**3. Results**

#### *3.1. Sampling Procedure and Outcome*

A sample of 460 firefighters from the two fire departments had complete data for analysis in the current study and represented 95% of all participants who consented to the parent clinical trial (Figure 1).

#### *3.2. General Characteristics of the Firefighters*

The majority of the firefighters were males (94.4%), with a mean age of 46.7 years (SD 8.3 years). Firefighters' personal characteristics are shown in Table 1. The mean mMDS in the study population was 21.88 (SD 6.68). The majority of the firefighters were overweight/obese, with an average body fat percentage of 28.10% (SD 6.55%).




**Table 1.** *Cont.*

\* Physical activity. Low: did not participate regularly in programmed recreation, sport, or heavy physical activity. Medium: participated regularly in recreation requiring modest physical activity, such as golf, horseback riding, calisthenics, gymnastics, table tennis, bowling, weight-lifting, yard work. High: participated regularly in heavy physical exercise such as running or jogging, swimming, rowing, skipping rope, running in place, or engaging in vigorous aerobic activity such as tennis. basketball, or handball. FFQ: Food Frequency questionnaire, mMDS: modified Mediterranean Diet Score, SD: Standard Deviation, BMI: body mass index, SBP: systolic blood pressure, DBP: diastolic blood pressure, HDL: high-density lipoprotein, LDL: low-density lipoprotein.

#### *3.3. Association of the Modified Mediterranean Diet Score with Anthropometric and Biochemical Indices*

The association of mMDS with the participants' anthropometric measures, blood pressure, and biochemical variables is shown in Table 2. When the mMDS scores were categorized into quartiles, multivariate analysis adjusted for age and gender revealed statistically significant inverse associations of mMDS quartiles with BMI (*p* = 0.030), waist circumference (*p* = 0.002), body fat percentage (*p* = 0.002), and total cholesterol/HDL ratio (*p* = 0.007), whereas there was a positive association with HDL-cholesterol (*p* = 0.002).



After further adjustment for subjects' ethnicity, physical activity, and smoking (Table 2), being in a higher mMDS quartile remained significantly inversely associated with the total cholesterol/HDL ratio (*p* = 0.020) and positively associated with HDL-cholesterol (*p* = 0.022).

#### *3.4. E*ff*ects of a Unitary Increase in the Modified Mediteranean Score on Anthropometric Measures, Blood Pressure, and Biochemical Indices*

The association of mMDS with subjects' anthropometric measures, blood pressure, and biochemical variables, as a continuous variable, was further analyzed using linear regression models (Table 3).



SD, standard deviation; B, unstandardized Beta coefficient; SE, standard error.

Multivariate linear regression analysis, adjusting for subjects' age and gender, revealed that a unitary increase in the mMDS was significantly inversely associated with BMI (β-coefficient −0.080, *p* = 0.008), waist circumference (β-coefficient −0.114, *p* < 0.001), body fat percentage (β-coefficient −0.141, *p* = 0.001), and total cholesterol/HDL ratio (β-coefficient −0.028, *p* = 0.002), whereas it was positively associated with HDL-cholesterol (β-coefficient 0.254, *p* < 0.001). After further adjustment for subjects' ethnicity, physical activity, and smoking, mMDS was significantly associated with a lower total cholesterol/HDL ratio (β-coefficient −0.030, *p* = 0.002), whereas there was a positive association of mMDS with HDL-cholesterol (β-coefficient 0.286, *p* = 0.004).

#### *3.5. E*ff*ects of Single Components of the Modified Mediteranean Score on Anthropometric Measures, Blood Pressure, and Biochemical Indices*

Examining component food items of the mMDS and total cholesterol/HDL ratio, total cholesterol-HDL ratio, and blood glucose, fast-food consumption was positively associated with a total cholesterol/HDL ratio >6 (*p* = 0.003) and with triglycerides levels ≥150 mg/dL (*p* < 0.001). Sweet desserts consumption was associated with a total cholesterol/HDL ratio >6 (*p* = 0.004) and with triglycerides levels ≥150 mg/dL (*p*=0.002), while lower consumption of fruits and vegetables was associated with a total cholesterol/HDL ratio >6 (*p* = 0.049). Fried food consumption was associated with a total cholesterol/HDL ratio >6 (*p* = 0.004) and with triglycerides levels ≥150 mg/dL (*p* = 0.037), and consumption of non-alcoholic beverages at home was associated with glucose levels ≥100 mg/dL (*p* = 0.036). No other statistically significant associations were observed (Appendix A Table A1).
