**5. Conclusions**

In conclusion, greater adherence to a Mediterranean diet, as measured by a higher mMDS, was favorably associated with lower measures of cardiometabolic risk. In fully adjusted models including physical activity level and smoking, the associations of a higher mMDS with a lower total cholesterol/HDL ratio and increased HDL-cholesterol remained robust. The mMDS has now evidence of validity with respect to more established questionnaires and has been determined in relation to additional biologically plausible associations from two different and independent mid-western (US) firefighter cohorts. Therefore, the mMDS should be a valid tool for assessing the outcome of cluster-randomized controlled trials of Mediterranean lifestyle interventions in this population and similar ones. It may also have further utility not only in research but also in clinical practice.

**Author Contributions:** Conceptualization, M.R., G.T., T.C.C., and S.N.K.; methodology, M.R., M.S.H., M.S.-P., S.N.K., G.T., C.C., formal analysis, M.R. and G.T.; resources and analysis of the samples S.M., M.R., G.T.,M.S.-P.; data curation, G.T., C.C.; writing—original draft preparation, M.R.; writing—review and editing, M.R., M.S.-P., C.C., S.N.K., G.T., M.S.H., T.C.C.; supervision, S.N.K., G.T., T.C.C.; project administration, S.M. and S.N.K.; funding acquisition, S.N.K and M.S.-P. All authors contributed to the interpretation of data and critical revision of the manuscript and approved the final version. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by EMW-2014-FP-00612, US Department of Homeland Security. Ohio University Ohio University OURC grant, CHSP Research Innovation Grant and Boston Nutrition Obesity Research Center small grant. M.S.-P. holds a Ramón y Cajal contract (RYC-2018-025069-I) from the Ministry of Science, Innovation and Universities and FEDER/FSE and FIS gran<sup>t</sup> PI20/00896. The funding agencies had no role in study design, data collection and analysis, interpretation of results, manuscript preparation or in the decision to submit this manuscript for publication.

**Acknowledgments:** We want to acknowledge the participation of the Indianapolis Fire Departments, the firefighters, and their spouses. We also thank Indiana Clinical and Translational Science Institute for the help with sample processing, Kroger Company (coupons and customer loyalty discounts), Barilla America (Barilla Plus Products), Arianna Trading Company, Innoliva and Molino de Zafra, Spain (extra virgin olive oil samples and discounts), and the Almond Board of California (free samples of roasted unsalted almonds). The sponsors have had no involvement in the overall study design; collection, analysis and interpretation of data; writing of the report; or the decision to submit the report for publication.

**Conflicts of Interest:** Maria Romanidou, Grigorios Tripsianis, Mercedes Sotos-Prieto, Maria Soledad Hershey, Costas Christophi, Theodoros Constantinidis, and Steven Moffatt declare no conflict of interest. Kales reports non-financial support from Barilla America, non-financial support from California Almond Board, non-financial support from Arianna Trading Company, non-financial support from Innoliva/Molina de Zafra, during the conduct of the study; personal fees from Medicolegal Consulting, personal fees from the Mediterranean Diet Roundtable, outside the submitted work.


**Table A1.** Comparison of the single items of the modified Mediterranean diet scores (mMDS) according to biochemical indices.

**Appendix A**
