Next Article in Journal
Effect of Periodontitis and Scaling and Root Planing on Risk of Pharyngeal Cancer: A Nested Case—Control Study
Next Article in Special Issue
Total Nut, Tree Nut, and Peanut Consumption and Metabolic Status in Southern Italian Adults
Previous Article in Journal
Measles and Rubella during COVID-19 Pandemic: Future Challenges in Japan
Previous Article in Special Issue
Mediterranean Lifestyle to Promote Physical, Mental, and Environmental Health: The Case of Chile
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
IJERPH
Volume 18
Issue 1
10.3390/ijerph18010010
ijerph-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Adherence to the Mediterranean Diet in Maltese Adults

by
Sarah Cuschieri
1,* and
Massimo Libra
2,3
1
Department Anatomy, Faculty of Medicine and Surgery, University of Malta, MSD2090 Msida, Malta
2
Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
3
Research Center for Prevention, Diagnosis and Treatment of Cancer, University of Catania, 95123 Catania, Italy
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2021, 18(1), 10; https://doi.org/10.3390/ijerph18010010
Submission received: 21 November 2020 / Revised: 14 December 2020 / Accepted: 19 December 2020 / Published: 22 December 2020
(This article belongs to the Special Issue The Influence of Mediterranean Diet on Health and Environment)
Versions Notes

Abstract

:
Background: Populations living in Mediterranean islands are experiencing a nutrition transition process from traditional to Westernized dietary patterns. No information on this matter regarding individuals living in Malta have been published to date. The aim of this study was to assess the level of adherence of the Maltese people to the Mediterranean diet and which factors were associated with it. Methods: A nationwide cross-sectional study was conducted in the island of Malta between 2014 and 2016. A literature-based Mediterranean diet adherence score was used to assess the level of adherence to the dietary pattern. Results: Out of 3947 adults, the overall Mediterranean diet adherence score mean was 7.19 (SD 1.91): being female, non-smoker, and having older age was associated with higher adherence to the Mediterranean diet. Less clear pattern of association was found for educational and occupational status, for which medium educational level and a high occupational level were associated with lower adherence to Mediterranean diet. Higher adherence was finally associated with consumption of healthier food groups (more rice and dark bread and less pasta and white bread; more all plant-food groups and fish, less animal-food sources, including fast foods; more light cheeses and yogurt were more frequently consumed among higher adherent individuals in spite of regular ones). Conclusions: Adherence to the Mediterranean diet in Malta is lower than in those of populations living in companion Mediterranean islands. Given the lack of data on this topic, further studies should be conducted among the Maltese people and public health nutrition interventions should be planned to improve current eating habits toward more traditional dietary patterns.

1. Introduction

The Mediterranean diet has been the focus of research for many scientists over the last decades due to its potential for preventing several non-communicable diseases [1]. This dietary pattern finds its origin in the traditional dietary habits handed down over the millennia by individuals living in the Mediterranean Basin, an area characterized by a fervent trading of olives and wine, great variety of fruits and vegetal species imported from other geographical regions of the world and easily acclimatized in the area [2]. However, it was not before the 1960s that the nomenclature “Mediterranean diet” was coined by Ancel Keys while studying the risk factors for coronary heart disease of individuals living in southern Italy. In that occasion, the peculiar lifestyle habits of such a population, in contrast with that of the United States, seemed, and later confirmed, to decrease the risk of coronary heart disease, corroborating the idea that such lifestyle would prevent chronic diseases [3]. The dietary pattern characterizing the habits of southern Italian populations had some specific features that could be summarized as follows: (i) high intake in plant-based foods, such as fruit and vegetables, but also whole-grain cereals and legumes, nuts and seeds, olive oil as main dressing and added fat, and moderate consumption of (red) wine consumed during meals; (ii) moderate intake of animal products, such as fish and poultry, milk and dairy foods, and eggs; and (iii) low consumption of red (processed) meat [4]. The following fifty years have been characterized by a deepening of research in this area, showing that a diet with such features would be associated with reduced risk of cardiovascular disease [5,6], metabolic disorders [7,8], neurodegenerative diseases [9], and certain cancers [10]. Eventually, the Mediterranean diet has been declared “Intangible Cultural Heritage of Urgent Safeguarding” by the United Nations Educational, Scientific and Cultural Organization (UNESCO), while the scientific community agreed that dietary patterns inspired by the Mediterranean diet may be beneficial for human health also in a non-Mediterranean context [11]. Finally, the Mediterranean dietary pattern has been also proven to be a sustainable choice for the environment [12,13,14].
While most scientific evidence and available reports on Mediterranean diet adherence refer to Italian, Greek, and Spanish islands when considering the Mediterranean Basin [15], adherence rates have been reported to be consistently lower in most populations worldwide [16,17], including those in the Mediterranean basin [18,19]. The Maltese Islands are found at crossroads between Sicily and Libya with an archipelago covering a total surface area of 316 km2, making it one of the smallest European nations with a total population of 493,559. Over the years, a number of studies have reported the high increase in the occurrence of obesity, diabetes, and other cardiometabolic diseases among the adult population in Malta [20,21,22,23]. While nutritional risk factors have been universally considered as major determinants of non-communicable diseases [24,25], only a few studies published dietary data on Maltese population [26,27,28]. Compared to other Mediterranean islands, Malta has preserved its original culture less intensively while better adapting to other cultural influences over the centuries [27]. The last foreign occupation by the British has had a tremendous impact on several aspects of the society, including Maltese food system and dietary habits [29]. As a result, a previous study investigating the level of adherence to the Mediterranean diet among Mediterranean islands revealed that Malta had the lowest adherence to this dietary pattern along with the lowest consumption of fish and fruit [28]. However, no other study has been published so far on this issue and current dietary habits of the Maltese population are largely unknown, while results from national surveys suggest a growing rise in metabolic disorders [30]. Thus, the aim of this study was to investigate the level of adherence to the Mediterranean diet and associated determinants of people living in Malta.

2. Materials and Methods

2.1. Study Population

A nationwide cross-sectional study was conducted in Malta island between 2014 and 2016 by following a health examination survey protocol. The detailed protocol can be found elsewhere [31]. Briefly, a randomized single stage sampling technique was followed to establish the sample population from a national register. A single stage sampling technique could be followed due to the small total population size (<500,000) and small geographical location (316 km2). The population sample was stratified by age (18 to 70 years) and gender living in each town in order for the total population to represent approximately 1% of each residential town. All individuals living in Malta for at least 6 months and holding a permanent identification permit were eligible. However, those individuals who were pregnant, too ill to attend the health examination hubs or living abroad at the time of the study were excluded. Invitations to the randomised population were sent out by post and those accepting to participate in the study were asked to visit their local peripheral health clinic fasted for at least 9 hours on a set day and time. Out of 3947 individuals invited, data from a total of 1861 participants was finally collected. A weighting factor was applied to the study population in order to maintain representation by considering each gender and age per residing town. The adjusted study population (n = 3947) was used for descriptive statistics while the unadjusted study population (n = 1861) was used for analytic statistics.
The Research Ethics Committee of the Faculty of Medicine and Surgery at the University of Malta (Ethics code 19/2014) together with the Information and Data protection commissioner gave their permission for this study. All participants gave their informed written consent to participate in the study.

2.2. Data Collection

As part of the health examination survey, each participant was invited to take part in an interviewer-led validated questionnaire [31]. The interviewers were physicians and trainee medical doctors trained throughout the study period. The questionnaire gathered socio-economic data (demography, education, occupation), lifestyle characteristics (smoking, alcohol intake, physical activity), and a food frequency questionnaire. The participants’ ages were subdivided into four age groups representing typical family generations. Beverage (such as tea, coffee, sugar-sweetened) and supplements data were not gathered. The educational status was categorised into (i) low (≤10 years), (ii) medium (11–13 years), and (iii) high (≥14 years). The occupation status was categorised into (i) unemployed, (ii) low (unskilled professions), (iii) medium (skilled professions), and (iv) high (managerial professions). Smoking status was defined as no smoking, current smoking, and former smoking, while physical activity categorisation was adopted from Merwether et al. assessment tool and grouped as (i) sedentary (less than 30 min of activity per week), (ii) low (walk at least for 30 min per week), (iii) moderate (30–60 min of physical activity other than walking per week), and (iv) high (>60 min of physical activity other than walking per week) [32].

2.3. Mediterranean Diet Adherence Assessment

Dietary information was included in the questionnaire used and frequency consumption of 29 food/beverage groups was investigated. The food frequency for each food item was converted into servings per day. The MEDI-LITE Mediterranean Diet adherence score was calculated through a literature-based score where consumption of fruit, vegetables, legumes, cereals, fish, meat and meat products (beef/veal, pork, poultry, fish, eggs, sausages and burgers were considered in this study), dairy products, alcohol, and olive oil portions per day were used to estimate the level of adherence. The study population Mediterranean diet score was then divided into tertiles and labeled as (i) low (≤6 score), (ii) medium (7–8 scores), and (iii) high (≥9 score). Of note, as part of the dairy products, the consumption of the Maltese traditional cheese known as “Gbejniet” (cheeselets, generally produced by pasteurized goat’s milk) was collected as a separate food item.

2.4. Statistical Analysis

Continuous variables were presented as means and standard deviations; Student’s t-test and one-way ANOVA for independent samples were used. Categorical variables were analysed using Chi squared test. In order to evaluate the association between demographic, socio-economic and lifestyle characteristics and adherence to the Mediterranean dietary pattern, regression analysis was performed by considering the Mediterranean diet score as the dependent variables (high vs. medium/low adherence). The results were presented as odds ratios with the corresponding 95% confidence interval. A p-value of <0.05 was considered as statistically significant. All analyses were conducted using IBM SPSS® version 21 software (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY, USA).

3. Results

The total adjusted study population was 3947 adults (18 to 70 years) with a slightly higher proportion of male (50.6%) and a mean age of 44.8 (SD 15.1) years. The overall Mediterranean diet adherence score mean was 7.19 (SD 1.91). The distribution of the study population demographic, socioeconomic, and lifestyle factors by tertiles of adherence score to the Mediterranean diet is shown in Table 1. A higher proportion of women scored in the highest tertile compared to men; similarly, individuals in the older age groups scored higher adherence to the Mediterranean diet (Table 1). Differences by educational and occupational status were also found, albeit with no clear trends: individuals in the highest and lowest educational categories had a higher proportion of high adherence to the Mediterranean diet; moreover, those in the highest category of occupational status had lowest adherence (Table 1). A higher mean adherence to the Mediterranean diet was also observed among those with healthier lifestyle habits including no smoking and increased physical activity (Table 1).
A number of demographic, socioeconomic, and lifestyle habits exhibited an association with adherence to the Mediterranean diet, as shown in Table 2. Being female was associated with 69% odds of higher adherence to Mediterranean diet than their counterparts. Similarly, increase in age exhibited a higher association with adherence to the Mediterranean diet. A medium educational level and a high occupational level were both associated with lower adherence to Mediterranean diet; similarly, low physical activity and smoking habits (current and former) were associated with lower adherence.
The adherence to the Mediterranean diet was further evaluated in accordance to the different food groups as shown in Table 3: individuals reporting higher adherence to the Mediterranean diet consumed more rice and dark bread and less pasta and white bread; all plant-food groups (fruit and vegetables) were more consumed in the high-adherent group while all animal-food sources, except fish, and fast foods were less consumed; among dairy products, light cheeses and yogurt were more frequently consumed among higher adherent individuals in spite of regular ones (Table 3).

4. Discussion

The present study aimed to investigate the dietary habits of Maltese population and to assess the level and the socio-demographic determinants of adherence to the Mediterranean diet. Compared to previous studies using this score [18,33,34], the adherence rate to the Mediterranean diet can be considered relatively low. However, the adherence was associated with some socio-demographic variables investigated.
Demographically, older women, non-smoker, unemployed, were more adherent to the Mediterranean diet. This result is generally in line with previous studies conducted in Mediterranean islands [33,35,36,37] and for the first time reported concerning the Maltese population. Younger generations have been often reported to be less likely to follow a Mediterranean dietary pattern [38,39,40,41,42,43]. The globalization process and the so-called “Westernization” of the diets have led to a slow, yet growing abandonment of traditional dietary habits in the Mediterranean countries together with the introduction of high-calorie, nutrient-poor ultra-processed foods [44]. This phenomenon, identified as a “nutrition transition” from traditional to globalized dietary patterns, is accompanied by other issues, such as scarce availability of local and seasonal foods and limited economical accessibility due to elevated costs for the recommended foods [45]. While in non-Mediterranean countries a higher adherence to this dietary pattern may be the result of a choice reflecting a health-conscious profile, we hypothesize that in Mediterranean islands, this adherence is only the result of a higher adherence to traditional lifestyle behaviours and maintenance of the cultural heritage. This hypothesis has been reported in other studies conducted in Mediterranean islands, where identification of higher adherence among unemployed women may depend on the social role of older generations of mothers in the management of the families, including preparation of meals [46,47,48]. In contrast, other studies yet conducted in Mediterranean countries reported that higher adherence to this dietary pattern was associated with a higher economic allowance, suggesting that the economic crisis occurred in the last decade and the rise in cost of healthier foods may have played a role in the observed abandonment of this traditional dietary pattern [49,50]. Both interpretations may not necessarily be in contrast: in fact, in our study, adherence to the Mediterranean diet has been related to the occupation of individuals; it is noteworthy to underline that occupation does not necessarily imply the economic status of a person, rather can be considered as a proxy variable. The economic crisis that affected Italy over the last years may have modified the salary of individuals: a number of conditions may affect the real economic disposability of individuals irrespectively of their occupational class (i.e., non-skilled workers having highly profitable commercial activity versus highly skilled workers underpaid by the system under crisis). As a result, evaluation of the occupational status may not reflect the real income of participants.
The Mediterranean dietary pattern has evolved over time, changing across countries and adapting to the available foods. This dietary pattern does not stand for a unique list of ingredients and foods, but rather is differently represented across Mediterranean countries although maintaining the common features previously listed. Concerning Malta, individuals more adherent to the Mediterranean had an obvious higher consumption of food groups characterizing the dietary score used (i.e., fruits, vegetables, legumes, fish) and lower of those considered not related to it (i.e., meat products); interestingly, regarding food groups unrelated to this dietary pattern, individuals reporting higher adherence had also less consumption of refined bread, ready-made meals, pizza/burgers, and full milk, accompanied with higher intake of brown bread, skimmed milk and light yogurt, suggesting food preferences toward a healthier diet. However, compared to previous reports on Maltese dietary habits conducted in the past, we recorded some differences. An early study published about 15 years ago conducted on two generations of women (mothers and daughters) showed an increase in legumes, meat products, poultry, and vegetables compared to the past [27]. In contrast, another study published later on contrasted with our findings, showing higher weekly intake of fruit, vegetables, and legumes, and lower intake of meat products (despite the study not distinguishing between poultry and red meat) [28]. Based on the timing of data collection, we may consider our findings as current dietary habits, especially relative to the newest generations of Maltese people. These findings may be the result of an overall larger availability of food variety and higher access to a greater diversity of foods by the whole population, leading to higher consumption of nutrient-rich foods, such as meat products, but also lower consumption of plant-derived foods. This hypothesis reflects the finding related to the low levels of adherence to the Mediterranean diet observed among individuals in the highest occupational category compared to the unemployed. Considering that Maltese dietary habits have never been displayed as fully meeting the Mediterranean diet because of the Anglo-Saxon influences, our findings depict an evolving scenario in which Maltese people are moving forward a more Westernized diet as well as the rest of Mediterranean islands while losing the dietary improvements observed in the last few generations.
The results of this study should be considered in light of some limitations. The information retrieved may suffer from recall bias and declared data may not correctly reflect real intakes. Moreover, the questionnaire used was not able to capture detailed information regarding other aspects of the Mediterranean diet often underrated and unexplored, such as the use of herbs, spices, and flavors that are known to contribute to the health benefits of this dietary pattern.

5. Conclusions

In conclusion, while scientific evidence and cultural recognition have emphasized the role of the Mediterranean diet for humans, current evidence suggests that modern generations are shifting away from this dietary pattern in favor of more Westernized diets. Malta is no exception to such trends, reporting an adherence rate to the Mediterranean diet lower than those of populations living in companion Mediterranean islands. Given the lack of data on this topic, further studies and investigations should be conducted among the Maltese people and public health nutrition interventions should be planned to improve current eating habits toward more traditional dietary patterns.

Author Contributions

Conceptualization, S.C. and M.L.; methodology, S.C.; formal analysis, S.C.; investigation, S.C.; resources, S.C.; data curation, S.C.; writing—original draft preparation, S.C. and M.L.; writing—review and editing, S.C. and M.L. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the University of Malta, Alfred Mizzi Foundation, and Atlas Health Insurance, Malta.

Data Availability Statement

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to ethics and data protection re-strictions.

Acknowledgments

The in-kind support and encouragement of the Parliamentary Secretariat for Health of the Government of Malta is gratefully acknowledged. Furthermore, a note of appreciation and acknowledgement is forwarded to Julian Mamo, Josanne Vassallo, and Neville Calleja for their continuous support and advise during the academic progression.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Dinu, M.; Pagliai, G.; Casini, A.; Sofi, F. Mediterranean diet and multiple health outcomes: An umbrella review of meta-analyses of observational studies and randomised trials. Eur. J. Clin. Nutr. 2018, 72, 30–43. [Google Scholar] [CrossRef] [PubMed]
  2. Berry, E.M.; Arnoni, Y.; Aviram, M. The Middle Eastern and biblical origins of the Mediterranean diet. Public Health Nutr. 2011, 14, 2288–2295. [Google Scholar] [CrossRef] [PubMed]
  3. Real, H.; Queiroz, J.; Graça, P. Mediterranean food pattern vs. Mediterranean diet: A necessary approach? Int. J. Food Sci. Nutr. 2020, 71, 1–12. [Google Scholar] [CrossRef] [PubMed]
  4. D’Alessandro, A.; De Pergola, G. The Mediterranean Diet: Its definition and evaluation of a priori dietary indexes in primary cardiovascular prevention. Int. J. Food Sci. Nutr. 2018, 69, 647–659. [Google Scholar] [CrossRef] [PubMed]
  5. Grosso, G.; Marventano, S.; Yang, J.; Micek, A.; Pajak, A.; Scalfi, L.; Galvano, F.; Kales, S.N. A comprehensive meta-analysis on evidence of Mediterranean diet and cardiovascular disease: Are individual components equal? Crit. Rev. Food Sci. Nutr. 2017, 57, 3218–3232. [Google Scholar] [CrossRef]
  6. Rosato, V.; Temple, N.J.; La Vecchia, C.; Castellan, G.; Tavani, A.; Guercio, V. Mediterranean diet and cardiovascular disease: A systematic review and meta-analysis of observational studies. Eur. J. Nutr. 2019, 58, 173–191. [Google Scholar] [CrossRef]
  7. Godos, J.; Zappalà, G.; Bernardini, S.; Giambini, I.; Bes-Rastrollo, M.; Martinez-Gonzalez, M. Adherence to the Mediterranean diet is inversely associated with metabolic syndrome occurrence: A meta-analysis of observational studies. Int. J. Food Sci. Nutr. 2017, 68, 138–148. [Google Scholar] [CrossRef]
  8. Rees, K.; Takeda, A.; Martin, N.; Ellis, L.; Wijesekara, D.; Vepa, A.; Das, A.; Hartley, L.; Stranges, S. Mediterranean-style diet for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst. Rev. 2019, 3, CD009825. [Google Scholar] [CrossRef] [Green Version]
  9. Gardener, H.; Caunca, M.R. Mediterranean diet in preventing neurodegenerative diseases. Curr. Nutr. Rep. 2018, 7, 10–20. [Google Scholar] [CrossRef]
  10. Morze, J.; Danielewicz, A.; Przybyłowicz, K.; Zeng, H.; Hoffmann, G.; Schwingshackl, L. An updated systematic review and meta-analysis on adherence to mediterranean diet and risk of cancer. Eur. J. Nutr. 2020. [Google Scholar] [CrossRef]
  11. Mocciaro, G.; Ziauddeen, N.; Godos, J.; Marranzano, M.; Chan, M.-Y.; Ray, S. Does a Mediterranean-type dietary pattern exert a cardio-protective effect outside the Mediterranean region? A review of current evidence. Int. J. Food Sci. Nutr. 2018, 69, 524–535. [Google Scholar] [CrossRef] [PubMed]
  12. Fresán, U.; Martínez-González, M.A.; Sabaté, J.; Bes-Rastrollo, M. Global sustainability (health, environment and monetary costs) of three dietary patterns: Results from a Spanish cohort (the SUN project). BMJ Open 2019, 9, e021541. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  13. Grosso, G.; Fresán, U.; Bes-Rastrollo, M.; Marventano, S.; Galvano, F. Environmental impact of dietary choices: Role of the mediterranean and other dietary patterns in an italian cohort. Int. J. Environ. Res. Public Health 2020, 17, 1468. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  14. Fresán, U.; Martínez-Gonzalez, M.-A.; Sabaté, J.; Bes-Rastrollo, M. The Mediterranean diet, an environmentally friendly option: Evidence from the Seguimiento Universidad de Navarra (SUN) cohort. Public Health Nutr. 2018, 21, 1573–1582. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  15. Grosso, G.; Galvano, F. Mediterranean diet adherence in children and adolescents in southern European countries. NFS J. 2016, 3, 13–19. [Google Scholar] [CrossRef] [Green Version]
  16. Vilarnau, C.; Stracker, D.M.; Funtikov, A.; da Silva, R.; Estruch, R.; Bach-Faig, A. Worldwide adherence to Mediterranean Diet between 1960 and 2011. Eur. J. Clin. Nutr. 2019, 72, 83–91. [Google Scholar] [CrossRef]
  17. da Silva, R.; Bach-Faig, A.; Quintana, B.R.; Buckland, G.; Vaz de Almeida, M.D.; Serra-Majem, L. Worldwide variation of adherence to the Mediterranean diet, in 1961–1965 and 2000–2003. Public Health Nutr. 2009, 12, 1676–1684. [Google Scholar] [CrossRef] [Green Version]
  18. Dinu, M.; Pagliai, G.; Giangrandi, I.; Colombini, B.; Toniolo, L.; Gensini, G.; Sofi, F. Adherence to the Mediterranean diet among Italian adults: Results from the web-based Medi-Lite questionnaire. Int. J. Food Sci. Nutr. 2020, 1–9. [Google Scholar] [CrossRef]
  19. Caparello, G.; Galluccio, A.; Giordano, C.; Lofaro, D.; Barone, I.; Morelli, C.; Sisci, D.; Catalano, S.; Andò, S.; Bonofiglio, D. Adherence to the Mediterranean diet pattern among university staff: A cross-sectional web-based epidemiological study in Southern Italy. Int. J. Food Sci. Nutr. 2020, 71, 581–592. [Google Scholar] [CrossRef]
  20. Cuschieri, S.; Vassallo, J.; Calleja, N.; Pace, N.; Mamo, J. The Effects of Socioeconomic Determinants on Hypertension in a Cardiometabolic At-Risk European Country. Int. J. Hypertens. 2017, 2017, 7107385. [Google Scholar] [CrossRef] [Green Version]
  21. Cuschieri, S.; Vassallo, J.; Calleja, N.; Barbara, C.; Mamo, J. The interaction of dyslipidaemia with glycaemia in an adult population study. J. Diabetes Metab. Disord. 2018, 17, 315–323. [Google Scholar] [CrossRef] [PubMed]
  22. Cuschieri, S. The diabetes epidemic in Malta. South East. Eur. J. Public Health (SEEJPH) 2020. [Google Scholar] [CrossRef]
  23. Cuschieri, S.; Vassallo, J.; Calleja, N.; Camilleri, R.; Borg, A.; Bonnici, G.; Zhang, Y.; Pace, N.; Mamo, J. Prevalence of obesity in Malta. Obes. Sci. Pract. 2016, 2, 466–470. [Google Scholar] [CrossRef]
  24. GBD 2017 Diet Collaborators Health effects of dietary risks in 195 countries, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2019, 393, 1958–1972. [CrossRef] [Green Version]
  25. GBD 2019 Risk Factors Collaborators Global burden of 87 risk factors in 204 countries and territories, 1990-2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020, 396, 1223–1249. [CrossRef]
  26. Tessier, S.; Gerber, M. Comparison between Sardinia and Malta: The Mediterranean diet revisited. Appetite 2005, 45, 121–126. [Google Scholar] [CrossRef]
  27. Tessier, S.; Gerber, M. Factors determining the nutrition transition in two Mediterranean islands: Sardinia and Malta. Public Health Nutr. 2005, 8, 1286–1292. [Google Scholar] [CrossRef] [Green Version]
  28. Tourlouki, E.; Matalas, A.-L.; Bountziouka, V.; Tyrovolas, S.; Zeimbekis, A.; Gotsis, E.; Tsiligianni, I.; Protopapa, I.; Protopapas, C.; Metallinos, G.; et al. Are current dietary habits in Mediterranean islands a reflection of the past? Results from the MEDIS study. Ecol. Food Nutr. 2013, 52, 371–386. [Google Scholar] [CrossRef]
  29. Atkins, P.J.; Gastoni, M. The Maltese food system and the Mediterranean. GeoJournal 1997, 41, 127–136. [Google Scholar] [CrossRef]
  30. Cuschieri, S.; Mamo, J. Malta: Mediterranean diabetes hub—A journey through the years. Malta Med. J. 2014, 26, 27–31. [Google Scholar]
  31. Cuschieri, S.; Vassallo, J.; Calleja, N.; Pace, N.; Mamo, J. Diabetes, pre-diabetes and their risk factors in Malta: A study profile of national cross-sectional prevalence study. Glob. Health Epidemiol. 2016, 1, e21. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  32. Meriwether, R.A.; McMahon, P.M.; Islam, N.; Steinmann, W.C. Physical activity assessment: Validation of a clinical assessment tool. Am. J. Prev. Med. 2006, 31, 484–491. [Google Scholar] [CrossRef] [PubMed]
  33. Marventano, S.; Godos, J.; Platania, A.; Galvano, F.; Mistretta, A.; Grosso, G. Mediterranean diet adherence in the Mediterranean healthy eating, aging and lifestyle (MEAL) study cohort. Int. J. Food Sci. Nutr. 2018, 69, 100–107. [Google Scholar] [CrossRef] [PubMed]
  34. Phan, C.; Touvier, M.; Kesse-Guyot, E.; Adjibade, M.; Hercberg, S.; Wolkenstein, P.; Chosidow, O.; Ezzedine, K.; Sbidian, E. Association Between Mediterranean Anti-inflammatory Dietary Profile and Severity of Psoriasis: Results From the NutriNet-Santé Cohort. JAMA Dermatol. 2018, 154, 1017–1024. [Google Scholar] [CrossRef]
  35. Kyprianidou, M.; Panagiotakos, D.; Faka, A.; Kambanaros, M.; Makris, K.C.; Christophi, C.A. Adherence to the Mediterranean Diet in Cyprus and its relationship to Multi-Morbidity: An epidemiological study. Public Health Nutr. 2020, 1–26. [Google Scholar] [CrossRef]
  36. Sotos-Prieto, M.; Ortolá, R.; López-García, E.; Rodríguez-Artalejo, F.; García-Esquinas, E. Adherence to the Mediterranean diet and physical resilience in older adults: The Seniors-ENRICA Cohort. J. Gerontol. A Biol. Sci. Med. Sci. 2020. [Google Scholar] [CrossRef]
  37. Grosso, G.; Pajak, A.; Mistretta, A.; Marventano, S.; Raciti, T.; Buscemi, S.; Drago, F.; Scalfi, L.; Galvano, F. Protective role of the Mediterranean diet on several cardiovascular risk factors: Evidence from Sicily, southern Italy. Nutr. Metab. Cardiovasc. Dis. 2014, 24, 370–377. [Google Scholar] [CrossRef]
  38. del Mar Bibiloni, M.; Pons, A.; Tur, J.A. Compliance with the Mediterranean Diet Quality Index (KIDMED) among Balearic Islands’ Adolescents and Its Association with Socioeconomic, Anthropometric and Lifestyle Factors. Ann. Nutr. Metab. 2016, 68, 42–50. [Google Scholar] [CrossRef]
  39. Grosso, G.; Marventano, S.; Buscemi, S.; Scuderi, A.; Matalone, M.; Platania, A.; Giorgianni, G.; Rametta, S.; Nolfo, F.; Galvano, F.; et al. Factors associated with adherence to the Mediterranean diet among adolescents living in Sicily, Southern Italy. Nutrients 2013, 5, 4908–4923. [Google Scholar] [CrossRef] [Green Version]
  40. Buja, A.; Grotto, G.; Brocadello, F.; Sperotto, M.; Baldo, V. Primary school children and nutrition: Lifestyles and behavioral traits associated with a poor-to-moderate adherence to the Mediterranean diet. A cross-sectional study. Eur. J. Pediatr. 2020, 179, 827–834. [Google Scholar] [CrossRef]
  41. Santomauro, F.; Lorini, C.; Tanini, T.; Indiani, L.; Lastrucci, V.; Comodo, N.; Bonaccorsi, G. Adherence to Mediterranean diet in a sample of Tuscan adolescents. Nutrition 2014, 30, 1379–1383. [Google Scholar] [CrossRef] [PubMed]
  42. Grassi, T.; Bagordo, F.; Panico, A.; De Giorgi, M.; Idolo, A.; Serio, F.; Tumolo, M.R.; De Donno, A. Adherence to Mediterranean diet of children living in small Southern Italian villages. Int. J. Food Sci. Nutr. 2020, 71, 490–499. [Google Scholar] [CrossRef] [PubMed]
  43. De Santi, M.; Callari, F.; Brandi, G.; Toscano, R.V.; Scarlata, L.; Amagliani, G.; Schiavano, G.F. Mediterranean diet adherence and weight status among Sicilian Middle school adolescents. Int. J. Food Sci. Nutr. 2020, 71, 1010–1018. [Google Scholar] [CrossRef] [PubMed]
  44. Martini, D.; Bes-Restrollo, M. Is Mediterranean diet still a common dietary pattern in the Mediterranean area? Int. J. Food Sci. Nutr. 2020, 71, 395–396. [Google Scholar] [CrossRef]
  45. Lăcătușu, C.-M.; Grigorescu, E.-D.; Floria, M.; Onofriescu, A.; Mihai, B.-M. The Mediterranean Diet: From an Environment-Driven Food Culture to an Emerging Medical Prescription. Int. J. Environ. Res. Public Health 2019, 16, 942. [Google Scholar] [CrossRef] [Green Version]
  46. Costarelli, V.; Michou, M.; Panagiotakos, D.B.; Lionis, C. Adherence to the Mediterranean diet and weight status in children: The role of parental feeding practices. Int. J. Food Sci. Nutr. 2020, 1–11. [Google Scholar] [CrossRef]
  47. Sanlier, N.; Ulusoy, H.G.; Kocabaş, S.; Çelik, B.; Göbel, P.; Yilmaz, S. Mediterranean Diet Adherence among Preschoolers and its Association with Parents’ Beliefs, Attitudes, and Practices. Ecol. Food Nutr. 2020, 1–19. [Google Scholar] [CrossRef]
  48. Kosti, R.I.; Kanellopoulou, A.; Fragkedaki, E.; Notara, V.; Giannakopoulou, S.-P.; Antonogeorgos, G.; Rojas-Gil, A.P.; Kornilaki, E.N.; Lagiou, A.; Panagiotakos, D.B. The Influence of Adherence to the Mediterranean Diet among Children and Their Parents in Relation to Childhood Overweight/Obesity: A Cross-Sectional Study in Greece. Child. Obes. 2020. [Google Scholar] [CrossRef]
  49. Bonaccio, M.; Bes-Rastrollo, M.; de Gaetano, G.; Iacoviello, L. Challenges to the Mediterranean diet at a time of economic crisis. Nutr. Metab. Cardiovasc. Dis. 2016, 26, 1057–1063. [Google Scholar] [CrossRef]
  50. Vitale, M.; Racca, E.; Izzo, A.; Giacco, A.; Parente, E.; Riccardi, G.; Giacco, R. Adherence to the traditional Mediterranean diet in a population of South of Italy: Factors involved and proposal of an educational field-based survey tool. Int. J. Food Sci. Nutr. 2019, 70, 195–201. [Google Scholar] [CrossRef]
Table
Table 1. Mediterranean diet adherence scores by demographic, socioeconomic, and lifestyle characteristics of the study sample (n = 3947).
Table 1. Mediterranean diet adherence scores by demographic, socioeconomic, and lifestyle characteristics of the study sample (n = 3947).
VariablesMediterranean Diet Score, Mean (SD)Mediterranean Diet Score Tertiles, n (%)p-Value
T1—Low (≤6) (n = 1498)T2—Medium (7–8) (n = 1489)T3—High (9+) (n = 960)
Gender <0.001
Male7.45 (1.96)871 (58.2)736 (49.5)391 (40.8)
Female6.93 (1.81)627 (41.8)753 (50.5)569 (59.2)
Age group, n (%) <0.001
<307.11 (1.83)327 (21.9)283 (19.0)201 (20.9)
30–446.89 (1.87)507 (33.8)422 (28.4)209 (21.7)
44–657.36 (1.92)536 (35.7)646 (43.3)431 (44.9)
>657.47 (1.97)128 (8.6)138 (9.3)120 (12.5)
Educational level, n (%) <0.001
Low7.38 (1.88)220 (14.7)232 (15.5)183 (19.1)
Medium6.73 (1.94)944 (63.0)882 (59.3)498 (51.9)
High7.16 (1.81)334 (22.3)375 (25.2)279 (29.0)
Occupational level, n (%) 0.002
Unemployed7.25 (2.99)149 (10.0)201 (13.5)120 (12.5)
Low7.25 (1.77)120 (8.0)111 (7.5)90 (9.3)
Medium7.27 (1.88)386 (25.8)432 (29.0)272 (28.3)
High7.27 (1.88)842 (56.2)744 (50.0)479 (49.9)
Smoking status, n (%) <0.001
Non-smoker7.40 (1.83)765 (51.1)858 (57.6)615 (64)
Current smoker7.03 (1.94)460 (30.7)316 (21.2)183 (19.1)
Former smoker7.40 (1.83)273 (18.2)315 (21.2)162 (16.9)
Physical activity level, n (%) 0.004
No activity7.39 (1.91)134 (9.1)145 (9.8)108 (11.2)
Low7.02 (1.91)309 (20.6)267 (17.9)176 (18.3)
Medium7.15 (1.86)905 (60.4)921 (61.9)542 (56.4)
High7.43 (2.08)148 (9.9)155 (10.4)135 (14.1)
Table
Table 2. Association between demographic characteristics and high adherence to Mediterranean diet (high vs. medium/low).
Table 2. Association between demographic characteristics and high adherence to Mediterranean diet (high vs. medium/low).
Variables-High Adherence OR (95% CI)
Gender
Male1
Female1.69 (1.51–1.90)
Age group
<301
30–440.79 (0.67–0.93)
44–651.25 (1.07–1.46)
>651.40 (1.12–1.74)
Educational level
Low1
Medium0.74 (0.63–0.87)
High1.02 (0.85–1.22)
Occupational level
Unemployed1
Low0.94 (0.72–1.22)
Medium0.91 (0.75–1.11)
High0.77 (0.64–0.92)
Smoking status
Non-smoker1
Current smoker0.57 (0.49–0.65)
Former smoker0.82 (0.70–0.95)
Physical activity level
No activity1
Low0.79 (0.63–0.99)
Medium0.86 (0.70–1.04)
High1.17 (0.91–1.50)
Table
Table 3. Consumption (servings per day) of selected food groups by level of adherence to the Mediterranean diet.
Table 3. Consumption (servings per day) of selected food groups by level of adherence to the Mediterranean diet.
Food ItemMediterranean Dietp-Value
TotalMedium/LowHigh
Carbohydrates, mean servings/d (SD)
Potatoes0.31 (0.22)0.32 (0.21)0.31 (0.22)0.26
Pasta0.25 (0.16)0.25 (0.16)0.23 (0.16)<0.001
Rice0.14 (0.15)0.13 (0.15)0.16 (0.16)<0.001
White Bread0.46 (0.36)0.48 (0.35)0.40 (0.35)<0.001
Brown Bread0.14 (0.26)0.12 (0.25)0.18 (0.28)<0.001
Plant food sources, mean servings/d (SD)
Salad / raw vegetables0.30 (0.27)0.27 (0.26)0.40 (0.30)<0.001
Boiled vegetables0.29 (0.25)0.25 (0.22)0.44 (0.28)<0.001
Vegetables in hot dishes0.18 (0.21)0.15 (0.19)0.28 (0.26)<0.001
Legumes0.02 (0.08)0.01 (0.06)0.03 (0.12)<0.001
Fruits1.97 (1.47)1.71 (1.41)2.81 (1.33)<0.001
Vegetable or Vegetarian dishes0.21 (0.25)0.18 (0.24)0.30 (0.29)<0.001
Animal food sources, mean servings/d (SD)
Beef/Veal0.16 (0.14)0.16 (0.14)0.15 (0.13)0.001
Pork0.12 (0.12)0.13 (0.12)0.12 (0.12)0.033
Poultry0.29 (0.19)0.29 (0.19)0.30 (0.20)0.171
Fish0.14 (0.15)0.12 (0.14)0.22 (0.15)<0.001
Egg0.16 (0.18)0.16 (0.18)0.15 (0.17)0.007
Ready-made meals0.09 (0.15)0.10 (0.16)0.06 (0.12)<0.001
Pizza/Burgers0.11 (0.13)0.12 (0.14)0.10 (0.11)<0.001
Sausages0.07 (0.12)0.07 (0.12)0.05 (0.10)<0.001
Dairy foods, mean servings/d (SD)
Light Cheese0.10 (0.21)0.09 (0.21)0.11 (0.21)0.064
Cheese0.32 (0.30)0.33 (0.30)0.28 (0.30)<0.0001
Cheeselet (“Gbejniet”)0.14 (0.18)0.13 (0.17)0.15 (0.19)0.005
Ricotta0.10 (0.15)0.10 (0.15)0.11 (0.15)0.232
Skimmed Milk0.41 (0.41)0.39 (0.41)0.46 (0.41)<0.001
Full Milk0.26 (0.38)0.29 (0.38)0.20 (0.35)<0.001
Light Yogurt0.16 (0.28)0.14 (0.27)0.23 (0.32)<0.001
Yogurt0.06 (0.17)0.06 (0.18)0.05 (0.16)0.096
Mozzarella0.07 (0.12)0.07 (0.12)0.07 (0.12)0.521
Alcohol (standard drink)0.29 (0.19)0.29 (0.19)0.30 (0.20)0.181
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Cuschieri, S.; Libra, M. Adherence to the Mediterranean Diet in Maltese Adults. Int. J. Environ. Res. Public Health 2021, 18, 10. https://doi.org/10.3390/ijerph18010010

AMA Style

Cuschieri S, Libra M. Adherence to the Mediterranean Diet in Maltese Adults. International Journal of Environmental Research and Public Health. 2021; 18(1):10. https://doi.org/10.3390/ijerph18010010

Chicago/Turabian Style

Cuschieri, Sarah, and Massimo Libra. 2021. "Adherence to the Mediterranean Diet in Maltese Adults" International Journal of Environmental Research and Public Health 18, no. 1: 10. https://doi.org/10.3390/ijerph18010010

APA Style

Cuschieri, S., & Libra, M. (2021). Adherence to the Mediterranean Diet in Maltese Adults. International Journal of Environmental Research and Public Health, 18(1), 10. https://doi.org/10.3390/ijerph18010010

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop