151 (2.01)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e551 (13.24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,610 (86.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding ongoing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,477 (96.32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133 (3.68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e981 (28.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,407 (40.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,101 (31.56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e121 (1.61)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious personal breast lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7,002 (93.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e442 (5.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (0.64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious familial breast lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,270 (70.52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e699 (9.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,504 (20.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e19 (0.25)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdherence to the MedDiet\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMEDAS score (continuous)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.99\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMEDAS score (categorical)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,617 (61.63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,784 (37.16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcellent adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91 (1.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cstrong\u003eAbbreviations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMEDAS = Mediterranean Diet Adherence Screener\u003c/p\u003e\n\u003cp\u003eMedDiet = Mediterranean Diet\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAdherence to the Mediterranean diet\u003c/h3\u003e\n\u003cp\u003eThe MEDAS score indicated a mean of 6.99 (SD 1.65), reflecting generally low adherence to the MedDiet among the participants. This finding was further supported by categorical analysis, which revealed that 61.63% (n\u0026thinsp;=\u0026thinsp;4,617) of participants exhibited low adherence, 37.16% (n\u0026thinsp;=\u0026thinsp;2,784) demonstrated good adherence, and only 1.21% (n\u0026thinsp;=\u0026thinsp;91) achieved excellent adherence (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe geographical distribution, stratified by adherence levels to the MedDiet, showed that the MEDAS score was generally consistent across regions. However, a significantly higher proportion of participants with \u0026ldquo;excellent\u0026rdquo; adherence was observed in Southern Italy, reaching 34.07% (p\u0026thinsp;=\u0026thinsp;0.002) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Mediterranean diet adherence across geographical area and breast cancer risk factor categories.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eMEDAS score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;4,617)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;2,784)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%) or\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%) or\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN (%) or\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGeographical area\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthern Italy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e842 (18.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e450 (16.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (14.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentral Italy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,634 (58.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,669 (60.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (51.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouthern Italy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,011 (22.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e637 (23.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (34.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIslands Italy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (0.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e112 (1.49)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e26 (0.34)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBreast Cancer Risk factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (continuous)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.29\u0026thinsp;\u0026plusmn;\u0026thinsp;9.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.91\u0026thinsp;\u0026plusmn;\u0026thinsp;10.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.67\u0026thinsp;\u0026plusmn;\u0026thinsp;13.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAge (categorical)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;45 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,117 (70.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,829 (67.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (60.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u0026ndash;74 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,303 (29.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e870 (31.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (37.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;75 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (0.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e164 (2.19)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e64 (0.85)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenarche age (continuous)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.34\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenarche age (categorical)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.195\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly menarche (\u0026le;\u0026thinsp;10 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e405 (10.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e219 (9.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (6.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal menarche (11\u0026ndash;15 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,289 (87.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,005 (87.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64 (88.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLate menarche (\u0026ge;\u0026thinsp;16 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82 (2.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (2.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (4.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e841 (11.22)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e497 (6.63)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e19 (0.25)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eMenopausal status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePremenopausal (no continuous amenorrhea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,776 (86.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,226 (84.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63 (70.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerimenopausal (\u0026le;12 months of continuous amenorrhea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117 (2.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (2.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostmenopausal (\u0026gt;\u0026thinsp;12 months of continuous amenorrhea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e462 (10.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e339 (12.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (26.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e262 (3.50)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e154 (2.05)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e2 (0.27)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHormonal therapies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,243 (70.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,976 (71.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (63.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn the past\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e906 (19.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e530 (19.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (24.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOngoing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e465 (10.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e276 (9.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (12.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e3 (0.04)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e2 (0.02)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003ePregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,936 (42.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,206 (44.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (42.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,592 (57.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,518 (55.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51 (57.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e89 (1.19)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e60 (0.80)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e2 (0.02)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eBreastfeeding time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.732\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e608 (28.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e363 (27.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (23.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e874 (40.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e516 (39.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (39.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e660 (30.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e425 (32.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (37.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e80 (1.07)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e37 (0.49)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e4 (0.05)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003ePrevious personal breast lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.276\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,295 (93.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,623 (94.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84 (92.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e291 (6.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144 (5.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (7.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003ePrevious familial breast lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,215 (69.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,987 (71.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68 (74.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e495 (10.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e202 (7.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e896 (19.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e587 (21.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (23.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e11 (0.15)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e8 (0.11)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious breast malignant lesion in a first-degree relative (parents, brothers, sons)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.674\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e263 (69.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e161 (66.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (63.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116 (30.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82 (33.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (36.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e10 (0.13)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e4 (0.05)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eAbbreviations\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eMEDAS\u0026thinsp;=\u0026thinsp;Mediterranean Diet Adherence Screener\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding breast cancer risk factors, the mean age increased significantly with higher levels of adherence to the MedDiet (p\u0026thinsp;=\u0026thinsp;0.036). Specifically, the mean age was 41.29 years (SD 9.96) in the low adherence group, 41.91 years (SD 10.13) in the good adherence group, and 43.67 years (SD 13.14) in the excellent adherence group.\u003c/p\u003e \u003cp\u003eAnalysis by age group revealed a significant increase in adherence to the MedDiet among participants aged 46\u0026ndash;74 years (p\u0026thinsp;=\u0026thinsp;0.022). In this age range, 29.26% of participants were in the low adherence group, 31.99% in the good adherence group, and 37.36% in the excellent adherence group.\u003c/p\u003e \u003cp\u003eMenarche age did not differ significantly across the adherence groups (p\u0026thinsp;=\u0026thinsp;0.287 for continuous data, p\u0026thinsp;=\u0026thinsp;0.195 for categorical data). In contrast, menopausal status was significantly associated with levels of adherence to the MedDiet (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In particular, adherence increased substantially among postmenopausal women, with 10.61% showing low adherence, 12.89% good adherence, and 26.97% excellent adherence.\u003c/p\u003e \u003cp\u003eThere was no significant difference between adherence and the use of hormonal therapies (p\u0026thinsp;=\u0026thinsp;0.643), pregnancy history (p\u0026thinsp;=\u0026thinsp;0.448), or breastfeeding duration (p\u0026thinsp;=\u0026thinsp;0.732).\u003c/p\u003e \u003cp\u003eRegarding the history of breast diseases, no significant difference was found between personal history and adherence to the MedDiet, whereas a significant difference was observed with family history (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Specifically, among individuals with a family history of benign breast lesions, adherence to the MedDiet decreased significantly, with only 2.20% reporting high adherence. When considering the presence of a previous breast malignant lesion in a first-degree relative (parents, brothers, or sons), the difference between the various MedDiet adherence groups was not significant (p\u0026thinsp;=\u0026thinsp;0.674).\u003c/p\u003e\n\u003ch3\u003eScreening result in the “Prevention Caravan”\u003c/h3\u003e\n\u003cp\u003eThe prevalence of malignant breast lesions diagnosed through screening was evaluated in a subgroup of 743 women from the original cohort of 7,492 participants, representing those who responded to follow-up contact. The results showed that 1.08% (n\u0026thinsp;=\u0026thinsp;8) of these women had malignant lesions (95% CI: 0.0054\u0026ndash;0.0214).\u003c/p\u003e \u003cp\u003eLow adherence to the MedDiet, ad indicated by the MEDAS score, was predominant in both groups: 82.31% among women without malignant lesions and 87.50% among those with malignant lesions (Additional File 3). A smaller proportion demonstrated good adherence (17.69% and 12.50%, respectively), while no participants in either group exhibited excellent adherence.\u003c/p\u003e \u003cp\u003eThe majority of women with malignant lesions were from Central Italy (57.14%), followed by Islands Italy (28.57%), and Southern Italy (14.29%), with no representation from Northern Italy.\u003c/p\u003e \u003cp\u003eThe mean age was higher in women with malignant lesions (47.75 years, SD 4.33) compared to those without malignant lesions (41.10 years, SD 8.65). When categorizing by age, most women without malignant lesions were \u0026le;\u0026thinsp;45 years (71.41%), while the majority with malignant lesions were aged 46\u0026ndash;74 years (75.00%).\u003c/p\u003e \u003cp\u003eAmong women with malignant breast lesions, 25.00% had experienced early menarche (\u0026le;\u0026thinsp;10 years), while none reported late menarche (\u0026ge;\u0026thinsp;16 years). Half had never used hormonal therapies, 12.50% had used them in the past, and 37.50% were undergoing treatment at the time of data collection. Regarding reproductive history, 87.50% had been pregnant at least once, and all had breastfed. The majority breastfed for 6\u0026ndash;12 months (57.14%), while 28.57% did so for over 12 months. In terms of previous breast conditions, 37.50% reported no prior lesions, 12.50% had a history of benign lesions, and 50.00% had previously been diagnosed with a malignant lesion. Additionally, 50.00% reported a family history of benign breast conditions.\u003c/p\u003e \u003cp\u003eFurther detailed information can be found in Additional File 3.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e The aim of this study was to assess adherence to the MedDiet among women who participated in the national free mammography screening program known as the \u0026ldquo;Prevention Caravan\u0026rdquo;. This population primarily includes women who, due to age or socio-economic conditions, are not eligible for organized screening programs offered by the NHS and may therefore be more vulnerable or less likely to be reached by conventional prevention initiatives. Assessing their dietary behaviours represents a crucial first step in identifying specific needs and developing targeted, integrated health promotion strategies. In this context, incorporating food insecurity screening tools may help identify individuals at greater risk and support the implementation of tailored interventions to improve participation in breast cancer screening [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results showed generally a low adherence to the MedDiet, with only 1.2% of participants achieving an \u0026ldquo;excellent\u0026rdquo; score. Similar findings have been reported in studies conducted in Italy and other Mediterranean countries, documenting a steady decline in adherence to this dietary pattern, particularly among younger adults and socioeconomically disadvantaged groups [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Factors such as education level, income, and the perception of the diet as healthy and sustainable are positively associated with adherence [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In particular, findings from the Moli-sani cohort showed a marked reduction in adherence among lower-income groups following the economic crisis, highlighting the influence of social inequalities on dietary choices [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite this evidence, our analysis showed a higher prevalence of \u0026ldquo;excellent\u0026rdquo; adherence among women from Southern Italy compared to those from Central and Northern regions. This geographical pattern likely reflects the persistence of traditional eating habits in Southern areas, where access to typical Mediterranean foods remains more widespread [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, this cultural advantage does not necessarily translate into better health outcomes: Southern Italy continues to report higher rates of obesity, diabetes, and sedentary behaviour [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These contradictions may be due to a progressive erosion of the Mediterranean Diet, especially among younger generations, and the growing consumption of ultra-processed foods, sugary drinks, and low-cost industrial products [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, adverse social conditions\u0026mdash;such as low education levels, family-related stress, and limited access to health resources\u0026mdash;contribute to poorer dietary quality and physical inactivity, even in regions where the Mediterranean model remains culturally relevant [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdherence to the MedDiet was significantly higher among older women and those who were postmenopausal. This result is consistent with national studies showing that adherence increases progressively with age and is highest among adults over 75. Among postmenopausal women, higher adherence has been associated with lower BMI, reduced fat mass, and smaller waist circumference\u0026mdash;indicators of greater health awareness and more stable, prevention-oriented dietary patterns [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNo significant association was found between adherence to the MedDiet and family history of breast conditions. Specifically, women with a family history of benign breast disease did not report healthier eating behaviours. This finding is supported by existing literature showing that, although individuals with a family history of breast disease may perceive a higher personal risk, they do not consistently adopt healthier lifestyle behaviours [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The only preventive behaviour more frequently observed in this group is greater participation in screening programs [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, no associations were observed between dietary adherence and hormonal or reproductive factors such as age at menarche, pregnancy, breastfeeding, or hormone therapy use. Some studies have suggested a link between adherence to the MedDiet and later menarche, although the evidence remains limited and inconclusive [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. While adherence tends to be lower during pregnancy [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], it generally improves in the postmenopausal period, likely reflecting increased health consciousness and more consistent lifestyle habits [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe prevalence of malignant breast lesions in the limited follow-up sample was small, preventing any reliable conclusions about the association between MedDiet and breast cancer outcomes.\u003c/p\u003e \u003cp\u003eAdherence to the MedDiet was low in both women with and without malignant lesions. While this may partly reflect the limited sample size, it also highlights the complexity of behavioural change after a cancer diagnosis. Several cohort studies and meta-analyses have shown that higher adherence to the MedDiet among breast cancer survivors is associated with reduced overall mortality and, to a lesser extent, lower risk of recurrence\u0026mdash;especially in postmenopausal women and those with receptor-negative tumors [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Although the DIANA-5 randomized controlled trial did not find a statistically significant difference in recurrence between intervention and control groups, it did show that women who closely followed dietary recommendations had a lower risk of recurrence (HR 0.59) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough many patients report positive lifestyle changes following a cancer diagnosis, a substantial proportion do not significantly modify their habits. According to the American Society of Clinical Oncology, about 75% of patients report changes in diet or physical activity, but evidence also highlights marked individual variability [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Multinational studies confirm that adopting healthy behaviours after diagnosis is associated with reduced cancer-specific and all-cause mortality, underscoring the need to support survivors in maintaining long-term lifestyle improvements [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has several limitations that must be considered when interpreting the findings. The cross-sectional design limits the ability to establish causal relationships between adherence to the MedDiet and breast cancer risk factors. Additionally, the study population consisted primarily of women who voluntarily participated in a free screening program, potentially introducing selection bias, as these women may differ from the general population in terms of socioeconomic status, health awareness, or access to healthcare. The lack of detailed data on some relevant variables\u0026mdash;such as the duration of hormone therapy\u0026mdash;may affect the accuracy of risk factor assessment. The use of self-reported data for dietary adherence and medical history could introduce recall bias. Objective dietary assessments and clinical verification of risk factors would enhance the reliability of the findings. The absence of longitudinal follow-up further limits our understanding of how dietary patterns evolve over time and their potential impact on long-term health outcomes. Finally, the small number of malignant lesions detected precluded statistically robust analyses between groups.\u003c/p\u003e \u003cp\u003eIn conclusion, this study highlights a generally low adherence to the MedDiet among women participating in the \u0026ldquo;Prevention Caravan\u0026rdquo; initiative in Italy. These findings emphasize the need to incorporate targeted nutritional education into public health strategies aimed at Italian women, particularly younger age groups. Leveraging the reach and accessibility of mobile screening programs such as the \u0026ldquo;Prevention Caravan\u0026rdquo; may offer an innovative public health opportunity to promote healthy lifestyles and reduce disparities in cancer prevention among underserved populations.\u003c/p\u003e \u003cp\u003eHowever, considering the limitations of this study, future research should aim to confirm these findings in larger and more diverse samples, in order to assess whether they accurately reflect dietary habits across different regions of Italy. Additionally, further investigation is needed to explore whether dietary adherence varies not only with a greater number of malignant lesions, but also in relation to the specific type of lesion detected.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e The study was approved by the Ethics Committee of Policlinico Universitario A. Gemelli \u0026ndash; IRCCS (protocol ID7535) and was conducted in accordance with the Declaration of Helsinki. Participation was voluntary and unpaid. All participants provided written informed consent, including authorization for anonymous publication of findings.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable. The study used anonymized data collected from participants who provided written informed consent to take part in the research.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors declare that they received no specific funding for this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSB, RP, and AM conceived and designed the study. ADL and RM were responsible for data collection. AM and RP performed the data analysis. AM and SDG drafted the manuscript, and SB and RP critically revised it for important intellectual content. All authors have read and approved the final version of the manuscript. They agree to be personally accountable for their own contributions and to ensure that any questions related to the accuracy or integrity of any part of the work, even those in which they were not directly involved, are appropriately investigated and resolved.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank Komen Italia for promoting and organizing the \u0026ldquo;Prevention Caravan\u0026rdquo; initiative, which made this study possible.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBreast cancer. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/breast-cancer\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/breast-cancer\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Int J Cancer. 2024;154:1709\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/IJC.34846\u003c/span\u003e\u003cspan address=\"10.1002/IJC.34846\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\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":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"mediterranean diet, dietary adherence, women’s health, health promotion, breast cancer","lastPublishedDoi":"10.21203/rs.3.rs-8099766/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8099766/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground.\u003c/h2\u003e \u003cp\u003eThe Mediterranean Diet (MedDiet) has been linked to lower breast cancer incidence through anti-inflammatory and antioxidant effects. This study evaluated adherence to the MedDiet among women undergoing mammographic screening provided by mobile units in Italy and explored its association with breast cancer risk factors.\u003c/p\u003e\u003ch2\u003eMethods.\u003c/h2\u003e \u003cp\u003eA cross-sectional study was carried out between January and December 2023 as part of the \u0026ldquo;Prevention Caravan\u0026rdquo; mobile health program. Eligible participants included women aged 18 years or older who underwent breast ultrasound or mammography and completed the 14-item Mediterranean Diet Adherence Screener (MEDAS). Descriptive analyses and differences across groups defined by known breast cancer risk factors, stratified by MedDiet adherence levels, were performed.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e \u003cp\u003eA total of 7,492 women were included, most of whom were \u0026lt;\u0026thinsp;45 years of age (69%) and from Central Italy (59%). The mean MEDAS score was 7.0 (SD 1.6), with 62% categorized as having low adherence to the MedDiet. Excellent adherence was more prevalent in women from Southern Italy (34%, p\u0026thinsp;=\u0026thinsp;0.002). MEDAS score increased by increasing age (p\u0026thinsp;=\u0026thinsp;0.036), with excellent adherence being more common among women aged 46\u0026ndash;74 years (37%, p\u0026thinsp;=\u0026thinsp;0.022) and postmenopausal women (27%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A significant association emerged with family history of breast conditions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), particularly benign lesions, who showed lower adherence.\u003c/p\u003e\u003ch2\u003eConclusion.\u003c/h2\u003e \u003cp\u003eMobile programs like the \u0026ldquo;Prevention Caravan\u0026rdquo; may help promote healthy lifestyles and reduce inequalities. Future studies should confirm these results in larger, more diverse populations and explore associations with lesion type and severity.\u003c/p\u003e","manuscriptTitle":"Mediterranean diet adherence among women attending mobile breast cancer prevention program: results of a cross-sectional study in Italy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 07:35:15","doi":"10.21203/rs.3.rs-8099766/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-07T07:19:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-30T17:16:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-30T12:26:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174149073950126923274044572026820448545","date":"2025-12-21T15:37:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234545433876119409441919268975469581698","date":"2025-12-15T08:35:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119573730956113010454951720598198074088","date":"2025-12-12T17:31:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63931348524258360434463328842792830931","date":"2025-12-12T12:22:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3148455485914586921274721895862700411","date":"2025-12-12T09:18:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-12T06:19:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-15T16:24:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-14T10:56:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-14T10:54:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-12T21:32:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f24c3ec5-3fb3-4966-98e9-8fd02fcdbb16","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-20T08:39:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-17 07:35:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8099766","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8099766","identity":"rs-8099766","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}