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Objective: To present the Mediterranean diet (MD) pyramid: a lifestyle for today. Design: A new graphic representation has been conceived as a simplified main frame to be adapted to the different nutritional and socio-economic contexts of the Mediterranean region. This review gathers updated recommendations considering the lifestyle, dietary, sociocultural, environmental and health challenges that the current Mediterranean populations are facing. Setting and Subjects: Mediterranean region and its populations. Results: Many innovations have arisen since previous graphical representations of the MD. First, the concept of composition of the 'main meals' is introduced to reinforce the plant-based core of the dietary pattern. Second, frugality and moderation is emphasised because of the major public health challenge of obesity. Third, qualitative cultural and lifestyle elements are taken into account, such as conviviality, culinary activities, physical activity and adequate rest, along with proportion and frequency recommendations of food consumption. These innovations are made without omitting other items associated with the production, selection, processing and consumption of foods, such as seasonality, biodiversity, and traditional, local and eco-friendly products. Conclusions: Adopting a healthy lifestyle and preserving cultural elements should be considered in order to acquire all the benefits from the MD and preserve this cultural heritage. Considering the acknowledgment of the MD as an Intangible Cultural Heritage of Humanity by UNESCO (2010), and taking into account its contribution to health and general well-being, we hope to contribute to a much better adherence to this healthy dietary pattern and its way of life with this new graphic representation.

Ensuring the accuracy of dietary assessment instruments is paramount for interpreting diet-disease relationships. The present study assessed the relative and construct validity of the 14-point Mediterranean Diet Adherence Screener (MEDAS) used in the Prevención con Dieta Mediterránea (PREDIMED) study, a primary prevention nutrition-intervention trial. A validated FFQ and the MEDAS were administered to 7146 participants of the PREDIMED study. The MEDAS-derived PREDIMED score correlated significantly with the corresponding FFQ PREDIMED score (r = 0.52; intraclass correlation coefficient = 0.51) and in the anticipated directions with the dietary intakes reported on the FFQ. Using Bland Altman's analysis, the average MEDAS Mediterranean diet score estimate was 105% of the FFQ PREDIMED score estimate. Limits of agreement ranged between 57 and 153%. Multiple linear regression analyses revealed that a higher PREDIMED score related directly (P < 0.001) to HDL-cholesterol (HDL-C) and inversely (P < 0.038) to BMI, waist circumference, TG, the TG:HDL-C ratio, fasting glucose, and the cholesterol:HDL-C ratio. The 10-y estimated coronary artery disease risk decreased as the PREDIMED score increased (P < 0.001). The MEDAS is a valid instrument for rapid estimation of adherence to the Mediterranean diet and may be useful in clinical practice.

Objective: To evaluate dietary habits in Spanish children and adolescents based on a Mediterranean Diet Quality Index tool, which considers certain principles sustaining and challenging traditional healthy Mediterranean dietary patterns. Design: Observational population-based cross-sectional study. A 16-item Mediterranean Diet Quality Index was included in data gathered for the EnKid study (in which two 24-hour recalls, a quantitative 169-item food-frequency questionnaire and a general questionnaire about socio-economic, demographic and lifestyle items were administered). Setting: Spain. Subjects: In total, 3850 children and youths aged 2-24 years residing in Spain.Results: Of the sample, 4.2% showed very low KIDMED index results, 49.4% had intermediate values and 46.4% had high index results. Important geographical differences were seen, with subjects from the Northeast showing the most favourable outcomes (52% with elevated scores vs. 37.5% of those from the North). Lower percentages of high diet quality were observed in low socio-economic groups, compared with middle and upper income cohorts (42.8%, 47.6% and 54.9%, respectively). Large cities had more positive results and only slight variations were seen for gender and age. Conclusions: The KIDMED index, the first to evaluate the adequacy of Mediterranean dietary patterns in children and youth, confirms that this collective is undergoing important changes, which makes them a priority target for nutrition interventions. Results challenge certain commonly perceived notions tied to income level, population size and diet quality.

ObjectiveIndependently of total caloric intake, a better quality of the diet (for example, conformity to the Mediterranean diet) is associated with lower obesity risk. It is unclear whether a brief dietary assessment tool, instead of full-length comprehensive methods, can also capture this association. In addition to reduced costs, a brief tool has the interesting advantage of allowing immediate feedback to participants in interventional studies. Another relevant question is which individual items of such a brief tool are responsible for this association. We examined these associations using a 14-item tool of adherence to the Mediterranean diet as exposure and body mass index, waist circumference and waist-to-height ratio (WHtR) as outcomes.DesignCross-sectional assessment of all participants in the “PREvención con DIeta MEDiterránea” (PREDIMED) trial.Subjects7,447 participants (55–80 years, 57% women) free of cardiovascular disease, but with either type 2 diabetes or ≥3 cardiovascular risk factors. Trained dietitians used both a validated 14-item questionnaire and a full-length validated 137-item food frequency questionnaire to assess dietary habits. Trained nurses measured weight, height and waist circumference.ResultsStrong inverse linear associations between the 14-item tool and all adiposity indexes were found. For a two-point increment in the 14-item score, the multivariable-adjusted differences in WHtR were −0.0066 (95% confidence interval, –0.0088 to −0.0049) for women and –0.0059 (–0.0079 to –0.0038) for men. The multivariable-adjusted odds ratio for a WHtR>0.6 in participants scoring ≥10 points versus ≤7 points was 0.68 (0.57 to 0.80) for women and 0.66 (0.54 to 0.80) for men. High consumption of nuts and low consumption of sweetened/carbonated beverages presented the strongest inverse associations with abdominal obesity.ConclusionsA brief 14-item tool was able to capture a strong monotonic inverse association between adherence to a good quality dietary pattern (Mediterranean diet) and obesity indexes in a population of adults at high cardiovascular risk.

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Across all sampled countries, children were exposed to high volumes of television advertising for unhealthy foods, featuring child-oriented persuasive techniques. Because of the proven connections between food advertising, preferences, and consumption, our findings lend support to calls for regulation of food advertising during children's peak viewing times.

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