Adherence to the Mediterranean diet and cardiometabolic risk factors in morbid obese patients candidate for bariatric surgery

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Hosseini, Seyed Ali Keshavarz, Hastimansooreh Ansar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6405349/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Morbid obesity significantly increases the risk of cardiometabolic disorders, complicating bariatric surgery outcomes. This study assessed the association between adherence to the Mediterranean diet (MD) and cardiometabolic risk factors among morbidly obese individuals undergoing bariatric surgery evaluation. A cross-sectional study was conducted with 369 morbidly obese patients (BMI ≥ 40 kg/m² or BMI ≥ 35 kg/m² with comorbidities) referred to Hazrat-Rasul-Akram Hospital obesity clinic between September 2023 and September 2024. Dietary adherence was evaluated using the Mediterranean Diet Score (MDS). Cardiometabolic risk factors were assessed according to ATP III criteria, including blood pressure, fasting blood sugar (FBS), triglycerides (TG), HDL cholesterol, and anthropometric measurements. Participants were categorized into quartiles based on MDS adherence.Participants in the highest quartile of MDS adherence exhibited significantly lower odds of elevated blood pressure (OR = 0.34, 95% CI: 0.16–0.70,p-trend = 0.01), low HDL cholesterol levels (OR = 0.34, 95% CI: 0.16–0.70,p-trend = 0.03), and elevated fasting blood sugar (OR = 0.42, 95% CI: 0.20–0.87,p-trend = 0.03). No significant associations were found for triglyceride levels.Higher adherence to the Mediterranean diet is inversely associated with key cardiometabolic risk factors among morbidly obese patients preparing for bariatric surgery. These results support integrating MD-based dietary interventions into preoperative nutritional counselling to improve cardiometabolic outcomes and surgical success. Health sciences/Health care/Nutrition Health sciences/Medical research/Epidemiology Mediterranean diet cardiometabolic risk factors bariatric surgery Introduction Obesity has become a major global health crisis, with its prevalence steadily increasing over the past decades 1 . Among individuals with obesity, morbid obesity—defined as a body mass index (BMI) of ≥ 40 kg/m² or ≥ 35 kg/m² with obesity-related comorbidities—poses significant health challenges, including an increased risk of cardiovascular diseases (CVD), type 2 diabetes mellitus (T2DM), hypertension, dyslipidemia, and metabolic syndrome 1 . These conditions not only contribute to increased morbidity and mortality but also impose a considerable economic and healthcare burden globally 2 . Among the available treatment strategies, bariatric surgery has emerged as the most effective long-term intervention for significant weight loss and the resolution of obesity-related metabolic disorders 3 . While bariatric surgery has been shown to improve metabolic health through mechanisms such as hormonal modulation, reduced caloric intake, and enhanced insulin sensitivity, the role of preoperative dietary patterns in shaping metabolic outcomes remains an area of growing interest 4 . Nutritional optimization before surgery is increasingly recognized as a key factor in improving surgical outcomes, reducing perioperative complications, and enhancing long-term metabolic benefits 5 . Identifying dietary patterns that positively influence cardiometabolic risk factors in this high-risk population could provide valuable insights into preoperative dietary interventions that improve both immediate and long-term health outcomes. The Mediterranean diet (MD) is a well-recognized dietary pattern characterized by a high intake of fruits, vegetables, whole grains, legumes, nuts, and olive oil; a moderate intake of fish, dairy, and wine; and a low intake of red meat and processed foods 6 . The Mediterranean Diet Score (MDS) is a validated tool commonly used to assess adherence to the MD, with higher scores indicating greater adherence to this beneficial dietary pattern 7 . Several studies have demonstrated the positive impact of the MD on weight management and metabolic health in individuals with overweight and obesity 6 , 8 . However, limited research has specifically examined the relationship between adherence to the MD and cardiometabolic risk factors in morbidly obese patients preparing for bariatric surgery. Given that preoperative nutritional status may influence both short-term surgical outcomes and long-term weight maintenance, understanding the role of the MD in this high-risk population is of particular importance 5 . Despite the well-documented benefits of the MD in promoting cardiovascular and metabolic health, research investigating its association with cardiometabolic risk factors in morbidly obese individuals preparing for bariatric surgery remains limited. Given this population's high prevalence of metabolic disturbances, identifying dietary strategies that enhance cardiometabolic profiles before surgery could have significant implications for postoperative success and long-term health. Therefore, this study aims to investigate the association between adherence to the MD, as assessed by the MDS, and key cardiometabolic risk factors—including high fasting blood sugar (FBS), high triglycerides (TG), high blood pressure (BP), and low High-density lipoprotein cholesterol (HDL-C) in morbidly obese patients who are candidates for bariatric surgery. By exploring these associations, our findings may provide valuable insights into the role of dietary patterns in metabolic health and contribute to the development of evidence-based preoperative dietary strategies designed to improve surgical success and long-term metabolic outcomes. Method This cross-sectional study was conducted between September 2023 and September 2024 among individuals referred to the obesity clinic of Hazrat Rasul Akram Hospital using the convenience sampling method. The sample size for this study was determined based on a prior investigation that assessed the relationship between MDS and obesity phenotype among Iranian obese adults 9 . Using G*Power software, the sample size was calculated with the following parameters: alpha error probability of 0.05, power of 0.90, a mean MDS of 4.0 ± 1.35, and an effect size of 1.3 9 , resulting in a minimum required sample size of 369 participants. We included bariatric surgery candidates based on the following criteria: (1) they were between 18 and 65 years of age, (2) they had no medical conditions, as determined by a physician’s evaluation and a comprehensive review of their medical history, including kidney or liver diseases (such as Wilson's disease, autoimmune liver disease, hemochromatosis, viral infections, and alcoholic fatty liver disease) or any malignancies, and (3) they were neither pregnant nor breastfeeding. The criteria for exclusion were as follows: individuals who (1) did not complete more than 90% of the descriptive and nutritional questionnaires, (2) lacked essential paraclinical data, including blood and anthropometric measurements, or (3) reported dietary energy intake that was significantly over- or under-represented, defined as values deviating by more than three standard deviations from the mean energy intake. The study protocol was developed in accordance with the Helsinki Declaration and received approval from the ethics committee at Islamic Azad University, Science and Research Branch (Approval ID: IR.IAU.SRB.Rec.1403.543). We obtained written informed consent from all participants involved in the study. Measurements Trained nutritionists conducted anthropometric measurements utilizing standardized methodologies to ensure accuracy and reliability. Weight was measured to the nearest 100 grams with a calibrated scale (Seca, Hamburg, Germany), with participants advised to wear no additional clothing or shoes during the process. Height was assessed by the participants standing barefoot, employing a standard measuring tape that provides precision to 0.5 cm. Waist circumference (WC) was measured at the midpoint, specifically at the level of the umbilicus, using an unstretched tape measure to prevent any undue pressure on the body surface. BMI was calculated by dividing the weight in kilograms by the height in square meters. Systolic and diastolic blood pressure measurements were conducted at least twice after a 5-minute resting period, at intervals of 15 minutes, using a mercury sphygmomanometer that has been calibrated by the National Institute of Standards and Industrial Technology. The average of these two measurements is used to determine an individual's blood pressure. Blood samples were collected between 7:00 and 9:00 AM following a 12–14-hour overnight fasting period. Samples were centrifuged within 30–45 minutes of collection and analyzed on the same day to ensure precision and reliability. Fasting blood glucose levels were determined using an enzymatic colorimetric method based on glucose oxidase activity. TG concentrations were measured through an enzymatic colorimetric assay utilizing glycerol phosphate oxidase. Total cholesterol (TC) levels were assessed using an enzymatic colorimetric technique involving cholesterol esterase and cholesterol oxidase. HDL-C was quantified after the selective precipitation of apolipoprotein B-containing lipoproteins using phosphotungstic acid. Low-density lipoprotein cholesterol (LDL-C) concentrations were estimated using the Friedewald equation, which calculates LDL-C levels based on serum TC, TG, and HDL-C concentrations, with values expressed in mg/dL 10 . Cardiometabolic risk factors According to the Adult Treatment Panel III (ATP III) criteria, cardiometabolic risk factors are defined based on specific clinical parameters 11 . These include high FBS, characterized by a FBS ≥ 100 mg/dL or a history of diabetes. Hypertriglyceridemia is identified as serum triglyceride levels of ≥ 150 mg/dL. Low HDL-C levels are defined as HDL-C concentrations below 40 mg/dL in men and below 50 mg/dL in women. High BP is classified as systolic blood pressure of ≥ 130 mmHg and/or diastolic blood pressure of ≥ 85 mmHg or a history of antihypertensive medication use. Participants' dietary intakes were evaluated using a validated and reliable semi-quantitative food frequency questionnaire (FFQ), which comprised 147 items 12 , 13 . A qualified dietitian administered this questionnaire during a structured in-person interview. Participants indicated the frequency of their consumption of each food item over the past year, selecting from daily, weekly, monthly, or yearly options. The serving sizes for each food item on the FFQ were meticulously defined in accordance with the guidelines established by the U.S. Department of Agriculture (USDA) whenever feasible. In instances where this information was unavailable, household measurements were recorded and subsequently converted into grams and servings to ensure accuracy and consistency. The MDS was assessed based on the methodology established by Trichopoulou et al., incorporating eight key dietary components characteristic of the MD 7 . These components included a higher intake of vegetables, legumes, nuts and fruits, and cereals, and a favorable monounsaturated to saturated fatty acid (MUFA/SFA) ratio; moderate consumption of fish; a low-to-moderate intake of dairy products, primarily cheese and yoghurt; and a limited intake of meat and poultry. To ensure comparability, all dietary components were adjusted for energy intake using the energy density method (grams per 1000 kcal). The scoring system used sex-specific median intake values as cutoffs within the study population. Participants received a score of 1 if their intake was equal to or exceeded the median for beneficial dietary components (vegetables, legumes, nuts and fruits, cereals, and fish) or fell below the median for less favorable components (meat and dairy). Conversely, a score of 0 was assigned if the intake was below the median for beneficial components or above the median for unfavorable components. For fat intake, the MUFA/SFA ratio was used as a criterion, with values above the median assigned a score of 1 and those below the median assigned a score of 0. Due to cultural and religious factors, alcohol consumption was not included in the scoring system, as it is infrequently reported in the Iranian population. The final MDS was calculated by summing the scores across all eight components, yielding a total score ranging from 0 (indicating no adherence to the Mediterranean diet) to 8 (reflecting the highest level of adherence). Statistical analysis Descriptive statistical methods were utilized to summarize participants' demographic and clinical characteristics, categorized according to quartiles of the MDS. The normality of data distribution was assessed using histogram plots and the Kolmogorov–Smirnov test. Continuous variables were expressed as mean ± standard deviation (SD) or median with interquartile range (IQR), while categorical variables were presented as percentages. Group comparisons were conducted using one-way analysis of variance (ANOVA) for continuous variables and the Chi-square test for categorical variables, as appropriate. Logistic regression models were employed to investigate the association between MDS adherence and the odds of cardiometabolic risk factors. Adjustments for potential confounders were applied across three models: (1) a crude model with no adjustments, (2) Model 1, adjusted for age and sex, and (3) Model 2, which incorporated additional adjustments for BMI, educational level, physical activity, smoking status, total energy intake, saturated fatty acid intake, and total fiber intake. Statistical significance was set at p < 0.05. All analyses were performed using SPSS version 26 (SPSS, Chicago, IL, USA). Results A total of 376 participants were initially involved in the study. Two participants were excluded due to incomplete dietary data, and five were excluded due to discrepancies in reporting, either dietary over- or under-reporting. Consequently, our statistical analysis was conducted based on a final sample of 369 participants. The study participants exhibited a mean age of 39.4 ± 10.0 years and a mean BMI of 45.5 ± 6.1. Furthermore, 12.7% of the participants were identified as men. Table 1 demonstrates the demographic, anthropometric, and lifestyle characteristics of participants stratified by quartiles of adherence to the MDS. There was no significant trend observed for age, BMI, or waist circumference across the quartiles (P-trend > 0.4). Physical activity levels improved with higher adherence to the Mediterranean diet score, though not statistically significant (P-trend = 0.46). Diastolic blood pressure showed a significant decrease across quartiles (P = 0.01), while no significant trends were observed for systolic blood pressure, FBS, TG, Chol, LDL, or HDL (P > 0.05). Table 1 Lifestyle and characteristics of participants according to the quartile of Mediterranean diet score. Q1 Q2 Q3 Q4 P-trend Age (year) 39.2 ± 10.5 39.2 ± 10.4 39.6 ± 9.1 39.6 ± 9.6 0.98 Men (%) 19 (12.9) 7 (8.6) 12 (19.0) 9 (11.8) 0.31 Body mass index (Kg/m2) 45.0 ± 6.1 45.4 ± 5.9 45.2 ± 7.0 46.5 ± 5.7 0.40 Waist circumference (cm) 116.0 ± 12.9 117.2 ± 12.4 118.8 ± 13.1 118.1 ± 12.8 0.43 Current smoker (%) 36 (24.5) 19 (23.5) 14 (22.2) 24 (31.6) 0.55 Academic education (%) 36 (24.5) 24 (29.6) 24 (38.1) 15 (19.7) 0.41 Physical activity level Low 108 (86.4) 54 (83.1) 38 (77.6) 46 (73.0) 0.46 Moderate 11 (8.8) 8 (12.3) 9 (4.1) 14 (22.2) High 6 (4.8) 3 (4.6) 2 (4.1) 3 (4.8) SBP 124.1 ± 17.2 124.4 ± 16.7 121.6 ± 17.5 124.6 ± 25.2 0.88 DBP 89.0 ± 12.6 85.1 ± 7.1 80.9 ± 12.1 83.5 ± 21.9 0.01 FBS 106.7 ± 23.0 104.6 ± 25.5 107.4 ± 31.4 105.3 ± 29.1 0.90 TG 145.2 ± 62.4 153.3 ± 82.1 163.7 ± 90.8 153.2 ± 83.9 0.44 Chol 193.3 ± 35.7 188.2 ± 37.4 185.4 ± 39.5 191.4 ± 35.0 0.48 HDL 45.4 ± 11.6 44.4 ± 10.4 42.7 ± 8.4 45.8 ± 8.9 0.28 LDL 119.2 ± 29.5 115.1 ± 30.5 116.7 ± 30.2 119.6 ± 26.2 0.70 Abbreviations: FBS: Fasting blood sugar; TG: Triglyceride; HDL: High-density lipoprotein; LDL: Low-density lipoprotein. Table 2 highlights differences in dietary intake by MDS quartiles. Higher adherence to the MDS was associated with increased consumption of whole grains, fish, legumes, nuts, fruits, and vegetables (P < 0.01). Additionally, participants in the highest quartile showed significantly higher intake of PUFA/SFA ratios, magnesium, and potassium (P < 0.01). Conversely, refined grain intake decreased significantly across MDS quartiles (P = 0.01). Table 2 Dietary intakes of participants according to the Mediterranean diet score. Q1 Q2 Q3 Q4 P-trend Total energy intake (kcal) 2566.0 ± 969.2 2828.3 ± 1060.6 2894.1 ± 1035.5 3128.8 ± 1066.4 0.01 Protein (% of energy) 13.9 ± 2.1 14.0 ± 2.4 14.8 ± 2.1 14.6 ± 2.5 0.02 Carbohydrate (% of energy) 59.2 ± 5.8 57.7 ± 6.5 58.1 ± 5.3 58.1 ± 5.8 0.20 Fat (% of energy) 28.7 ± 5.7 30.6 ± 6.5 30.0 ± 5.1 29.7 ± 5.9 0.09 Whole grain (gram per 1000 kcal) 54.2 ± 48.3 54.8 ± 46.9 70.0 ± 42.9 68.8 ± 39.0 0.02 Refined grain (gram per 1000 kcal) 173.8 ± 69.2 173.8 ± 69.2 135.6 ± 56.4 120.9 ± 44.2 0.01 Total dairy (gram per 1000 kcal) 149.7 ± 115.1 124.4 ± 89.1 123.7 ± 71.0 119.5 ± 92.1 0.08 Fish (gram per 1000 kcal) 2.4 ± 2.6 3.3 ± 3.0 3.7 ± 3.4 5.4 ± 6.1 0.01 Legumes (gram per 1000 kcal) 12.6 ± 8.6 15.0 ± 10.3 16.2 ± 10.1 21.3 ± 13.1 0.01 Nuts (gram per 1000 kcal) 2.4 ± 2.3 4.5 ± 6.0 5.1 ± 5.4 5.5 ± 5.4 0.01 Fruits (gram per 1000 kcal) 108.7 ± 66.7 145.8 ± 87.3 152.1 ± 95.3 166.7 ± 89.3 0.01 Vegetables (gram per 1000 kcal) 115.4 ± 62.3 150.0 ± 83.5 155.8 ± 79.2 211.8 ± 128.5 0.01 PUFA/SFA ratio 0.59 ± 0.21 0.70 ± 0.30 0.72 ± 0.23 0.74 ± 0.23 0.01 Calcium (mg per 1000 kcal) 517.0 ± 176.8 527.7 ± 196.6 534.0 ± 177.3 547.2 ± 207.3 0.71 Magnesium (mg per 1000 kcal) 169.1 ± 37.5 179.0 ± 41.4 195.6 ± 35.1 206.7 ± 40.3 0.01 Potassium (mg per 1000 kcal) 1498.5 ± 413.3 1685.4 ± 510.7 1805.7 ± 473.4 1998.3 ± 595.7 0.01 Total dietary fiber (gram per 1000 kcal) 20.3 ± 10.0 21.1 ± 9.5 19.3 ± 6.7 19.8 ± 5.3 0.62 Abbreviations: PUFA: Polyunsaturated fatty acid; SFA: Saturated fatty acid Table 3 . represents the multivariable-adjusted ORs (95% CIs) for the odds of cardiometabolic risk factors according to the quartiles of the MDS. The multivariable-adjusted analysis revealed a significant inverse association between adherence to the MDS and cardiometabolic risk factors among morbidly obese patients. Compared to participants in the lowest quartile of MDS (Q1), those in the highest quartile (Q4) had 66% lower odds of high BP (OR = 0.34, 95% CI: 0.16–0.70, P-trend = 0.01). Similarly, adherence to a higher MDS was associated with 58% lower odds of low HDL-C (OR = 0.34, 95% CI: 0.16–0.70, P-trend = 0.03). Moreover, the odds of high FBS was significantly lower in Q4 compared to Q1 (OR = 0.42, 95% CI: 0.20–0.87, P-trend = 0.03). However, no significant association was observed between MDS adherence and high triglyceride levels (P-trend = 0.62). Table 3 Multivariable-adjusted ORs (95% CIs) for the odds of cardiometabolic risk factors according to the quartiles of the Mediterranean diet score. Q1 Q2 Q3 Q4 P-value for trend * High Blood pressure Median Score 3.0 5.0 6.0 7.0 Cases/total 75/147 34/81 16/63 22/76 Crude model 1 (Ref) 0.69 (0.40–1.20) 0.32 (0.17–0.62) 0.39 (0.21–0.70) 0.01 Model 1 a 1 (Ref) 0.69 (0.39–1.22) 0.28 (0.14–0.56) 0.35 (0.19–0.66) 0.01 Model 2 b 1 (Ref) 0.68 (0.35–1.31) 0.33 (0.15–0.72) 0.34 (0.16–0.70) 0.01 High FBS Median Score 3.0 5.0 6.0 7.0 Cases/total 85/147 32/81 32/63 33/76 Crude model 1 (Ref) 0.47 (0.27–0.82) 0.75 (0.41–1.36) 0.56 (0.32–0.98) 0.06 Model 1 1 (Ref) 0.45 (0.25–0.81) 0.70 (0.37–1.29) 0.52 (0.29–0.93) 0.04 Model 2 1 (Ref) 0.50 (0.25–0.97) 0.80 (0.38–1.68) 0.42 (0.20–0.87) 0.03 Hight TG Median Score 3.0 5.0 6.0 7.0 Cases/total 58/147 31/81 26/63 30/76 Crude model 1 (Ref) 0.95 (0.54–1.66) 1.07 (0.59–1.96) 1.00 (0.56–1.76) 0.91 Model 1 1 (Ref) 0.96 (0.55–1.68) 1.05 (0.57–1.93) 1.00 (0.57–1.77) 0.93 Model 2 1 (Ref) 0.89 (0.47–1.69) 0.95 (0.48–2.05) 0.80 (0.40–1.59) 0.62 Low HDL Median Score 3.0 5.0 6.0 7.0 Cases/total 105/147 57/81 49/63 45/76 Crude model 1 (Ref) 0.95 (0.52–1.72) 1.40 (0.70–2.80) 0.58 (0.32–1.03) 0.19 Model 1 1 (Ref) 0.87 (0.47–1.62) 1.60 (0.77–3.32) 0.55 (0.30-1.00) 0.20 Model 2 1 (Ref) 0.78 (0.38–1.57) 1.37 (0.58–3.24) 0.34 (0.16–0.70) 0.03 Abbreviations: FBS: Fasting blood sugar; TG: Triglyceride; HDL: High-density lipoprotein. Obtained by Logistic regression analysis. * P-trend was obtained using a quartile of dietary exposure as an ordinal variable in the model. Significant p-values are highlighted in bold. a Model 1: adjusted for age and sex. b Model 2: additionally adjusted for body mass index, educational level, physical activity, smoking, total energy intake, saturated fatty acid intake, and total fiber intake. Discussion The present study highlights a significant inverse association between adherence to the MD and key cardiometabolic risk factors, particularly high BP, low HDL-C, and high FBS, in morbidly obese patients preparing for bariatric surgery. These findings reinforce the growing body of evidence supporting the beneficial metabolic effects of the MD and suggest that promoting adherence to this dietary pattern may be an effective strategy for improving preoperative cardiometabolic health in this high-risk population. Our study found that individuals with the highest adherence to the MD had a 66% lower likelihood of hypertension compared to those in the lowest quartile, which is consistent with previous research demonstrating the antihypertensive effects of the MD 14 . The MD is rich in fruits, vegetables, whole grains, nuts, and olive oil, which provide essential micronutrients such as potassium and magnesium, known for their vasodilatory and blood pressure-lowering properties 8 . Potassium plays a crucial role in reducing blood pressure by counteracting the effects of sodium, modulating vascular tone, and enhancing renal sodium excretion 15 . Additionally, the high intake of polyphenols, particularly from olive oil and plant-based foods, has been shown to improve endothelial function, reduce arterial stiffness, and lower oxidative stress, contributing to blood pressure regulation 16 , 17 . Moreover, the MD's emphasis on unsaturated fats, mainly monounsaturated fatty acids (MUFA) from olive oil and polyunsaturated fatty acids (PUFA) from fish, may further support blood pressure reduction by modulating lipid metabolism and reducing systemic inflammation 18 . PUFAs, specifically omega-3 fatty acids, have been shown to decrease blood pressure by inhibiting vasoconstriction, reducing platelet aggregation, and improving endothelial function 19 . Given that hypertension is a major risk factor for cardiovascular disease (CVD) and an independent predictor of postoperative complications in bariatric surgery patients, adherence to the MD may provide an effective non-pharmacological approach to improving cardiovascular health prior to surgery 4 , 5 . Our findings also indicate that adherence to the MD is associated with a 58% lower odds of low HDL-C, aligning with previous studies that have demonstrated the lipid-modulating effects of the MD 20 , 21 . A higher HDL-C level is associated with a lower risk of atherosclerosis and cardiovascular events, making it an important target for metabolic health improvement in obese individuals (17). Several dietary components of the MD may contribute to higher HDL-C levels. The consumption of MUFAs from olive oil and PUFAs from fish and nuts has been shown to enhance HDL-C functionality by promoting cholesterol efflux capacity and improving the anti-inflammatory and antioxidant properties of HDL particles 21 , 22 . Furthermore, polyphenols present in the MD, particularly in extra virgin olive oil, have been shown to increase HDL-C levels by enhancing the activity of paraoxonase-1, an enzyme associated with HDL that exerts anti-inflammatory and anti-atherogenic effects 23 . Additionally, the high intake of dietary fiber from whole grains, legumes, fruits, and vegetables in the MD may play a role in lipid metabolism by reducing cholesterol absorption and promoting bile acid excretion 24 . Whole grains, in particular, contain beta-glucans and other soluble fibers that have been shown to lower LDL-C and improve HDL-C concentrations 25 . Given that dyslipidemia is a common comorbidity among bariatric surgery candidates, incorporating the MD into preoperative dietary interventions may help optimize lipid profiles and reduce the risk of CVD in this population 4 , 5 . The significant reduction in the odds of high FBS among individuals with higher MD adherence supports the role of this dietary pattern in glycemic regulation. These results are in line with previous studies demonstrating that adherence to the MD is associated with improved insulin sensitivity, lower fasting glucose levels, and a reduced risk of type 2 diabetes (26,27). The MD’s beneficial effects on glycemic control are likely mediated through multiple mechanisms, including its high fiber content, low glycemic index (GI), and rich polyphenol composition. Whole grains, legumes, fruits, and vegetables, which are central components of the MD, provide a substantial amount of dietary fiber, which slows gastric emptying, reduces glucose absorption, and improves postprandial glycemic response 26 , 27 . The high intake of complex carbohydrates with a low GI in the MD contributes to a more stable blood glucose profile, reducing insulin demand and improving pancreatic β-cell function 27 . Additionally, polyphenols found in olive oil, nuts, and certain fruits have been reported to enhance insulin sensitivity by modulating glucose uptake in peripheral tissues and reducing inflammation in pancreatic β-cells 28 . Moreover, omega-3 fatty acids from fish have been shown to improve insulin sensitivity and reduce hepatic glucose production by modulating adipocyte function and reducing ectopic fat deposition in the liver 29 , 30 . This mechanism is particularly relevant for morbidly obese individuals, as excessive visceral fat accumulation is a major contributor to insulin resistance and metabolic dysfunction. The beneficial effects of the MD on cardiometabolic health may be explained by several interrelated biological mechanisms. Chronic low-grade inflammation is a key driver of cardiometabolic disorders in obesity 1 . The MD’s high intake of antioxidants, polyphenols, and unsaturated fats exerts anti-inflammatory effects by reducing pro-inflammatory cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) 17 – 19 . The MD is rich in antioxidant compounds that counteract oxidative stress, which is implicated in endothelial dysfunction, hypertension, and insulin resistance 19 , 20 , 29 . Olive oil polyphenols, in particular, have been shown to enhance endothelial function and reduce oxidative damage in vascular tissues 19 , 31 . Emerging evidence suggests that the gut microbiota plays a crucial role in metabolic health 32 , 33 . The MD promotes a favorable gut microbiome composition by increasing beneficial bacterial strains that produce short-chain fatty acids (SCFAs), which have been linked to improved glucose metabolism and reduced systemic inflammation 32 , 33 The MD’s emphasis on healthy fats and fiber promotes lipid homeostasis by enhancing hepatic cholesterol clearance, improving HDL-C functionality, and reducing LDL-C oxidation 22 , 24 , 29 , 30 . Given the high prevalence of metabolic disturbances in bariatric surgery candidates, optimizing dietary patterns before surgery may significantly impact both short-term surgical outcomes and long-term metabolic health. Preoperative adherence to the MD could help reduce perioperative complications, improve weight loss outcomes, and enhance cardiometabolic resilience following surgery. Integrating MD-based dietary interventions into preoperative nutritional counseling may provide a practical and sustainable approach to improving metabolic health in this population. Strengths and limitations To our knowledge, this study is the first to examine the relationship between adherence to the MDS and the odds of cardiometabolic risk factors in morbidly obese patients preparing for bariatric surgery. We utilized validated and reliable questionnaires to gather nutritional data through face-to-face interviews, ensuring the accuracy of the information collected. Furthermore, all dietary and anthropometric assessments were conducted by highly trained dietitians, minimizing potential errors in data gathering. One of the key strengths of this study is the use of the widely recognized MDS, a reliable and reproducible tool that provides a well-established measure of dietary adherence. This makes the MDS particularly valuable for clinical and epidemiological research. However, several limitations must be considered. The cross-sectional nature of the study restricts the ability to draw causal conclusions, and dietary intake was assessed using a FFQ, which is susceptible to recall bias. While the MDS is a well-established method, it does have limitations when applied to non-Mediterranean populations. For instance, the exclusion of alcohol from the MDS—due to cultural and religious factors in the Iranian population—may limit the generalizability of the findings to regions or populations where alcohol consumption is more common. Additionally, the MDS does not account for variations in food preparation, such as the use of unhealthy cooking oils or added sugars, which may influence the health benefits of the Mediterranean diet. The study also lacks an assessment of other potential confounders, such as genetic predispositions, psychological factors (e.g., depression or stress), or medication use, all of which could impact metabolic health in bariatric surgery candidates. Furthermore, while the study focuses on a high-risk population of morbidly obese patients, its findings may not be directly applicable to individuals with less severe obesity or those who are not candidates for bariatric surgery. The effects of diet may vary across different levels of obesity, warranting further investigation to assess the generalizability of these results. Future research should include prospective studies and randomized controlled trials to explore the causal relationship between adherence to the Mediterranean diet and cardiometabolic health in morbidly obese patients. Additionally, assessing the impact of Mediterranean diet adherence on postoperative outcomes, such as long-term weight loss maintenance and improvements in metabolic health, would offer valuable insights that could inform dietary recommendations for this population. Conclusion In conclusion, adherence to the Mediterranean diet is significantly associated with lower odds of high BP, low HDL-C, and high FBS in morbidly obese individuals preparing for bariatric surgery. These findings underscore the potential role of the MD as a beneficial dietary strategy for optimizing cardiometabolic health in this high-risk population. Future research should focus on integrating MD-based dietary interventions into preoperative nutritional counseling to enhance both surgical success and long-term metabolic outcomes. Declarations Acknowledgements: The authors express their appreciation to the participants of the study for their enthusiastic support and to the staff of the involved hospitals for their valuable help. Author contributions: Overall, SAK and HA, supervised the project and approved the final version of the manuscript to be submitted. SAK designed the research; HA analyzed and interpreted the data; FSH drafted the initial manuscript; and HA critically revised the manuscript. All authors approved the final version of the manuscript submitted for publication. Funding Statement: No financial support was provided in any way for this research. Data availability statement: The datasets analyzed in the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare no competing interests. Ethics approval and consent to participate: The studies involving humans were approved by the ethics committee at Islamic Azad University, Science and Research Branch (Approval ID: IR.IAU.SRB.Rec.1403.543). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’. Consent for publication: Not applicable. References Mehrabani, J. & Ganjifar, Z. Overweight and obesity: a brief challenge on prevalence, complications and physical activity among men and women. MOJ Womens Health . 7 , 19–24 (2018). Abdelaal, M., le Roux, C. W. & Docherty, N. G. Morbidity and mortality associated with obesity. Ann. Transl Med. 5 , 161. 10.21037/atm.2017.03.107 (2017). Liao, J. et al. Bariatric surgery and health outcomes: An umbrella analysis. Front. Endocrinol. 13 , 1016613 (2022). Bettini, S., Belligoli, A., Fabris, R. & Busetto, L. Diet approach before and after bariatric surgery. Reviews Endocr. Metabolic Disorders . 21 , 297–306 (2020). Holderbaum, M. S. & Buss, C. Dietary management in the immediate preoperative period of bariatric surgery: a national overview: bariatric preoperative diets. Obes. Surg. 28 , 1688–1696 (2018). Estruch, R. & Ros, E. The role of the Mediterranean diet on weight loss and obesity-related diseases. Reviews Endocr. Metabolic Disorders . 21 , 315–327 (2020). Trichopoulou, A., Costacou, T., Bamia, C. & Trichopoulos, D. Adherence to a Mediterranean diet and survival in a Greek population. N. Engl. J. Med. 348 , 2599–2608 (2003). Muscogiuri, G. et al. Mediterranean diet and obesity-related disorders: what is the evidence? Curr. Obes. Rep. 11 , 287–304 (2022). Hosseini-Esfahani, F. et al. Mediterranean dietary pattern adherence modify the association between FTO genetic variations and obesity phenotypes. Nutrients 9 , 1064 (2017). Warnick, G. R., Knopp, R. H., Fitzpatrick, V. & Branson, L. Estimating low-density lipoprotein cholesterol by the Friedewald equation is adequate for classifying patients on the basis of nationally recommended cutpoints. Clin. Chem. 36 , 15–19 (1990). Eckel, R. H. & Cornier, M. A. Update on the NCEP ATP-III emerging cardiometabolic risk factors. BMC Med. 12 , 1–9 (2014). Esfahani, F. H., Asghari, G., Mirmiran, P. & Azizi, F. Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for the Tehran Lipid and Glucose Study. J. Epidemiol. 20 , 150–158. 10.2188/jea.je20090083 (2010). Asghari, G. et al. Reliability, comparative validity and stability of dietary patterns derived from an FFQ in the Tehran Lipid and Glucose Study. Br. J. Nutr. 108 , 1109–1117. 10.1017/s0007114511006313 (2012). Filippou, C. D. et al. Mediterranean diet and blood pressure reduction in adults with and without hypertension: A systematic review and meta-analysis of randomized controlled trials. Clin. Nutr. 40 , 3191–3200. 10.1016/j.clnu.2021.01.030 (2021). Aburto, N. J. et al. Effect of increased potassium intake on cardiovascular risk factors and disease: systematic review and meta-analyses. Bmj 346 (2013). Shannon, O. M. et al. Mediterranean diet increases endothelial function in adults: a systematic review and meta-analysis of randomized controlled trials. J. Nutr. 150 , 1151–1159 (2020). Yamagata, K., Tagami, M. & Yamori, Y. Dietary polyphenols regulate endothelial function and prevent cardiovascular disease. Nutrition 31 , 28–37 (2015). Schwingshackl, L. & Hoffmann, G. Mediterranean dietary pattern, inflammation and endothelial function: a systematic review and meta-analysis of intervention trials. Nutr. Metabolism Cardiovasc. Dis. 24 , 929–939 (2014). Scoditti, E., Capurso, C., Capurso, A. & Massaro, M. Vascular effects of the Mediterranean diet—Part II: Role of omega-3 fatty acids and olive oil polyphenols. Vascul. Pharmacol. 63 , 127–134 (2014). Kastorini, C. M. et al. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J. Am. Coll. Cardiol. 57 , 1299–1313 (2011). Grao-Cruces, E., Varela, L. M., Martin, M. E. & Bermudez, B. Montserrat-de la Paz, S. High-density lipoproteins and mediterranean diet: A systematic review. Nutrients 13 , 955 (2021). Rondanelli, M. et al. MediterrAsian diet products that could raise HDL-cholesterol: A systematic review. BioMed Research International 2025687 (2016). (2016). Zupo, R. et al. Olive Oil Polyphenols Improve HDL Cholesterol and Promote Maintenance of Lipid Metabolism: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Metabolites 13 , 1187 (2023). Mekki, N. et al. Effects of lowering fat and increasing dietary fiber on fasting and postprandial plasma lipids in hypercholesterolemic subjects consuming a mixed Mediterranean-Western diet. Am. J. Clin. Nutr. 66 , 1443–1451. https://doi.org/10.1093/ajcn/66.6.1443 (1997). de Morais Junior, A. C. et al. The separate effects of whole oats and isolated beta-glucan on lipid profile: A systematic review and meta-analysis of randomized controlled trials. Clin. Nutr. ESPEN . 53 , 224–237. https://doi.org/10.1016/j.clnesp.2022.12.019 (2023). Biesalski, H. K. Diabetes preventive components in the Mediterranean diet. Eur. J. Nutr. 43 , i26–i30 (2004). Esposito, K. et al. A journey into a Mediterranean diet and type 2 diabetes: a systematic review with meta-analyses. BMJ Open. 5 , e008222. 10.1136/bmjopen-2015-008222 (2015). Guasch-Ferré, M., Merino, J., Sun, Q., Fitó, M. & Salas-Salvadó, J. Dietary polyphenols, Mediterranean diet, prediabetes, and type 2 diabetes: a narrative review of the evidence. Oxidative medicine and cellular longevity 6723931 (2017). (2017). Vetrani, C., Verde, L., Colao, A., Barrea, L. & Muscogiuri, G. The Mediterranean Diet: effects on insulin resistance and secretion in individuals with overweight or obesity. Nutrients 15 , 4524 (2023). Scorletti, E. & Byrne, C. D. Omega-3 fatty acids, hepatic lipid metabolism, and nonalcoholic fatty liver disease. Annu. Rev. Nutr. 33 , 231–248 (2013). Manna, C. et al. Protective effect of the phenolic fraction from virgin olive oils against oxidative stress in human cells. J. Agric. Food Chem. 50 , 6521–6526 (2002). Barber, T. M., Kabisch, S., Pfeiffer, A. F. & Weickert, M. O. The effects of the Mediterranean diet on health and gut microbiota. Nutrients 15 , 2150 (2023). Kimble, R. et al. Effects of a mediterranean diet on the gut microbiota and microbial metabolites: A systematic review of randomized controlled trials and observational studies. Crit. Rev. Food Sci. Nutr. 63 , 8698–8719. 10.1080/10408398.2022.2057416 (2023). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6405349","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":489163526,"identity":"f44078ec-fb4c-4f58-9b31-642b50922b30","order_by":0,"name":"Fatemeh S. Hosseini","email":"","orcid":"","institution":"Islamic Azad University","correspondingAuthor":false,"prefix":"","firstName":"Fatemeh","middleName":"S.","lastName":"Hosseini","suffix":""},{"id":489163527,"identity":"57bbdf7e-b012-477d-9de5-906a89414677","order_by":1,"name":"Seyed Ali Keshavarz","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seyed","middleName":"Ali","lastName":"Keshavarz","suffix":""},{"id":489163528,"identity":"bceeeeee-9d81-4bbf-b8fe-178168251bf6","order_by":2,"name":"Hastimansooreh Ansar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYBACAxCRAGYyHwASEjLEaGFsgGhhA1ESPMRpgTB5wDYS1mLOfvz5gwc1d+z5Z5/5/OpGjQUPA/vhoxvwabHsyTFsSDj2LHHGudxt1jnHgA7jSUu7gddhB3KAfmE7nMBwhnebcQ4bUIsEjxl+LeefP2xI+HfYXv4MzzPjnH/EaLmRYNiQ2HaYccMZHubHuW1EaXljOCOx73DixjNsZsy5fRI8bAT9cj79wccf3w7by51hfvw551udHD/74WN4tSADNgkwSaxyEGD+QIrqUTAKRsEoGDkAAK8hTFtKOO8CAAAAAElFTkSuQmCC","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Hastimansooreh","middleName":"","lastName":"Ansar","suffix":""}],"badges":[],"createdAt":"2025-04-08 16:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6405349/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6405349/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87935088,"identity":"ddd76ec4-eaef-4c01-8342-e7744a35be4e","added_by":"auto","created_at":"2025-07-30 14:17:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":785942,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6405349/v1/7f330111-f082-4c19-b2c6-3b3b815f4e88.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adherence to the Mediterranean diet and cardiometabolic risk factors in morbid obese patients candidate for bariatric surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eObesity has become a major global health crisis, with its prevalence steadily increasing over the past decades \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Among individuals with obesity, morbid obesity\u0026mdash;defined as a body mass index (BMI) of \u0026ge;\u0026thinsp;40 kg/m\u0026sup2; or \u0026ge;\u0026thinsp;35 kg/m\u0026sup2; with obesity-related comorbidities\u0026mdash;poses significant health challenges, including an increased risk of cardiovascular diseases (CVD), type 2 diabetes mellitus (T2DM), hypertension, dyslipidemia, and metabolic syndrome \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. These conditions not only contribute to increased morbidity and mortality but also impose a considerable economic and healthcare burden globally \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Among the available treatment strategies, bariatric surgery has emerged as the most effective long-term intervention for significant weight loss and the resolution of obesity-related metabolic disorders \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. While bariatric surgery has been shown to improve metabolic health through mechanisms such as hormonal modulation, reduced caloric intake, and enhanced insulin sensitivity, the role of preoperative dietary patterns in shaping metabolic outcomes remains an area of growing interest \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Nutritional optimization before surgery is increasingly recognized as a key factor in improving surgical outcomes, reducing perioperative complications, and enhancing long-term metabolic benefits \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Identifying dietary patterns that positively influence cardiometabolic risk factors in this high-risk population could provide valuable insights into preoperative dietary interventions that improve both immediate and long-term health outcomes.\u003c/p\u003e\u003cp\u003eThe Mediterranean diet (MD) is a well-recognized dietary pattern characterized by a high intake of fruits, vegetables, whole grains, legumes, nuts, and olive oil; a moderate intake of fish, dairy, and wine; and a low intake of red meat and processed foods \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The Mediterranean Diet Score (MDS) is a validated tool commonly used to assess adherence to the MD, with higher scores indicating greater adherence to this beneficial dietary pattern \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Several studies have demonstrated the positive impact of the MD on weight management and metabolic health in individuals with overweight and obesity \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. However, limited research has specifically examined the relationship between adherence to the MD and cardiometabolic risk factors in morbidly obese patients preparing for bariatric surgery. Given that preoperative nutritional status may influence both short-term surgical outcomes and long-term weight maintenance, understanding the role of the MD in this high-risk population is of particular importance \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDespite the well-documented benefits of the MD in promoting cardiovascular and metabolic health, research investigating its association with cardiometabolic risk factors in morbidly obese individuals preparing for bariatric surgery remains limited. Given this population's high prevalence of metabolic disturbances, identifying dietary strategies that enhance cardiometabolic profiles before surgery could have significant implications for postoperative success and long-term health. Therefore, this study aims to investigate the association between adherence to the MD, as assessed by the MDS, and key cardiometabolic risk factors\u0026mdash;including high fasting blood sugar (FBS), high triglycerides (TG), high blood pressure (BP), and low High-density lipoprotein cholesterol (HDL-C) in morbidly obese patients who are candidates for bariatric surgery. By exploring these associations, our findings may provide valuable insights into the role of dietary patterns in metabolic health and contribute to the development of evidence-based preoperative dietary strategies designed to improve surgical success and long-term metabolic outcomes.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThis cross-sectional study was conducted between September 2023 and September 2024 among individuals referred to the obesity clinic of Hazrat Rasul Akram Hospital using the convenience sampling method. The sample size for this study was determined based on a prior investigation that assessed the relationship between MDS and obesity phenotype among Iranian obese adults \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Using G*Power software, the sample size was calculated with the following parameters: alpha error probability of 0.05, power of 0.90, a mean MDS of 4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35, and an effect size of 1.3 \u003csup\u003e9\u003c/sup\u003e, resulting in a minimum required sample size of 369 participants.\u003c/p\u003e\u003cp\u003eWe included bariatric surgery candidates based on the following criteria: (1) they were between 18 and 65 years of age, (2) they had no medical conditions, as determined by a physician\u0026rsquo;s evaluation and a comprehensive review of their medical history, including kidney or liver diseases (such as Wilson's disease, autoimmune liver disease, hemochromatosis, viral infections, and alcoholic fatty liver disease) or any malignancies, and (3) they were neither pregnant nor breastfeeding. The criteria for exclusion were as follows: individuals who (1) did not complete more than 90% of the descriptive and nutritional questionnaires, (2) lacked essential paraclinical data, including blood and anthropometric measurements, or (3) reported dietary energy intake that was significantly over- or under-represented, defined as values deviating by more than three standard deviations from the mean energy intake.\u003c/p\u003e\u003cp\u003e The study protocol was developed in accordance with the Helsinki Declaration and received approval from the ethics committee at Islamic Azad University, Science and Research Branch (Approval ID: IR.IAU.SRB.Rec.1403.543). We obtained written informed consent from all participants involved in the study.\u003c/p\u003e\u003cp\u003eMeasurements\u003c/p\u003e\u003cp\u003eTrained nutritionists conducted anthropometric measurements utilizing standardized methodologies to ensure accuracy and reliability. Weight was measured to the nearest 100 grams with a calibrated scale (Seca, Hamburg, Germany), with participants advised to wear no additional clothing or shoes during the process. Height was assessed by the participants standing barefoot, employing a standard measuring tape that provides precision to 0.5 cm. Waist circumference (WC) was measured at the midpoint, specifically at the level of the umbilicus, using an unstretched tape measure to prevent any undue pressure on the body surface. BMI was calculated by dividing the weight in kilograms by the height in square meters.\u003c/p\u003e\u003cp\u003eSystolic and diastolic blood pressure measurements were conducted at least twice after a 5-minute resting period, at intervals of 15 minutes, using a mercury sphygmomanometer that has been calibrated by the National Institute of Standards and Industrial Technology. The average of these two measurements is used to determine an individual's blood pressure.\u003c/p\u003e\u003cp\u003eBlood samples were collected between 7:00 and 9:00 AM following a 12\u0026ndash;14-hour overnight fasting period. Samples were centrifuged within 30\u0026ndash;45 minutes of collection and analyzed on the same day to ensure precision and reliability. Fasting blood glucose levels were determined using an enzymatic colorimetric method based on glucose oxidase activity. TG concentrations were measured through an enzymatic colorimetric assay utilizing glycerol phosphate oxidase. Total cholesterol (TC) levels were assessed using an enzymatic colorimetric technique involving cholesterol esterase and cholesterol oxidase. HDL-C was quantified after the selective precipitation of apolipoprotein B-containing lipoproteins using phosphotungstic acid. Low-density lipoprotein cholesterol (LDL-C) concentrations were estimated using the Friedewald equation, which calculates LDL-C levels based on serum TC, TG, and HDL-C concentrations, with values expressed in mg/dL \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eCardiometabolic risk factors\u003c/h2\u003e\u003cp\u003eAccording to the Adult Treatment Panel III (ATP III) criteria, cardiometabolic risk factors are defined based on specific clinical parameters \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. These include high FBS, characterized by a FBS\u0026thinsp;\u0026ge;\u0026thinsp;100 mg/dL or a history of diabetes. Hypertriglyceridemia is identified as serum triglyceride levels of \u0026ge;\u0026thinsp;150 mg/dL. Low HDL-C levels are defined as HDL-C concentrations below 40 mg/dL in men and below 50 mg/dL in women. High BP is classified as systolic blood pressure of \u0026ge;\u0026thinsp;130 mmHg and/or diastolic blood pressure of \u0026ge;\u0026thinsp;85 mmHg or a history of antihypertensive medication use.\u003c/p\u003e\u003cp\u003eParticipants' dietary intakes were evaluated using a validated and reliable semi-quantitative food frequency questionnaire (FFQ), which comprised 147 items \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. A qualified dietitian administered this questionnaire during a structured in-person interview. Participants indicated the frequency of their consumption of each food item over the past year, selecting from daily, weekly, monthly, or yearly options. The serving sizes for each food item on the FFQ were meticulously defined in accordance with the guidelines established by the U.S. Department of Agriculture (USDA) whenever feasible. In instances where this information was unavailable, household measurements were recorded and subsequently converted into grams and servings to ensure accuracy and consistency.\u003c/p\u003e\u003cp\u003eThe MDS was assessed based on the methodology established by Trichopoulou et al., incorporating eight key dietary components characteristic of the MD \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. These components included a higher intake of vegetables, legumes, nuts and fruits, and cereals, and a favorable monounsaturated to saturated fatty acid (MUFA/SFA) ratio; moderate consumption of fish; a low-to-moderate intake of dairy products, primarily cheese and yoghurt; and a limited intake of meat and poultry. To ensure comparability, all dietary components were adjusted for energy intake using the energy density method (grams per 1000 kcal). The scoring system used sex-specific median intake values as cutoffs within the study population. Participants received a score of 1 if their intake was equal to or exceeded the median for beneficial dietary components (vegetables, legumes, nuts and fruits, cereals, and fish) or fell below the median for less favorable components (meat and dairy). Conversely, a score of 0 was assigned if the intake was below the median for beneficial components or above the median for unfavorable components. For fat intake, the MUFA/SFA ratio was used as a criterion, with values above the median assigned a score of 1 and those below the median assigned a score of 0. Due to cultural and religious factors, alcohol consumption was not included in the scoring system, as it is infrequently reported in the Iranian population. The final MDS was calculated by summing the scores across all eight components, yielding a total score ranging from 0 (indicating no adherence to the Mediterranean diet) to 8 (reflecting the highest level of adherence).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistical methods were utilized to summarize participants' demographic and clinical characteristics, categorized according to quartiles of the MDS. The normality of data distribution was assessed using histogram plots and the Kolmogorov\u0026ndash;Smirnov test. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median with interquartile range (IQR), while categorical variables were presented as percentages. Group comparisons were conducted using one-way analysis of variance (ANOVA) for continuous variables and the Chi-square test for categorical variables, as appropriate.\u003c/p\u003e\u003cp\u003eLogistic regression models were employed to investigate the association between MDS adherence and the odds of cardiometabolic risk factors. Adjustments for potential confounders were applied across three models: (1) a crude model with no adjustments, (2) Model 1, adjusted for age and sex, and (3) Model 2, which incorporated additional adjustments for BMI, educational level, physical activity, smoking status, total energy intake, saturated fatty acid intake, and total fiber intake. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All analyses were performed using SPSS version 26 (SPSS, Chicago, IL, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 376 participants were initially involved in the study. Two participants were excluded due to incomplete dietary data, and five were excluded due to discrepancies in reporting, either dietary over- or under-reporting. Consequently, our statistical analysis was conducted based on a final sample of 369 participants. The study participants exhibited a mean age of 39.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0 years and a mean BMI of 45.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1. Furthermore, 12.7% of the participants were identified as men.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e demonstrates the demographic, anthropometric, and lifestyle characteristics of participants stratified by quartiles of adherence to the MDS. There was no significant trend observed for age, BMI, or waist circumference across the quartiles (P-trend\u0026thinsp;\u0026gt;\u0026thinsp;0.4). Physical activity levels improved with higher adherence to the Mediterranean diet score, though not statistically significant (P-trend\u0026thinsp;=\u0026thinsp;0.46). Diastolic blood pressure showed a significant decrease across quartiles (P\u0026thinsp;=\u0026thinsp;0.01), while no significant trends were observed for systolic blood pressure, FBS, TG, Chol, LDL, or HDL (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\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\u003eLifestyle and characteristics of participants according to the quartile of Mediterranean diet score.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP-trend\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e39.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMen (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (12.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (8.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (19.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody mass index (Kg/m2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e46.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWaist circumference (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e116.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e117.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e118.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e118.1\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent smoker (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (24.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24 (31.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic education (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (24.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (29.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24 (38.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15 (19.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical activity level\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e108 (86.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54 (83.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38 (77.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e46 (73.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (8.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (12.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14 (22.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (4.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (4.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSBP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e124.1\u0026thinsp;\u0026plusmn;\u0026thinsp;17.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e124.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e121.6\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e124.6\u0026thinsp;\u0026plusmn;\u0026thinsp;25.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDBP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e89.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e83.5\u0026thinsp;\u0026plusmn;\u0026thinsp;21.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFBS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e106.7\u0026thinsp;\u0026plusmn;\u0026thinsp;23.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104.6\u0026thinsp;\u0026plusmn;\u0026thinsp;25.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e107.4\u0026thinsp;\u0026plusmn;\u0026thinsp;31.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e105.3\u0026thinsp;\u0026plusmn;\u0026thinsp;29.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.90\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e145.2\u0026thinsp;\u0026plusmn;\u0026thinsp;62.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e153.3\u0026thinsp;\u0026plusmn;\u0026thinsp;82.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e163.7\u0026thinsp;\u0026plusmn;\u0026thinsp;90.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e153.2\u0026thinsp;\u0026plusmn;\u0026thinsp;83.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChol\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e193.3\u0026thinsp;\u0026plusmn;\u0026thinsp;35.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e188.2\u0026thinsp;\u0026plusmn;\u0026thinsp;37.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e185.4\u0026thinsp;\u0026plusmn;\u0026thinsp;39.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e191.4\u0026thinsp;\u0026plusmn;\u0026thinsp;35.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHDL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e119.2\u0026thinsp;\u0026plusmn;\u0026thinsp;29.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e115.1\u0026thinsp;\u0026plusmn;\u0026thinsp;30.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e116.7\u0026thinsp;\u0026plusmn;\u0026thinsp;30.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e119.6\u0026thinsp;\u0026plusmn;\u0026thinsp;26.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eAbbreviations: FBS: Fasting blood sugar; TG: Triglyceride; HDL: High-density lipoprotein; LDL: Low-density lipoprotein.\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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e highlights differences in dietary intake by MDS quartiles. Higher adherence to the MDS was associated with increased consumption of whole grains, fish, legumes, nuts, fruits, and vegetables (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Additionally, participants in the highest quartile showed significantly higher intake of PUFA/SFA ratios, magnesium, and potassium (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Conversely, refined grain intake decreased significantly across MDS quartiles (P\u0026thinsp;=\u0026thinsp;0.01).\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\u003eDietary intakes of participants according to the Mediterranean diet score.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP-trend\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal energy intake (kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2566.0\u0026thinsp;\u0026plusmn;\u0026thinsp;969.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2828.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1060.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2894.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1035.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3128.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1066.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProtein (% of energy)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCarbohydrate (% of energy)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFat (% of energy)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhole grain (gram per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54.2\u0026thinsp;\u0026plusmn;\u0026thinsp;48.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.8\u0026thinsp;\u0026plusmn;\u0026thinsp;46.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70.0\u0026thinsp;\u0026plusmn;\u0026thinsp;42.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e68.8\u0026thinsp;\u0026plusmn;\u0026thinsp;39.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRefined grain (gram per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e173.8\u0026thinsp;\u0026plusmn;\u0026thinsp;69.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e173.8\u0026thinsp;\u0026plusmn;\u0026thinsp;69.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e135.6\u0026thinsp;\u0026plusmn;\u0026thinsp;56.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e120.9\u0026thinsp;\u0026plusmn;\u0026thinsp;44.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal dairy (gram per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e149.7\u0026thinsp;\u0026plusmn;\u0026thinsp;115.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e124.4\u0026thinsp;\u0026plusmn;\u0026thinsp;89.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e123.7\u0026thinsp;\u0026plusmn;\u0026thinsp;71.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e119.5\u0026thinsp;\u0026plusmn;\u0026thinsp;92.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFish (gram per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLegumes (gram per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNuts (gram per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFruits (gram per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e108.7\u0026thinsp;\u0026plusmn;\u0026thinsp;66.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e145.8\u0026thinsp;\u0026plusmn;\u0026thinsp;87.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e152.1\u0026thinsp;\u0026plusmn;\u0026thinsp;95.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e166.7\u0026thinsp;\u0026plusmn;\u0026thinsp;89.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVegetables (gram per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e115.4\u0026thinsp;\u0026plusmn;\u0026thinsp;62.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e150.0\u0026thinsp;\u0026plusmn;\u0026thinsp;83.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e155.8\u0026thinsp;\u0026plusmn;\u0026thinsp;79.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e211.8\u0026thinsp;\u0026plusmn;\u0026thinsp;128.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePUFA/SFA ratio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.70\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCalcium (mg per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e517.0\u0026thinsp;\u0026plusmn;\u0026thinsp;176.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e527.7\u0026thinsp;\u0026plusmn;\u0026thinsp;196.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e534.0\u0026thinsp;\u0026plusmn;\u0026thinsp;177.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e547.2\u0026thinsp;\u0026plusmn;\u0026thinsp;207.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMagnesium (mg per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e169.1\u0026thinsp;\u0026plusmn;\u0026thinsp;37.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e179.0\u0026thinsp;\u0026plusmn;\u0026thinsp;41.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e195.6\u0026thinsp;\u0026plusmn;\u0026thinsp;35.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e206.7\u0026thinsp;\u0026plusmn;\u0026thinsp;40.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePotassium (mg per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1498.5\u0026thinsp;\u0026plusmn;\u0026thinsp;413.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1685.4\u0026thinsp;\u0026plusmn;\u0026thinsp;510.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1805.7\u0026thinsp;\u0026plusmn;\u0026thinsp;473.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1998.3\u0026thinsp;\u0026plusmn;\u0026thinsp;595.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal dietary fiber (gram per 1000 kcal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eAbbreviations: PUFA: Polyunsaturated fatty acid; SFA: Saturated fatty acid\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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. represents the multivariable-adjusted ORs (95% CIs) for the odds of cardiometabolic risk factors according to the quartiles of the MDS. The multivariable-adjusted analysis revealed a significant inverse association between adherence to the MDS and cardiometabolic risk factors among morbidly obese patients. Compared to participants in the lowest quartile of MDS (Q1), those in the highest quartile (Q4) had 66% lower odds of high BP (OR\u0026thinsp;=\u0026thinsp;0.34, 95% CI: 0.16\u0026ndash;0.70, P-trend\u0026thinsp;=\u0026thinsp;0.01). Similarly, adherence to a higher MDS was associated with 58% lower odds of low HDL-C (OR\u0026thinsp;=\u0026thinsp;0.34, 95% CI: 0.16\u0026ndash;0.70, P-trend\u0026thinsp;=\u0026thinsp;0.03). Moreover, the odds of high FBS was significantly lower in Q4 compared to Q1 (OR\u0026thinsp;=\u0026thinsp;0.42, 95% CI: 0.20\u0026ndash;0.87, P-trend\u0026thinsp;=\u0026thinsp;0.03). However, no significant association was observed between MDS adherence and high triglyceride levels (P-trend\u0026thinsp;=\u0026thinsp;0.62).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariable-adjusted ORs (95% CIs) for the odds of cardiometabolic risk factors according to the quartiles of the Mediterranean diet score.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP-value for trend\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHigh Blood pressure\u003c/b\u003e\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCases/total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75/147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34/81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16/63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22/76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrude model\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.69 (0.40\u0026ndash;1.20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.32 (0.17\u0026ndash;0.62)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.39 (0.21\u0026ndash;0.70)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel 1\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.69 (0.39\u0026ndash;1.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.28 (0.14\u0026ndash;0.56)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.35 (0.19\u0026ndash;0.66)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel 2\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.68 (0.35\u0026ndash;1.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.33 (0.15\u0026ndash;0.72)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.34 (0.16\u0026ndash;0.70)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHigh FBS\u003c/b\u003e\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCases/total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85/147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32/81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32/63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33/76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrude model\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.47 (0.27\u0026ndash;0.82)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.75 (0.41\u0026ndash;1.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.56 (0.32\u0026ndash;0.98)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.45 (0.25\u0026ndash;0.81)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.70 (0.37\u0026ndash;1.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.52 (0.29\u0026ndash;0.93)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.50 (0.25\u0026ndash;0.97)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.80 (0.38\u0026ndash;1.68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.42 (0.20\u0026ndash;0.87)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHight TG\u003c/b\u003e\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCases/total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58/147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31/81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26/63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30/76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrude model\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.95 (0.54\u0026ndash;1.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.07 (0.59\u0026ndash;1.96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00 (0.56\u0026ndash;1.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.96 (0.55\u0026ndash;1.68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.05 (0.57\u0026ndash;1.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00 (0.57\u0026ndash;1.77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.93\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.89 (0.47\u0026ndash;1.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.95 (0.48\u0026ndash;2.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.80 (0.40\u0026ndash;1.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLow HDL\u003c/b\u003e\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCases/total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e105/147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57/81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49/63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45/76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrude model\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.95 (0.52\u0026ndash;1.72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.40 (0.70\u0026ndash;2.80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.58 (0.32\u0026ndash;1.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.87 (0.47\u0026ndash;1.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.60 (0.77\u0026ndash;3.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.55 (0.30-1.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModel 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.78 (0.38\u0026ndash;1.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.37 (0.58\u0026ndash;3.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.34 (0.16\u0026ndash;0.70)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eAbbreviations: FBS: Fasting blood sugar; TG: Triglyceride; HDL: High-density lipoprotein.\u003c/p\u003e\u003cp\u003eObtained by Logistic regression analysis.\u003c/p\u003e\u003cp\u003e* P-trend was obtained using a quartile of dietary exposure as an ordinal variable in the model.\u003c/p\u003e\u003cp\u003eSignificant p-values are highlighted in bold.\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Model 1: adjusted for age and sex.\u003c/p\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Model 2: additionally adjusted for body mass index, educational level, physical activity, smoking, total energy intake, saturated fatty acid intake, and total fiber intake.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study highlights a significant inverse association between adherence to the MD and key cardiometabolic risk factors, particularly high BP, low HDL-C, and high FBS, in morbidly obese patients preparing for bariatric surgery. These findings reinforce the growing body of evidence supporting the beneficial metabolic effects of the MD and suggest that promoting adherence to this dietary pattern may be an effective strategy for improving preoperative cardiometabolic health in this high-risk population.\u003c/p\u003e\u003cp\u003eOur study found that individuals with the highest adherence to the MD had a 66% lower likelihood of hypertension compared to those in the lowest quartile, which is consistent with previous research demonstrating the antihypertensive effects of the MD \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The MD is rich in fruits, vegetables, whole grains, nuts, and olive oil, which provide essential micronutrients such as potassium and magnesium, known for their vasodilatory and blood pressure-lowering properties \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Potassium plays a crucial role in reducing blood pressure by counteracting the effects of sodium, modulating vascular tone, and enhancing renal sodium excretion \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Additionally, the high intake of polyphenols, particularly from olive oil and plant-based foods, has been shown to improve endothelial function, reduce arterial stiffness, and lower oxidative stress, contributing to blood pressure regulation \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Moreover, the MD's emphasis on unsaturated fats, mainly monounsaturated fatty acids (MUFA) from olive oil and polyunsaturated fatty acids (PUFA) from fish, may further support blood pressure reduction by modulating lipid metabolism and reducing systemic inflammation \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. PUFAs, specifically omega-3 fatty acids, have been shown to decrease blood pressure by inhibiting vasoconstriction, reducing platelet aggregation, and improving endothelial function \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Given that hypertension is a major risk factor for cardiovascular disease (CVD) and an independent predictor of postoperative complications in bariatric surgery patients, adherence to the MD may provide an effective non-pharmacological approach to improving cardiovascular health prior to surgery \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOur findings also indicate that adherence to the MD is associated with a 58% lower odds of low HDL-C, aligning with previous studies that have demonstrated the lipid-modulating effects of the MD \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. A higher HDL-C level is associated with a lower risk of atherosclerosis and cardiovascular events, making it an important target for metabolic health improvement in obese individuals (17). Several dietary components of the MD may contribute to higher HDL-C levels. The consumption of MUFAs from olive oil and PUFAs from fish and nuts has been shown to enhance HDL-C functionality by promoting cholesterol efflux capacity and improving the anti-inflammatory and antioxidant properties of HDL particles \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Furthermore, polyphenols present in the MD, particularly in extra virgin olive oil, have been shown to increase HDL-C levels by enhancing the activity of paraoxonase-1, an enzyme associated with HDL that exerts anti-inflammatory and anti-atherogenic effects \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Additionally, the high intake of dietary fiber from whole grains, legumes, fruits, and vegetables in the MD may play a role in lipid metabolism by reducing cholesterol absorption and promoting bile acid excretion \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Whole grains, in particular, contain beta-glucans and other soluble fibers that have been shown to lower LDL-C and improve HDL-C concentrations \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Given that dyslipidemia is a common comorbidity among bariatric surgery candidates, incorporating the MD into preoperative dietary interventions may help optimize lipid profiles and reduce the risk of CVD in this population \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe significant reduction in the odds of high FBS among individuals with higher MD adherence supports the role of this dietary pattern in glycemic regulation. These results are in line with previous studies demonstrating that adherence to the MD is associated with improved insulin sensitivity, lower fasting glucose levels, and a reduced risk of type 2 diabetes (26,27). The MD\u0026rsquo;s beneficial effects on glycemic control are likely mediated through multiple mechanisms, including its high fiber content, low glycemic index (GI), and rich polyphenol composition.\u003c/p\u003e\u003cp\u003eWhole grains, legumes, fruits, and vegetables, which are central components of the MD, provide a substantial amount of dietary fiber, which slows gastric emptying, reduces glucose absorption, and improves postprandial glycemic response \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. The high intake of complex carbohydrates with a low GI in the MD contributes to a more stable blood glucose profile, reducing insulin demand and improving pancreatic β-cell function \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Additionally, polyphenols found in olive oil, nuts, and certain fruits have been reported to enhance insulin sensitivity by modulating glucose uptake in peripheral tissues and reducing inflammation in pancreatic β-cells \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eMoreover, omega-3 fatty acids from fish have been shown to improve insulin sensitivity and reduce hepatic glucose production by modulating adipocyte function and reducing ectopic fat deposition in the liver \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. This mechanism is particularly relevant for morbidly obese individuals, as excessive visceral fat accumulation is a major contributor to insulin resistance and metabolic dysfunction.\u003c/p\u003e\u003cp\u003eThe beneficial effects of the MD on cardiometabolic health may be explained by several interrelated biological mechanisms. Chronic low-grade inflammation is a key driver of cardiometabolic disorders in obesity \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The MD\u0026rsquo;s high intake of antioxidants, polyphenols, and unsaturated fats exerts anti-inflammatory effects by reducing pro-inflammatory cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) \u003csup\u003e\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. The MD is rich in antioxidant compounds that counteract oxidative stress, which is implicated in endothelial dysfunction, hypertension, and insulin resistance \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Olive oil polyphenols, in particular, have been shown to enhance endothelial function and reduce oxidative damage in vascular tissues \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Emerging evidence suggests that the gut microbiota plays a crucial role in metabolic health \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. The MD promotes a favorable gut microbiome composition by increasing beneficial bacterial strains that produce short-chain fatty acids (SCFAs), which have been linked to improved glucose metabolism and reduced systemic inflammation \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e The MD\u0026rsquo;s emphasis on healthy fats and fiber promotes lipid homeostasis by enhancing hepatic cholesterol clearance, improving HDL-C functionality, and reducing LDL-C oxidation \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eGiven the high prevalence of metabolic disturbances in bariatric surgery candidates, optimizing dietary patterns before surgery may significantly impact both short-term surgical outcomes and long-term metabolic health. Preoperative adherence to the MD could help reduce perioperative complications, improve weight loss outcomes, and enhance cardiometabolic resilience following surgery. Integrating MD-based dietary interventions into preoperative nutritional counseling may provide a practical and sustainable approach to improving metabolic health in this population.\u003c/p\u003e\u003cp\u003eStrengths and limitations\u003c/p\u003e\u003cp\u003eTo our knowledge, this study is the first to examine the relationship between adherence to the MDS and the odds of cardiometabolic risk factors in morbidly obese patients preparing for bariatric surgery. We utilized validated and reliable questionnaires to gather nutritional data through face-to-face interviews, ensuring the accuracy of the information collected. Furthermore, all dietary and anthropometric assessments were conducted by highly trained dietitians, minimizing potential errors in data gathering. One of the key strengths of this study is the use of the widely recognized MDS, a reliable and reproducible tool that provides a well-established measure of dietary adherence. This makes the MDS particularly valuable for clinical and epidemiological research.\u003c/p\u003e\u003cp\u003eHowever, several limitations must be considered. The cross-sectional nature of the study restricts the ability to draw causal conclusions, and dietary intake was assessed using a FFQ, which is susceptible to recall bias. While the MDS is a well-established method, it does have limitations when applied to non-Mediterranean populations. For instance, the exclusion of alcohol from the MDS\u0026mdash;due to cultural and religious factors in the Iranian population\u0026mdash;may limit the generalizability of the findings to regions or populations where alcohol consumption is more common. Additionally, the MDS does not account for variations in food preparation, such as the use of unhealthy cooking oils or added sugars, which may influence the health benefits of the Mediterranean diet. The study also lacks an assessment of other potential confounders, such as genetic predispositions, psychological factors (e.g., depression or stress), or medication use, all of which could impact metabolic health in bariatric surgery candidates. Furthermore, while the study focuses on a high-risk population of morbidly obese patients, its findings may not be directly applicable to individuals with less severe obesity or those who are not candidates for bariatric surgery. The effects of diet may vary across different levels of obesity, warranting further investigation to assess the generalizability of these results.\u003c/p\u003e\u003cp\u003eFuture research should include prospective studies and randomized controlled trials to explore the causal relationship between adherence to the Mediterranean diet and cardiometabolic health in morbidly obese patients. Additionally, assessing the impact of Mediterranean diet adherence on postoperative outcomes, such as long-term weight loss maintenance and improvements in metabolic health, would offer valuable insights that could inform dietary recommendations for this population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, adherence to the Mediterranean diet is significantly associated with lower odds of high BP, low HDL-C, and high FBS in morbidly obese individuals preparing for bariatric surgery. These findings underscore the potential role of the MD as a beneficial dietary strategy for optimizing cardiometabolic health in this high-risk population. Future research should focus on integrating MD-based dietary interventions into preoperative nutritional counseling to enhance both surgical success and long-term metabolic outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements: The authors express their appreciation to the participants of the study for their enthusiastic support and to the staff of the involved hospitals for their valuable help.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor contributions: Overall, SAK and HA, supervised the project and approved the final version of the manuscript to be submitted. SAK designed the research; HA analyzed and interpreted the data; FSH drafted the initial manuscript; and HA critically revised the manuscript. All authors approved the final version of the manuscript submitted for publication.\u003c/p\u003e\n\u003cp\u003eFunding Statement: No financial support was provided in any way for this research.\u003c/p\u003e\n\u003cp\u003eData availability statement: The datasets analyzed in the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe studies involving humans were approved by the ethics committee at Islamic Azad University, Science and Research Branch (Approval ID: IR.IAU.SRB.Rec.1403.543). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMehrabani, J. \u0026amp; Ganjifar, Z. Overweight and obesity: a brief challenge on prevalence, complications and physical activity among men and women. \u003cem\u003eMOJ Womens Health\u003c/em\u003e. \u003cb\u003e7\u003c/b\u003e, 19\u0026ndash;24 (2018).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdelaal, M., le Roux, C. W. \u0026amp; Docherty, N. G. Morbidity and mortality associated with obesity. \u003cem\u003eAnn. Transl Med.\u003c/em\u003e \u003cb\u003e5\u003c/b\u003e, 161. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/atm.2017.03.107\u003c/span\u003e\u003cspan address=\"10.21037/atm.2017.03.107\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2017).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiao, J. et al. Bariatric surgery and health outcomes: An umbrella analysis. \u003cem\u003eFront. Endocrinol.\u003c/em\u003e \u003cb\u003e13\u003c/b\u003e, 1016613 (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBettini, S., Belligoli, A., Fabris, R. \u0026amp; Busetto, L. Diet approach before and after bariatric surgery. \u003cem\u003eReviews Endocr. Metabolic Disorders\u003c/em\u003e. \u003cb\u003e21\u003c/b\u003e, 297\u0026ndash;306 (2020).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHolderbaum, M. S. \u0026amp; Buss, C. Dietary management in the immediate preoperative period of bariatric surgery: a national overview: bariatric preoperative diets. \u003cem\u003eObes. Surg.\u003c/em\u003e \u003cb\u003e28\u003c/b\u003e, 1688\u0026ndash;1696 (2018).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEstruch, R. \u0026amp; Ros, E. The role of the Mediterranean diet on weight loss and obesity-related diseases. \u003cem\u003eReviews Endocr. Metabolic Disorders\u003c/em\u003e. \u003cb\u003e21\u003c/b\u003e, 315\u0026ndash;327 (2020).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTrichopoulou, A., Costacou, T., Bamia, C. \u0026amp; Trichopoulos, D. Adherence to a Mediterranean diet and survival in a Greek population. \u003cem\u003eN. Engl. J. Med.\u003c/em\u003e \u003cb\u003e348\u003c/b\u003e, 2599\u0026ndash;2608 (2003).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMuscogiuri, G. et al. Mediterranean diet and obesity-related disorders: what is the evidence? \u003cem\u003eCurr. Obes. Rep.\u003c/em\u003e \u003cb\u003e11\u003c/b\u003e, 287\u0026ndash;304 (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHosseini-Esfahani, F. et al. Mediterranean dietary pattern adherence modify the association between FTO genetic variations and obesity phenotypes. \u003cem\u003eNutrients\u003c/em\u003e \u003cb\u003e9\u003c/b\u003e, 1064 (2017).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWarnick, G. R., Knopp, R. H., Fitzpatrick, V. \u0026amp; Branson, L. Estimating low-density lipoprotein cholesterol by the Friedewald equation is adequate for classifying patients on the basis of nationally recommended cutpoints. \u003cem\u003eClin. Chem.\u003c/em\u003e \u003cb\u003e36\u003c/b\u003e, 15\u0026ndash;19 (1990).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEckel, R. H. \u0026amp; Cornier, M. A. Update on the NCEP ATP-III emerging cardiometabolic risk factors. \u003cem\u003eBMC Med.\u003c/em\u003e \u003cb\u003e12\u003c/b\u003e, 1\u0026ndash;9 (2014).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEsfahani, F. H., Asghari, G., Mirmiran, P. \u0026amp; Azizi, F. Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for the Tehran Lipid and Glucose Study. \u003cem\u003eJ. Epidemiol.\u003c/em\u003e \u003cb\u003e20\u003c/b\u003e, 150\u0026ndash;158. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2188/jea.je20090083\u003c/span\u003e\u003cspan address=\"10.2188/jea.je20090083\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2010).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAsghari, G. et al. Reliability, comparative validity and stability of dietary patterns derived from an FFQ in the Tehran Lipid and Glucose Study. \u003cem\u003eBr. J. Nutr.\u003c/em\u003e \u003cb\u003e108\u003c/b\u003e, 1109\u0026ndash;1117. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/s0007114511006313\u003c/span\u003e\u003cspan address=\"10.1017/s0007114511006313\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2012).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFilippou, C. D. et al. Mediterranean diet and blood pressure reduction in adults with and without hypertension: A systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eClin. Nutr.\u003c/em\u003e \u003cb\u003e40\u003c/b\u003e, 3191\u0026ndash;3200. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.clnu.2021.01.030\u003c/span\u003e\u003cspan address=\"10.1016/j.clnu.2021.01.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAburto, N. J. et al. Effect of increased potassium intake on cardiovascular risk factors and disease: systematic review and meta-analyses. \u003cem\u003eBmj\u003c/em\u003e \u003cb\u003e346\u003c/b\u003e (2013).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShannon, O. M. et al. Mediterranean diet increases endothelial function in adults: a systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eJ. Nutr.\u003c/em\u003e \u003cb\u003e150\u003c/b\u003e, 1151\u0026ndash;1159 (2020).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYamagata, K., Tagami, M. \u0026amp; Yamori, Y. Dietary polyphenols regulate endothelial function and prevent cardiovascular disease. \u003cem\u003eNutrition\u003c/em\u003e \u003cb\u003e31\u003c/b\u003e, 28\u0026ndash;37 (2015).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchwingshackl, L. \u0026amp; Hoffmann, G. Mediterranean dietary pattern, inflammation and endothelial function: a systematic review and meta-analysis of intervention trials. \u003cem\u003eNutr. Metabolism Cardiovasc. Dis.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e, 929\u0026ndash;939 (2014).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eScoditti, E., Capurso, C., Capurso, A. \u0026amp; Massaro, M. Vascular effects of the Mediterranean diet\u0026mdash;Part II: Role of omega-3 fatty acids and olive oil polyphenols. \u003cem\u003eVascul. Pharmacol.\u003c/em\u003e \u003cb\u003e63\u003c/b\u003e, 127\u0026ndash;134 (2014).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKastorini, C. M. et al. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. \u003cem\u003eJ. Am. Coll. Cardiol.\u003c/em\u003e \u003cb\u003e57\u003c/b\u003e, 1299\u0026ndash;1313 (2011).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrao-Cruces, E., Varela, L. M., Martin, M. E. \u0026amp; Bermudez, B. Montserrat-de la Paz, S. High-density lipoproteins and mediterranean diet: A systematic review. \u003cem\u003eNutrients\u003c/em\u003e \u003cb\u003e13\u003c/b\u003e, 955 (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRondanelli, M. et al. MediterrAsian diet products that could raise HDL-cholesterol: A systematic review. \u003cem\u003eBioMed Research International\u003c/em\u003e 2025687 (2016). (2016).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZupo, R. et al. Olive Oil Polyphenols Improve HDL Cholesterol and Promote Maintenance of Lipid Metabolism: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. \u003cem\u003eMetabolites\u003c/em\u003e \u003cb\u003e13\u003c/b\u003e, 1187 (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMekki, N. et al. Effects of lowering fat and increasing dietary fiber on fasting and postprandial plasma lipids in hypercholesterolemic subjects consuming a mixed Mediterranean-Western diet. \u003cem\u003eAm. J. Clin. Nutr.\u003c/em\u003e \u003cb\u003e66\u003c/b\u003e, 1443\u0026ndash;1451. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ajcn/66.6.1443\u003c/span\u003e\u003cspan address=\"10.1093/ajcn/66.6.1443\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (1997).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede Morais Junior, A. C. et al. The separate effects of whole oats and isolated beta-glucan on lipid profile: A systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eClin. Nutr. ESPEN\u003c/em\u003e. \u003cb\u003e53\u003c/b\u003e, 224\u0026ndash;237. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clnesp.2022.12.019\u003c/span\u003e\u003cspan address=\"10.1016/j.clnesp.2022.12.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBiesalski, H. K. Diabetes preventive components in the Mediterranean diet. \u003cem\u003eEur. J. Nutr.\u003c/em\u003e \u003cb\u003e43\u003c/b\u003e, i26\u0026ndash;i30 (2004).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEsposito, K. et al. A journey into a Mediterranean diet and type 2 diabetes: a systematic review with meta-analyses. \u003cem\u003eBMJ Open.\u003c/em\u003e \u003cb\u003e5\u003c/b\u003e, e008222. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2015-008222\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2015-008222\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2015).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuasch-Ferr\u0026eacute;, M., Merino, J., Sun, Q., Fit\u0026oacute;, M. \u0026amp; Salas-Salvad\u0026oacute;, J. Dietary polyphenols, Mediterranean diet, prediabetes, and type 2 diabetes: a narrative review of the evidence. \u003cem\u003eOxidative medicine and cellular longevity\u003c/em\u003e 6723931 (2017). (2017).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVetrani, C., Verde, L., Colao, A., Barrea, L. \u0026amp; Muscogiuri, G. The Mediterranean Diet: effects on insulin resistance and secretion in individuals with overweight or obesity. \u003cem\u003eNutrients\u003c/em\u003e \u003cb\u003e15\u003c/b\u003e, 4524 (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eScorletti, E. \u0026amp; Byrne, C. D. Omega-3 fatty acids, hepatic lipid metabolism, and nonalcoholic fatty liver disease. \u003cem\u003eAnnu. Rev. Nutr.\u003c/em\u003e \u003cb\u003e33\u003c/b\u003e, 231\u0026ndash;248 (2013).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eManna, C. et al. Protective effect of the phenolic fraction from virgin olive oils against oxidative stress in human cells. \u003cem\u003eJ. Agric. Food Chem.\u003c/em\u003e \u003cb\u003e50\u003c/b\u003e, 6521\u0026ndash;6526 (2002).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarber, T. M., Kabisch, S., Pfeiffer, A. F. \u0026amp; Weickert, M. O. The effects of the Mediterranean diet on health and gut microbiota. \u003cem\u003eNutrients\u003c/em\u003e \u003cb\u003e15\u003c/b\u003e, 2150 (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKimble, R. et al. Effects of a mediterranean diet on the gut microbiota and microbial metabolites: A systematic review of randomized controlled trials and observational studies. \u003cem\u003eCrit. Rev. Food Sci. Nutr.\u003c/em\u003e \u003cb\u003e63\u003c/b\u003e, 8698\u0026ndash;8719. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/10408398.2022.2057416\u003c/span\u003e\u003cspan address=\"10.1080/10408398.2022.2057416\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2023).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mediterranean diet, cardiometabolic risk factors, bariatric surgery","lastPublishedDoi":"10.21203/rs.3.rs-6405349/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6405349/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMorbid obesity significantly increases the risk of cardiometabolic disorders, complicating bariatric surgery outcomes. This study assessed the association between adherence to the Mediterranean diet (MD) and cardiometabolic risk factors among morbidly obese individuals undergoing bariatric surgery evaluation. A cross-sectional study was conducted with 369 morbidly obese patients (BMI\u0026thinsp;\u0026ge;\u0026thinsp;40 kg/m\u0026sup2; or BMI\u0026thinsp;\u0026ge;\u0026thinsp;35 kg/m\u0026sup2; with comorbidities) referred to Hazrat-Rasul-Akram Hospital obesity clinic between September 2023 and September 2024. Dietary adherence was evaluated using the Mediterranean Diet Score (MDS). Cardiometabolic risk factors were assessed according to ATP III criteria, including blood pressure, fasting blood sugar (FBS), triglycerides (TG), HDL cholesterol, and anthropometric measurements. Participants were categorized into quartiles based on MDS adherence.Participants in the highest quartile of MDS adherence exhibited significantly lower odds of elevated blood pressure (OR\u0026thinsp;=\u0026thinsp;0.34, 95% CI: 0.16\u0026ndash;0.70,p-trend\u0026thinsp;=\u0026thinsp;0.01), low HDL cholesterol levels (OR\u0026thinsp;=\u0026thinsp;0.34, 95% CI: 0.16\u0026ndash;0.70,p-trend\u0026thinsp;=\u0026thinsp;0.03), and elevated fasting blood sugar (OR\u0026thinsp;=\u0026thinsp;0.42, 95% CI: 0.20\u0026ndash;0.87,p-trend\u0026thinsp;=\u0026thinsp;0.03). No significant associations were found for triglyceride levels.Higher adherence to the Mediterranean diet is inversely associated with key cardiometabolic risk factors among morbidly obese patients preparing for bariatric surgery. These results support integrating MD-based dietary interventions into preoperative nutritional counselling to improve cardiometabolic outcomes and surgical success.\u003c/p\u003e","manuscriptTitle":"Adherence to the Mediterranean diet and cardiometabolic risk factors in morbid obese patients candidate for bariatric surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-24 10:59:25","doi":"10.21203/rs.3.rs-6405349/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a0aafb92-a81c-4571-9134-517971f0a479","owner":[],"postedDate":"July 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":51931402,"name":"Health sciences/Health care/Nutrition"},{"id":51931403,"name":"Health sciences/Medical research/Epidemiology"}],"tags":[],"updatedAt":"2025-07-30T14:09:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-24 10:59:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6405349","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6405349","identity":"rs-6405349","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}