European Journal of Nutrition

, Volume 49, Issue 2, pp 91–99 | Cite as

Predictors of adherence to a Mediterranean-type diet in the PREDIMED trial

  • Itziar ZazpeEmail author
  • Ramón Estruch
  • Estefanía Toledo
  • Ana Sánchez-Taínta
  • Dolores Corella
  • Mónica Bulló
  • Miquel Fiol
  • Pablo Iglesias
  • Enrique Gómez-Gracia
  • Fernando Arós
  • Emilio Ros
  • Helmut Schröder
  • Lluis Serra-Majem
  • Xavier Pintó
  • Rosa Lamuela-Raventós
  • Valentina Ruiz-Gutiérrez
  • Miguel Ángel Martínez-González
Original Contribution



Determinants of dietary changes obtained with a nutritional intervention promoting the Mediterranean diet have been rarely evaluated.


To identify predictors of higher success of an intervention aimed to increase adherence to a Mediterranean diet (MeDiet) in individuals at high cardiovascular risk participating in a trial for primary prevention of cardiovascular disease: the PREDIMED (PREvención con DIeta MEDiterránea) trial. Candidate predictors included demographic and socioeconomic characteristics, cardiovascular risk factors, and baseline dietary habits.


A total of 1,048 asymptomatic subjects aged 55–80 years allocated to the active intervention groups (subjects in the control group were excluded). Participants’ characteristics were assessed at baseline among subjects. Dietary changes were evaluated after 12 months. Main outcome measures were: attained changes in five dietary goals: increases in (1) fruit consumption, (2) vegetable consumption, (3) monounsaturated fatty acid (MUFA)/saturated fatty acid (SFA) ratio, and decreases in (4) sweets and pastries consumption, (5) and meat consumption. Univariate and multivariate logistic regression analyses were used to examine associations between the candidate predictors and likelihood of attaining optimum dietary change (improved adherence to a MeDiet).


Among men, positive changes toward better compliance with the MeDiet were more frequent among non-diabetics, and among those with worse dietary habits at baseline (higher consumption of meat, higher SFA intake, lower consumption of fruit and vegetables). Among women, marital status (married) and worse baseline dietary habits (high in meats, low in fruits and vegetables) were the strongest predictors of success in improving adherence to the MeDiet.


Some participant characteristics (marital status and baseline dietary habits) could contribute to predicting the likelihood of achieving dietary goals in interventions aimed to improve adherence to a MeDiet, and may be useful for promoting individualized long-term dietary changes and improving the effectiveness of dietary counseling.


Dietary predictors Dietary adherence Mediterranean diet Cardiovascular risk PREDIMED study 



The authors thank the participants for their enthusiastic collaboration, the PREDIMED personnel for excellent assistance and the personnel of all primary care centers affiliated, especially to Beatriz San Julian, Pilar Buil Cosiales, Javier Díez Espino, Ana García-Arellano, Julia Wärnberg, Jordi Salas- Salvadó, José Lapetra, Maria Isabel Covas, Manolo Serrano and Jackeline Alvarez. We gratefully acknowledge the Instituto de Salud Carlos III (ISCIII) and other funding sources (see below).

Conflict of interest statement

Spanish Government (Instituto de Salud Carlos III, RTIC RD06/0045, Fondo de Investigaciones Sanitarias, FIS PI04/0233, PI04/2239, PI05/2368, PI05/1839, PI081943, PI07/0312, PI04/2241, PI05/0976, PI07/0240, and PE 087/0819), CIBEROBN, “CIBER Fisiopatologia de la Obesidad y Nutricion (CIBEROBN) is an initiative of ISCIII”), the Navarra Government (PI41/2005), Generalitat Valenciana (ACOMP06109). Fundación Patrimonio Comunal Olivarero and Hojiblanca SA (Málaga, Spain), California Walnut Commission (Sacramento, CA), Borges SA (Reus, Spain) and Morella Nuts SA (Reus, Spain) donated the olive oil, walnuts, almonds, and hazelnuts, respectively, used in the study. None of the funding sources played a role in the design, collection, analysis or interpretation of the data or in the decision to submit this manuscript.


  1. 1.
    Ballesteros-Pomar MD, Rubio-Herrera MA, Gutiérrez-Fuentes JA, Gómez-Gerique JA, Gómez-de-la-Cámara A, Pascual O, Gárate I, Montero R, Campiña S (2000) Dietary habits and cardiovascular risk in the Spanish population: the DRECE study (I). Diet and cardiovascular events risk in Spain. Ann Nutr Metab 44:108–114CrossRefGoogle Scholar
  2. 2.
    Belahsen R, Rguibi M (2006) Population health and Mediterranean diet in southern Mediterranean countries. Public Health Nutr 9:1130–1135CrossRefGoogle Scholar
  3. 3.
    Benetou V, Trichopoulou A, Orfanos P, Naska A, Lagiou P, Boffetta P, Trichopoulos D (2008) Greek EPIC cohort conformity to traditional Mediterranean diet and cancer incidence: the Greek EPIC cohort. Br J Cancer 99:191–195CrossRefGoogle Scholar
  4. 4.
    Beresford SA, Curry SJ, Kristal AR, Lazovich D, Feng Z, Wagner EH (1997) A dietary intervention in primary care practice: the eating patterns study. Am J Public Health 87:610–616CrossRefGoogle Scholar
  5. 5.
    Elosua R, Garcia M, Aguilar A, Molina L, Covas MI, Marrugat J (2000) Validation of the Minnesota leisure time physical activity questionnaire in Spanish women. Investigators of the MARATDON Group. Med Sci Sports Exerc 32:1431–1437CrossRefGoogle Scholar
  6. 6.
    Elosua R, Marrugat J, Molina L, Pons S, Pujol E (1994) Validation of the Minnesota leisure time physical activity questionnaire in Spanish men. The MARATHOM Investigators. Am J Epidemiol 139:1197–1209Google Scholar
  7. 7.
    Estruch R, Martínez-González MA, Corella D, Salas-Salvadó J, Ruiz-Gutiérrez V, Covas MI, Fiol M, Gómez-Gracia E, López-Sabater MC, Vinyoles E, Arós F, Conde M, Lahoz C, Lapetra J, Sáez G, Ros E (2006) PREDIMED study investigators effects of a Mediterranean-style diet on cardiovascular risk factors: a randomised trial. Ann Intern Med 145:1–11Google Scholar
  8. 8.
    Giuseppe R, Bonanni A, Olivieri M, Castelnuovo AD, Donati MB, Gaetano G, Cerletti C, Iacoviello L (2008) Adherence to Mediterranean diet and anthropometric and metabolic parameters in an observational study in the ‘Alto Molise’ region: The MOLI-SAL project. Nutr Metab Cardiovasc Dis 18:415–421CrossRefGoogle Scholar
  9. 9.
    Goulet J, Lamarche B, Lemieux S (2007) Factors influencing the dietary response to a nutritional intervention promoting the Mediterranean food pattern in healthy women from the Quebec City metropolitan area. Health Educ Res 22:718–726CrossRefGoogle Scholar
  10. 10.
    Group DPPR (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393–403CrossRefGoogle Scholar
  11. 11.
    Howard BV, Van Horn L, Hsia J, Manson JE, Stefanick ML, Wassertheil-Smoller S, Kuller LH, LaCroix AZ, Langer RD, Lasser NL, Lewis CE, Limacher MC, Margolis KL, Mysiw WJ, Ockene JK, Parker LM, Perri MG, Phillips L, Prentice RL, Robbins J, Rossouw JE, Sarto GE, Schatz IJ, Snetselaar LG, Stevens VJ, Tinker LF, Trevisan M, Vitolins MZ, Anderson GL, Assaf AR, Bassford T, Beresford SA, Black HR, Brunner RL, Brzyski RG, Caan B, Chlebowski RT, Gass M, Granek I, Greenland P, Hays J, Heber D, Heiss G, Hendrix SL, Hubbell FA, Johnson KC, Kotchen JM (2006) Low-fat dietary pattern and risk of cardiovascular disease: the women’s health initiative randomised controlled dietary modification trial. JAMA 295:655–666CrossRefGoogle Scholar
  12. 12.
    James PT, Rigby N, Leach R (2004) The obesity epidemic, metabolic syndrome and future prevention strategies. Eur J Cardiovasc Prev Rehabil 11:3–8CrossRefGoogle Scholar
  13. 13.
    Krauss RM, Eckel RH, Howard B, Appel LJ, Daniels SR, Deckelbaum RJ, Erdman JW Jr, Kris-Etherton P, Goldberg IJ, Kotchen TA, Lichtenstein AH, Mitch WE, Mullis R, Robinson K, Wylie-Rosett J, St Jeor S, Suttie J, Tribble DL, Bazzarre TL (2000) AHA dietary guidelines: revision 2000: a statement for healthcare professionals from the Nutrition Committee of the American Heart Association. Stroke 31:2751–2766Google Scholar
  14. 14.
    Kristal AR, Hedderson MM, Patterson RE, Neuhouser M (2001) Predictors of self-initiated, healthful dietary change. J Am Diet Assoc 101:762–766CrossRefGoogle Scholar
  15. 15.
    Martinez-Gonzalez MA, Sanchez-Villegas A (2004) The emerging role of Mediterranean diets in cardiovascular epidemiology: monounsaturated fats, olive oil, red wine or the whole pattern? Eur J Epidemiol 19:9–13CrossRefGoogle Scholar
  16. 16.
    Martínez-González MA, de la Fuente-Arrillaga C, Nunez-Cordoba JM, Basterra-Gortari FJ, Beunza JJ, Vazquez Z, Benito S, Tortosa A, Bes-Rastrollo M (2008) Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study. BMJ 336:1348–1351CrossRefGoogle Scholar
  17. 17.
    Martinez-Gonzalez MA, Fernandez-Jarne E, Serrano-Martinez M, Wright M, Gomez-Gracia E (2004) Development of a short dietary intake questionnaire for the quantitative estimation of adherence to a cardioprotective Mediterranean diet. Eur J Clin Nutr 58:1550–1552CrossRefGoogle Scholar
  18. 18.
    Martin-Moreno JM, Boyle P, Gorgojo L, Maisonneuve P, Fernandez-Rodriguez JC, Salvini S, Willett WC (1993) Development and validation of a food frequency questionnaire in Spain. Int J Epidemiol 22:512–519CrossRefGoogle Scholar
  19. 19.
    Mataix J (2003) Tablas de composición de alimentos (Spanish food composition tables), 4th edn. Universidad de Granada, Granada (in Spanish)Google Scholar
  20. 20.
    Mitrou PN, Kipnis V, Thiébaut AC, Reedy J, Subar AF, Wirfält E, Flood A, Mouw T, Hollenbeck AR, Leitzmann MF, Schatzkin A (2007) Mediterranean dietary pattern and prediction of all-cause mortality in a US population: results from the NIH-AARP diet and health study. Arch Intern Med 167:2461–2468CrossRefGoogle Scholar
  21. 21.
    Moreiras O, Carvajal A, Cabrera L (2005) Tablas de composición de alimentos (Food composition tables), 9th edn. Ediciones Pirámide, Madrid (in Spanish)Google Scholar
  22. 22.
    Patterson RE, Kristal AR, White E (1996) Do beliefs, knowledge, and perceived norms about diet and cancer predict dietary change? Am J Public Health 86:1394–1400CrossRefGoogle Scholar
  23. 23.
    Popkin BM, Kim S, Rusev ER, Du S, Zizza C (2006) Measuring the full economic costs of diet, physical activity and obesity-related chronic diseases. Obes Rev 7:271–293CrossRefGoogle Scholar
  24. 24.
    Rodrigues SS, Caraher M, Trichopoulou A, de Almeida MD (2008) Portuguese households’ diet quality (adherence to Mediterranean food pattern and compliance with WHO population dietary goals): trends, regional disparities and socioeconomic determinants. Eur J Clin Nutr 11:1263–1272CrossRefGoogle Scholar
  25. 25.
    Salas-Salvadó J, Garcia-Arellano A, Estruch R, Marquez-Sandoval F, Corella D, Fiol M, Gómez-Gracia E, Viñoles E, Arós F, Herrera C, Lahoz C, Lapetra J, Perona JS, Muñoz-Aguado D, Martínez-González MA, Ros E (2008) PREDIMED investigators components of the mediterranean-type food pattern and serum inflammatory markers among patients at high risk for cardiovascular disease. Eur J Clin Nutr 62:651–659CrossRefGoogle Scholar
  26. 26.
    Sanchez-Villegas A, Martinez JA, De Irala J, Martinez-Gonzalez MA (2002) Determinants of the adherence to an “a priori” defined Mediterranean dietary pattern. Eur J Nutr 41:249–257CrossRefGoogle Scholar
  27. 27.
    Serra-Majem L, Roman B, Estruch R (2006) Scientific evidence of interventions using the Mediterranean diet: a systematic review. Nutr Rev 64:S27–S47CrossRefGoogle Scholar
  28. 28.
    Steptoe AP, Perkins-Porras L, Rink E, Hilton S, Cappuccio FP (2004) Phychological and social predictors of changes in fruit and vegetable consumption over 12-months following behavioral and nutrition education counselling. Health Psychol 23:574–581CrossRefGoogle Scholar
  29. 29.
    Tinker LF, Rosal MC, Young AF, Perri MG, Patterson RE, Van Horn L, Assaf AR, Bowen DJ, Ockene J, Hays J, Wu L (2007) Predictors of dietary change and maintenance in the women’s health initiative dietary modification trial. J Am Diet Assoc 107:1155–1166CrossRefGoogle Scholar
  30. 30.
    Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M, Finnish Diabetes Prevention Study Group (2001) Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344:1343–1350CrossRefGoogle Scholar
  31. 31.
    Tur JA, Romaguera D, Pons A (2004) Adherence to the Mediterranean dietary pattern among the population of the Balearic Islands. Br J Nutr 92:341–346CrossRefGoogle Scholar
  32. 32.
    Willett WC, Howe GR, Kushi LH (1997) Adjustment for total energy intake in epidemiologic studies. Am J Clin Nutr 65:1220S–1228S; discussion 1229S–1231SGoogle Scholar
  33. 33.
    Willett WC (1998) Issues in analysis and presentation of dietary data. Nutritional epidemiology. Oxford University Press, New YorkGoogle Scholar
  34. 34.
    WMA (2004) World Medical Association Declaration of Helsinki, TokyoGoogle Scholar
  35. 35.
    Women’s Health Initiative Study Group (2004) Dietary adherence in the women’s health initiative dietary modification trial. J Am Diet Assoc 104:654–658CrossRefGoogle Scholar
  36. 36.
    World Health Organization (2003) Diet, nutrition and the prevention of chronic diseases. World Health Organ Tech Rep Ser 916:i–viii, 1–149, backcoverGoogle Scholar
  37. 37.
    Zazpe I, Sánchez-Taínta A, Estruch R, Lamuela-Raventos R, Schröder H, Salas-Salvadó J, Corella D, Fiol M, Gómez-Gracia E, Aros F, Ros E, Ruíz-Gutierrez V, Iglesias P, Conde-Herrera M, Martínez-González MA (2008) A large randomised individual and group intervention conducted by registered dietitians increased adherence to Mediterranean-type diets: the PREDIMED study. J Am Diet Assoc 108:1134–1144CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Itziar Zazpe
    • 1
    • 2
    • 18
    Email author
  • Ramón Estruch
    • 3
    • 4
  • Estefanía Toledo
    • 5
  • Ana Sánchez-Taínta
    • 1
  • Dolores Corella
    • 4
    • 6
  • Mónica Bulló
    • 7
  • Miquel Fiol
    • 4
    • 8
  • Pablo Iglesias
    • 9
  • Enrique Gómez-Gracia
    • 10
  • Fernando Arós
    • 11
  • Emilio Ros
    • 4
    • 12
  • Helmut Schröder
    • 4
    • 13
  • Lluis Serra-Majem
    • 14
  • Xavier Pintó
    • 15
  • Rosa Lamuela-Raventós
    • 16
  • Valentina Ruiz-Gutiérrez
    • 17
  • Miguel Ángel Martínez-González
    • 1
  1. 1.Department of Preventive Medicine and Public HealthUniversity of NavarraPamplonaSpain
  2. 2.Department of Nutrition and Food Sciences, Physiology and ToxicologyUniversity of NavarraPamplonaSpain
  3. 3.Department of Internal MedicineIDIBAPS, Hospital Clinic, University of BarcelonaBarcelonaSpain
  4. 4.CIBER CB06/03 Fisiopatología de la Obesidad y NutriciónInstituto de Salud Carlos IIIMadridSpain
  5. 5.Department of Preventive Medicine and Quality ManagementHospital Virgen del CaminoPamplonaSpain
  6. 6.Department of Preventive MedicineUniversity of ValenciaValenciaSpain
  7. 7.Human Nutrition DepartmentUniversity Rovira i VirgiliReusSpain
  8. 8.Institut Universitàri de Ciències de la Salut (IUNICS)Universidad de les Illes BalearsPalma de MallorcaSpain
  9. 9.Department of Family Medicine, Primary Care Division of SevillaBellavista Health CenterSevillaSpain
  10. 10.Department of Preventive MedicineUniversity of MalagaMalagaSpain
  11. 11.Department of CardiologyHospital Universitario TxagorritxuVitoriaSpain
  12. 12.Unitat de Lípids, Servei d’Endocrinologia i Nutrició, Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital ClínicBarcelonaSpain
  13. 13.Lipids and Cardiovascular Epidemiology Research UnitInstitut Municipal d’Investigació Mèdica, IMIM- Hospital del MarBarcelonaSpain
  14. 14.Department of Clinical SciencesUniversity of Las Palmas de Gran CanariaLas PalmasSpain
  15. 15.Lipids and Vascular Risk UnitInternal Medicine Service Hospital Universitario de Bellvitge, Hospitalet de LlobregatBarcelonaSpain
  16. 16.Department of Nutrition and Food ScienceUniversity of BarcelonaBarcelonaSpain
  17. 17.Instituto de la grasaConsejo Superior de Investigaciones CientíficasSevillaSpain
  18. 18.School of MedicineClinica Universitaria de NavarraPamplonaSpain

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