What are the determinants of adherence to the mediterranean diet?

Current evidence suggests that adherence to traditional dietary patterns are slowly disappearing in favour of a globalised market, in which higher availability of processed, ready-to-use, energy-dense foods undermines the consumption of fresh, locally produced goods (Srour and Touvier 2020). When exploring the nutritional quality of processed foods, excess content in added free sugars, saturated and hydrogenated fats, together with scarcity in fibre and vitamins, provide the rationale for the retrieved associations between the nutrition transition processes and increased burden of non-communicable diseases (Silva Meneguelli et al. 2020). Several areas in the world may claim traditional healthy dietary patterns, but to date, the Mediterranean diet has been among the most studied for the optimal mix between health benefits, palatable taste, and an overall healthier lifestyle to which is associated (Real et al. 2020).

In this issue, the study of Dinu et al. (2020) aimed to assess the level of adherence to the Mediterranean diet and to investigate the potential determinants in a sample of Italian adults. The overall level of adherence was relatively good; this finding has been previously registered in the Italian population (Pelucchi et al. 2010; Grosso et al. 2014; Marventano et al. 2018; Buscemi et al. 2020), although adherence to the Mediterranean diet would be supposed to be even higher than observed. In fact, other studies showed negative trends towards decreasing adherence to the Mediterranean diet also in the Italian population (Bonaccio et al. 2014; Leone et al. 2017). A comparison of trends over time at global level showed a substantial decline between 1961–65 and 2000–03, whereas from 2004–2011 there was a stabilisation in certain countries, including Italy (Vilarnau et al. 2019).

Major determinants of adherence to the Mediterranean diet are currently the object of modern research on the topic. Availability of fresh goods (fruit, vegetable, legume, whole grain, fish), together with olive oil and wine, is still largely possible at affordable prices in southern European regions and Mediterranean islands (Vasto et al. 2014). It has been recently argued that the economic crisis may have affected affordability of such goods (Martini and Bes-Restrollo 2020), but also foods not characterising the Mediterranean dietary pattern, for instance, meat and sweets, are not necessarily cheaper than healthier ones and have demonstrated an increased consumption over the last decades (da Silva et al. 2009). Thus, the reasons for such changing trends of adherence to the Mediterranean diet have to be better elucidated. Age seems to be related to dietary choices, with older individuals consistently associated with higher adherence to the Mediterranean dietary pattern across various studies conducted in the Italian population (Pelucchi et al. 2010; Bonaccio et al. 2014; Grosso et al. 2014; Leone et al. 2017; Marventano et al. 2018; Ruggiero et al. 2019; Vitale et al. 2019; Caparello et al. 2020). Such findings are in line with other investigations restricted to adolescents (Grosso et al. 2013; De Santi et al. 2020; Rosi et al. 2020) and even younger generations (Grassi et al. 2020; Rosi et al. 2020), in which the vast majority of participants score medium-low adherence to the Mediterranean diet. The second variable consistently associated with better adherence to the Mediterranean diet in most of studies is higher cultural level (Pelucchi et al. 2010; Bonaccio et al. 2014; Grosso et al. 2014; Leone et al. 2017; Marventano et al. 2018; Ruggiero et al. 2019; Vitale et al. 2019; Caparello et al. 2020). However, it is arguable that higher education is generally associated with adoption of healthier diets and consumption of healthier foods (i.e. fruits, vegetables, whole-grain, etc.), which are also part of the main features characterising the Mediterranean diet. Thus, in light of such scientific evidence and considerations, the main drive for preference of a Mediterranean dietary pattern relies mostly on age: while older generations stick with their traditional meals and food preferences, younger ones are more likely to choose new food markets where palatability and sensory perception-driven food design may overcome nutritional quality. Whether these differences in nutritional preferences depend on the different cultural heritage or higher sensibility to a modern market driven by the environment through modern lifestyles, or perhaps a mix of the two, it is unclear. However, adoption or, at least, bring closer the interest of the younger generation towards the older culinary heritage of the Mediterranean area can be achieved on a large scale only through targeted interventions, information, and, at an even larger scale, through modification of the markets and increased availability of healthy foods from the industry remarking the nutritional quality of the principles of the Mediterranean diet.

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