International Journal of Obesity (2006) 30, 350358

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ORIGINAL ARTICLE
Adherence to a Mediterranean dietary pattern and
weight gain in a follow-up study: the SUN cohort
A Sanchez-Villegas1,2, M Bes-Rastrollo2, MA Martnez-Gonzalez2 and L Serra-Majem1
1
Department of Clinical Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain and 2Department of
Preventive Medicine and Public Health, University of Navarra, Navarra, Spain

Introduction: The promotion of Mediterranean Diets has generated some doubts, because of the concern that its high fat
content might lead to the development of obesity.
Methods: Longitudinal analysis of 6319 participants in the SUN cohort study. We used a validated semiquantitative food
frequency questionnaire (136 items). Baseline adherence to a Mediterranean dietary pattern (MDP) was assessed using a score
(score_1) including vegetables, fruits, cereals, nuts, pulses, fish, olive oil and moderate consumption of red wine (positively
weighted), whereas meat and dairy products were negatively weighted. We assessed the association between the overall
baseline adherence to the MDP (score_1) and subsequent weight change after 28 months of follow-up. We also built another
score (score_2) to assess changes in diet during follow-up and appraised the association between the joint exposure to both
scores and weight change during follow-up.
Results: Participants in the first quartile of score_1 (lowest baseline adherence to MDP) showed a higher weight gain ( 0.73 kg)
than those in the top quartile ( 0.45 kg). The results indicated an inverse doseresponse relationship (P for trend 0.016). A
similar inverse association was apparent when we used change in adherence to the MDP (score_2). However, both inverse
associations did not remain statistically significant after adjusting for relevant confounders. Consumption of dairy products was
inversely associated with weight gain.
Conclusions: Although participants increased their average weight during the follow-up period, weight increments were smaller
among those with a higher adherence to an a priori defined MDP. Results did not remain statistically significant after
multivariate adjustment.
International Journal of Obesity (2006) 30, 350358. doi:10.1038/sj.ijo.0803118; published online 11 October 2005

Keywords: Mediterranean dietary pattern; olive oil; overweight; weight gain; cohort study

Introduction
Obesity is a growing health problem around the world. By
2025, it has been estimated that the prevalence will be
440% in the US, 430% in England and 420% in Brazil.1
Although the obesity rates are dramatically increasing in
Western countries, a rapid increase has been also observed in
developing countries. Moreover, the prevalence of obesity is
higher in Mediterranean countries (i.e. prevalence among
Greek women is around 38%) than in Nordic countries (i.e.
prevalence among Danish women is around 6%).2 The
reason for the reported difference is not known, but genetic
Correspondence: Dr A Sanchez-Villegas, Department of Clinical Sciences,
Center for Health Sciences, University of Las Palmas de Gran Canaria, PO Box
550, Las Palmas de Gran Canaria, Las Palmas 35080, Spain.
E-mail: asanchez@dcc.ulpgc.es
Received 22 March 2005; revised 24 June 2005; accepted 20 July 2005;
published online 11 October 2005
and lifestyle factors such as diet and physical activity pattern
in the Mediterranean area could play an essential role in the
development of obesity.2
On the other hand, Mediterranean diets have been shown
to be protective against mortality for all causes or the
development of coronary heart disease, stroke, hypertension
or cancer.36 A triangle (pyramid) has become the standard
pictorial way to represent food-based dietary guidelines. The
base of the pyramid shows foods which should be consumed
most frequently and the top includes those to be consumed
rarely. In this context, the food pyramid created by the US
Department of Agriculture (USDA) has been proposed to be
replaced by other models, including the Mediterranean Diet
Pyramid.5 In the Mediterranean Pyramid, nonrefined (i.e.
whole-grain) cereals, fruits, vegetables and legumes are the
base, whereas red meat is in the top, olive oil is closer to
the base than to the top (see http://www.oldwayspt.org/
pyramids/med/p_med.html and http://www.nut.uoa.gr/
english/Greekguid.htm#diatr9).

However, the increased likelihood to obtain a high
percentage of energy from fats (specifically monounsatu-
rated fatty acids such as oleic acid) when populations follow
this dietary pattern generates doubts regarding its effect on
weight gain and obesity.
The Seguimiento Universidad de Navarra Follow-up Uni-
versity of Navarra (SUN Project) is a prospective dynamic
cohort study designed to establish the association between
the adherence to a Mediterranean dietary pattern (MDP) and
several diseases and health conditions like overweight,
obesity or weight change along time.7 The aim of the
present prospective research was to evaluate the potential
relation between compliance with traditional Mediterranean
habits and subsequent weight maintenance and changes.
Methods
The SUN Project is a Spanish prospective cohort study
designed in collaboration with the Harvard School of Public
Health that uses a similar methodology as large American
cohorts such as the Nurses Health Study and the Health
Professionals Follow-up Study.7
Information is collected using self-administered question-
naires sent by postal mail every 2 years. The follow-up rate
exceeds 90% for the first 2-year period. The recruitment of
participants started in December 1999 and it is permanently
ongoing as this is a dynamic cohort study. All participants
are university graduates. For the present analyses we
included participants who had already been followed up
for at least 2 years (n 7908). Those participants who
reported extremely low or high values for total energy intake
(less than 800 kcal/day in men and 600 kcal/day in women or
more than 4200 kcal/day in men and 3500 kcal/day in
women), subjects with missing values in the variables of
interest in the analysis and participants with biological
implausible values for the weight or height values were
excluded. Finally, data from 6319 participants remained
available for the analysis.
The study was approved by the Human Research Ethical
Committee at the University of Navarra. Voluntary comple-
tion of the first self-administered questionnaire was con-
sidered to imply informed consent.
Assessment of exposure: A priori MDP
Dietary exposures were assessed through a self-administered
questionnaire (baseline questionnaire) including a 136-item
food frequency questionnaire (FFQ) previously validated in
Spain.8 This questionnaire was included in the baseline
assessment (Q_0, hereafter).
Nutrient intake scores were computed using an ad hoc
computer program specifically developed for this aim. A
trained dietitian updated the nutrient data bank using the
latest available information included in food composition
tables for Spain.9,10 Nutrient scores were calculated as
Mediterranean dietary pattern and weight gain
A Sanchez-Villegas et al
351
frequency  nutrient composition of specified portion size,
where frequencies were measured in nine categories (6 per
day/46 per day/23 per day/1 per day/56 per week/24 per
week/1 per week/13 per month/never or almost never for
each food item).
All dietary intakes were adjusted for total energy intake
using the residuals method.11
The MDP was defined according to an a priori defined
overall score previously used in the scientific literature.4,1216
This score was calculated according to the tertile distribution
for the consumption of several components of the Mediter-
ranean diet. Eight of them were positively weighted (cereals,
vegetables, fruits, legumes, fish, nuts, olive oil and moderate
red wine consumption) and two others were negatively
weighted (meat/meat products and whole-fat dairy pro-
ducts). The lowest tertile was coded as 1, the medium tertile
as 2 and the highest tertile as 3 in the case of the eight
beneficial (positive) components. For the two negatively
weighted items (meat/meat products and whole-fat dairy
products), we inversely ranked the score, with 1 representing
the highest and 3 representing the lowest tertile. Finally, we
summed up the 10 tertile values for each participant,
obtaining a score (score_1, hereafter) ranging from 10 to 30.
Red wine consumption was defined as moderate red wine
consumption. For scoring moderate red wine consumption,
a transformation centered at the level of consuming 20 g/day
for men (20|20-absolute wine intake|) and 10 g/day for
women (10|10-absolute wine intake|) was used to obtain the
highest value for men consuming 20 g/day or women
consuming 10 g/day, and progressive lower values as the
consumption was lower or higher than these values. The
continuous variable thus built was then categorized in
tertiles and included as a positively weighted component
in the pattern.
Additionally, the 2-year follow-up questionnaire (Q_2,
hereafter) included several items regarding changes in the
main dietary habits (consumption in fruits, vegetables,
meat/meat products, fish, olive oil and alcohol). These items
were combined to assess whether the adherence to the MDP
had increased or not during the follow-up period. Thus, we
built another score (score_2, hereafter) using these changes.
For any increase in the consumption of fruit, vegetables,
olive oil, fish or alcohol we summed 2 points, for no change
in each of these items we summed 1 point and for any
reduction we summed no point. On the other hand, for any
increase in the consumption of meat/meat products we
summed no point, for no change we summed 1 point and for
any decrease we summed 2 points. Therefore, score_2 ranged
from 0 to 8. The new score was further categorized in two
groups (subjects with p4 points versus subjects with 44
points).
Assessment of other variables
The baseline questionnaire also included different questions
related to lifestyle, with 46 items for men and 54 items for
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women. Socio-demographic (gender, age, marital status,
university degree or employment), anthropometric (weight,
height, body image or weight change), health-related habits
(e.g. smoking status, consumption of alcoholic beverages
(wine, beer or spirits) and their patterns of use or physical
activity) and medical history variables (exposure to screening
of chronic diseases, medication use, cholesterol level, blood
pressure or family history of several diseases) were collected.
Participants were classified as nonsmokers, ex-smokers and
current smokers. A physical activity questionnaire including
17 activities was completed at baseline by the participants.
To quantify the volume of activity during leisure time, an
activity metabolic equivalent (MET) index was computed by
assigning a multiple of resting metabolic rate (MET score) to
each activity. METs represent the ratio of energy expended
during each specific activity to the resting metabolic rate and
are independent of body weight. Time spent in each of the
activities was multiplied by the MET score specific to each
activity, and then summed over all activities, obtaining a
value of overall weekly MET-hours.17 In the validation study,
there was a highly significant correlation between objec-
tively measured physical activity through an accelerometer
and the overall weekly MET-hours assessed using our
questionnaire (r 0.51, Po0.001).18
Assessment of the outcome
Information on weight was collected at baseline and on the
biennial questionnaire. The reproducibility and validity of
the self-reported weight and body mass index (BMI) were
assessed in a representative subsample of the cohort. The
mean relative errors in self-reported weight and BMI were 1.5
and 2.6%, respectively. The correlation coefficients between
measured and self-reported weights and BMI were 0.991
(95% confidence interval (CI): 0.9860.994) and 0.944 (95%
CI: 0.9860.965), respectively.
BMI was calculated as weight in kilograms divided by the
square of height in meters. The outcomes after 2 years of
follow-up were: (1) change in weight after 2 years of follow-
up (weight in Q_2 minus weight in Q_0); (2) change in BMI
after 2 years of follow-up (BMI in Q_2 minus BMI in Q_0); (3)
incident overweight or obesity (defined as participants with
a baseline BMI value lower than 24.9 kg/m2 in Q_0 and with
a BMIX25 kg/m2 in Q_2).
Statistical analysis
Linear regression models were used to assess the association
between each component of the baseline score (score_1) and
weight or BMI change, and also between the overall
adherence to the MDP (quartiles of score_1) and weight or
BMI change. Nonconditional logistic regression models were
fit to assess the relationship between baseline adherence to
the MDP (score_1) and the risk of incident overweight/
obesity during follow-up. Odds ratios (OR) and their 95% CI
International Journal of Obesity
were calculated for the three upper quartiles, considering the
lowest quartile of the overall score as the reference category.
Tests of linear trend across increasing tertiles of each
component of score_1 and across increasing quartiles of the
overall score were calculated for weight change, BMI change
and risk of overweight/obesity. The median value of
consumption was imputed for each tertile of consumption.
Similarly, we imputed the median value of the score for each
quartile of adherence to the MDP. Subsequently, the median
values were used as a continuous variable in the regression
models to assess doseresponse relationships (i.e. test of
linear trend).
We fit a crude (univariate) model, an age- and gender-
adjusted model and a multivariate-adjusted model control-
ling for the following variables: baseline BMI, physical
activity during leisure time (MET-hours/week), smoking
status (smoker, ex-smoker, never smoker), alcohol consump-
tion (no/yes), energy intake (kcal/day), change in dietary
habits (fruits, vegetables, meat/meat products, fish, olive oil
and alcohol) and change in physical activity from Q_0 to
Q_2.
To assess diet changes during follow-up, we used score_2. It
was categorized in two groups (cutoff: 4 points). To assess the
joint exposure to both scores (baseline adherence and
changes in adherence follow-up), we considered the partici-
pants in the lowest quartile of score_1 and with score_2p4 as
the reference category and compared them with the other
seven categories combining both exposures. All P-values
presented are two-tailed; Po0.05 was considered statistically
significant.
Results
The adherence to a MDP was higher among women, older
subjects, ex-smokers and among those participants more
physically active. Subjects belonging to the highest quartile
of baseline adherence to a MDP increased during follow-up
their consumption of fish and olive oil and decreased their
consumption of meat/meat products. Regarding nutrient
intake, subjects with a higher baseline adherence to a MDP
showed a higher intake of carbohydrates, fiber, omega-3 fatty
acids and a higher monounsaturated to saturated fatty acid
ratio (Table 1).
Table 2 shows weight change according to tertiles of
consumption of each component involved in the score to
assess adherence to MDP. A higher baseline consumption of
meat/meat products was associated with higher weight gain
(mean changes (kg) 0.41, 0.63 and 0.82 for tertiles
1, 2 and 3 respectively; P for trend o0.001). When the model
was also adjusted for the other components of the score, the
results did not change (P for trend o0.001).
Conversely, a higher baseline consumption of whole-fat
dairy products was associated with lower weight gain (mean
changes (kg) 0.64, 0.79, 0.43 for succesive tertiles;
P for trend 0.003).
 Mediterranean dietary pattern and weight gain
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Table 1 Main characteristicsa (mean and standard deviation (s.d.)) of the 6319 participants of the SUN Study according to baseline adherence to the
Mediterranean dietary pattern (score_1)

Baseline adherence to the Mediterranean dietary pattern (score_1)

Quartile 1 Quartile 2 Quartile 3 Quartile 4

n 1336 2143 1458 1382

Score_1 (range) o18 18o20 20o22 X20
Age (years) 34.0 (10.1) 36.4 (11.5) 37.7 (11.6) 40.0 (13.1)
Baseline BMI (kg/m2) 23.4 (3.4) 23.4 (3.4) 23.4 (3.4) 23.3 (3.4)
Follow-up BMI (kg/m2) 23.6 (3.4) 23.6 (3.5) 23.6 (3.5) 23.4 (3.5)
Baseline weight (kg) 68.6 (13.4) 67.2 (13.7) 66.2 (13.1) 65.4 (13.0)
Follow-up weight (kg) 69.3 (13.4) 67.9 (13.9) 66.7 (13.1) 65.8 (13.1)
Physical activity during leisure time (MET-h/week) 17.1 (21.7) 17.5 (20.8) 19.1 (22.2) 20.5 (21.3)
Increase in physical activity (%) 26.8 31.1 30.6 32.6

Gender (%)
Men 56.1 43.0 36.9 34.2

Smoking status (%)

Ex-smoker 21.8 26.4 28.4 32.3
Current smoker 28.1 25.7 25.4 22.2
Increase in fruit and vegetables consumption (%) 27.5 29.6 28.7 31.2
Increase in meat consumption (%) 4.9 4.2 3.8 3.5
Increase in fish consumption (%) 17.5 20.0 20.0 22.8
Increase in olive oil consumption (%) 20.9 20.7 21.3 21.6
Increase in alcohol intake (%) 4.9 3.0 3.1 3.1
Alcohol drinking (%) 78.7 78.3 77.9 77.5
Alcohol intake (%E) 2.3 (3.4) 2.1 (3.0) 1.8 (2.5) 1.6 (2.6)
CHO intake (%E) 40.5 (7.2) 42.3 (7.2) 43.3 (7.4) 45.7 (7.0)
Protein intake (%E) 17.6 (3.4) 17.9 (3.4) 18.3 (3.6) 18.3 (3.1)

Lipid intake (%E) 39.7 (5.9) 37.7 (6.4) 36.6 (6.4) 34.4 (6.4)
PUFA (%E) 5.7 (1.7) 5.3 (1.6) 5.3 (1.6) 5.1 (1.5)
MUFA/SFA ratio 1.1 (0.2) 1.2 (0.3) 1.4 (0.3) 1.5 (0.4)
Omega-3 (%E) 0.3 (0.2) 0.4 (0.3) 0.5 (0.4) 0.5 (0.3)
Trans fatty acids (%E) 0.3 (0.3) 0.2 (0.3) 0.2 (0.3) 0.1 (0.2)

Fiber intake (g/day) 20.3 (8.5) 24.6 (9.8) 29.1 (12.2) 34.3 (12.6)
Calcium intake (mg/day) 1235.4 (479.7) 1222.0 (486.3) 1212.6 (486.3) 1244.9 (436,3)
Energy-adjusted whole fat dairy products (g/day) 329 (225.2) 249 (197.8) 184 (159.0) 127 (123.7)
Energy intake (kcal/day) 2569 (636.6) 2386 (647.3) 2323 (645.0) 2301 (600.3)
a
Mean and s.d. unless otherwise stated. BMI: body mass index, MET: metabolic equivalents, CHO: carbohydrates, PUFA: polyunsaturated fatty acids, MUFA:
monounsaturated fatty acids, SFA: saturated fatty acids.

Although the point estimates suggested a beneficial effect
of a high consumption of fruit, nuts and olive oil on weight
gain, the results were not statistically significant.
Table 3 shows that although, on average, participants
increased their weight and their BMI throughout follow-up,
weight increments were smaller among participants with a
higher adherence to an MDP. Subjects with the lowest
baseline adherence to an MDP (quartile 1 of score_1) showed
weight gain 0.73 kg, whereas subjects with the highest
adherence (quartile 4) experienced weight gain 0.45 kg
(P 0.05). The results indicated a statistically significant
doseresponse relationship (P for trend 0.016). However,
although the trends were similar, these associations did not
remain statistically significant in the multivariate model.
Subjects belonging to the first quartile of score_1 showed
an increment 0.26 kg/m2 in BMI, whereas subjects in the
highest quartile had an increment 0.17 kg/m2 (P 0.06).
In addition, the results for BMI also indicated a statistically
significant inverse doseresponse relationship (P for tren-
d 0.026). However, this association did not remain statis-
tically significant after adjusting for relevant confounding
factors. Adjustment in model 2 (Table 3) includes energy
intake; when we alternatively controlled for baseline weight
(instead of energy and BMI) this alternative adjustment did
not materially affect our results (data not shown).
When we analysed 1763 prevalent cases of overweight or
obesity reported in the baseline questionnaire (defined as
BMIX25 kg/m2 in Q_0), the results did not substantially
differ. No statistically significant association between the
adherence to the MDP and weight gain was found in the
regression models (mean changes [kg] 0.21, 0.49,
0.09, 0.37 for quartiles 14; P for trend 0.950).

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Table 2 Association between the consumption of each component of the score built to assess baseline adherence to Mediterranean Dietary Pattern (score_1) and
weight change after 2 years of follow-up

Components of score_1 adjusted Weight changea (kg) 95% CI Weight changeb 95% CI Weight changec 95% CI
for energy (tertiles: T1T3) (mean) (kg) (mean) (kg) (mean)

Cereals (g/day, limits)

T1: o61.2 +0.72 +0.55 to +0.88 +0.72 +0.55 to +0.88 +0.72 +0.55 to +0.88
T2: 61.2104.7 +0.54 +0.31 to +0.76 +0.53 +0.30 to +0.75 +0.61 +0.32 to +0.90
T3: 4104.7 +0.62 +0.39 to +0.84 +0.61 +0.39 to +0.83 +0.69 +0.41 to +0.87
P for trend 0.46 0.42 0.58

Vegetables (g/day, limits)

T1: o356.8 +0.73 +0.57 to +0.89 +0.73 +0.57 to +0.89 +0.73 +0.57 to +0.89
T2: 356.8567.4 +0.54 +0.32 to +0.77 +0.63 +0.40 to +0.85 +0.61 +0.38 to +0.84
T3: 4567.4 +0.58 +0.36 to +0.81 +0.74 +0.51 to +0.97 +0.69 +0.45 to +0.94
P for trend 0.25 0.84 0.88

Fruit (g/day, limits)

T1: o189.2 +0.77 +0.61 to +0.93 +0.77 +0.61 to +0.93 +0.77 +0.61 to +0.93
T2: 189.2355.0 +0.61 +0.39 to +0.84 +0.73 +0.50 to +0.95 +0.76 +0.53 to +0.99
T3: 4355.0 +0.49 +0.26 to +0.71 +0.69 +0.45 to +0.92 +0.68 +0.44 to +0.93
P for trend 0.02 0.48 0.46

Legumes (g/day, limits)

T1: o16.2 +0.58 +0.43 to +0.73 +0.58 +0.43 to +0.73 +0.58 +0.43 to +0.73
T2: 16.224.6 +0.69 +0.47 to +0.92 +0.66 +0.44 to +0.88 +0.68 +0.46 to +0.91
T3: 424.6 +0.58 +0.36 to +0.81 +0.59 +0.37 to +0.81 +0.57 +0.35 to +0.80
P for trend 0.96 0.98 0.90

Fish (g/day, limits)

T1: o64.9 +0.71 +0.55 to +0.87 +0.71 +0.55 to +0.87 +0.71 +0.55 to +0.87
T2: 64.9107.4 +0.46 +0.24 to +0.69 +0.58 +0.36 to +0.80 +0.59 +0.36 to +0.81
T3: 4107.4 +0.68 +0.46 to +0.91 +0.90 +0.67 to +1.12 +0.88 +0.65 to +1.11
P for trend 0.92 0.05 0.09

Nuts (g/day, limits)

T1: o4.1 +0.73 +0.56 to +0.89 +0.73 +0.56 to +0.89 +0.73 +0.56 to +0.89
T2: 4.111.3 +0.63 +0.40 to +0.85 +0.67 +0.42 to +0.91 +0.66 +0.42 to +0.91
T3: 411.3 +0.52 +0.29 to +0.74 +0.56 +0.33 to +0.80 +0.57 +0.33 to +0.80
P for trend 0.07 0.15 0.17

Meat (g/day, limits)

T1: o149.7 +0.41 +0.26 to +0.56 +0.41 +0.26 to +0.56 +0.41 +0.26 to +0.56
T2: 149.7205.0 +0.63 +0.41 to +0.86 +0.63 +0.41 to +0.85 +0.62 +0.40 to +0.84
T3: 4205.0 +0.82 +0.59 to +1.04 +0.85 +0.62 to +1.07 +0.79 +0.56 to +1.02
P for trend o0.001 o0.001 0.001

Whole-fat dairy (g/day, limits)

T1: o122.4 +0.64 +0.48 to +0.81 +0.64 +0.48 to +0.81 +0.64 +0.48 to +0.81
T2: 122.4254.2 +0.79 +0.56 to +1.01 +0.69 +0.46 to +0.92 +0.68 +0.45 to +0.91
T3: 4254.2 +0.43 +0.21 to +0.66 +0.28 +0.05 to +0.50 +0.26 +0.03 to +0.49
P for trend 0.03 o0.001 o0.001

Olive oil (g/day, limits)

T1: o11.0 +0.71 +0.55 to +0.87 +0.71 +0.55 to +0.87 +0.71 +0.55 to +0.87
T2: 11.022.3 +0.57 +0.34 to +0.79 +0.57 +0.34 to +0.79 +0.55 +0.32 to +0.78
T3: 422.3 +0.58 +0.35 to +0.80 +0.56 +0.34 to +0.79 +0.55 +0.32 to +0.78
P for trend 0.31 0.26 0.23

Mod. red wine (g/day, limits)

T1: o10.0 +0.65 +0.47 to +0.83 +0.65 +0.47 to +0.83 +0.65 +0.47 to +0.83
T2: 10 +0.55 +0.32 to +0.78 +0.38 +0.12 to +0.65 +0.38 +0.12 to +0.65
T3: 410.0 +0.71 +0.46 to +0.96 +0.57 +0.31 to +0.82 +0.57 +0.31 to +0.82
P for trend 0.89 0.22 0.22

T1: lowest tertile, T2: medium tertile, T3: highest tertile. aCrude. bAdjusted for age, gender, baseline BMI, smoking, physical activity, alcohol consumption, energy
intake, change in dietary habits (fruits, vegetables, meat/meat products, fish, olive oil and alcohol) and physical activity from Q_0 to Q_2. cAdditionally adjusted for
all the other food items shown in the table. Weight change: weight (kg) in Q_2 minus weight (kg) in Q_0. s.d.: standard deviation.

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Table 3 Association between the adherence to a Mediterranean dietary pattern (score_1) and body mass index and weight change in two years of follow-up

Mediterranean dietary pattern quartiles

Quartile 1 Quartile 2 Quartile 3 Quartile 4 P for trend

Range of score_1 o18 1819 2021 X22

Number participants 1336 2143 1458 1382

Weight change (kg) (mean (95% CI))

Model 1 +0.73 (+0.53 to +0.93) (ref.) +0.73 (+0.48 to +0.99) +0.51 (+0.23 to +0.78) +0.45 (+0.17 to +0.73) 0.016
Model 2 Idem. (ref.) +0.80 (+0.54 to +1.05) +0.60 (+0.32 to +0.88) +0.55 (+0.26 to +0.84) 0.108
Model 3 Idem. (ref.) +0.87 (+0.68 to +0.86) +0.66 (+0.61 to +0.80) +0.65 (+0.59 to +0.80) 0.291

BMI change (kg/m2) (mean (95% CI))

Model 1 +0.26 (+0.19 to +0.33) (ref.) +0.26 (+0.17 to +0.35) +0.19 (+0.09 to +0.29) +0.17 (+0.07 to +0.26) 0.026
Model 2 Idem. (ref.) +0.27 (+0.18 to +0.36) +0.22 (+0.12 to +0.32) +0.19 (+0.09 to +0.29) 0.105
Model 3 Idem. (ref.) +0.30 (+0.21 to +0.39) +0.24 (+0.14 to +0.33) +0.23 (+0.12 to +0.33) 0.279

95% CI: 95% confidence interval. Model 1: crude. Model 2: adjusted for baseline age, gender, BMI, smoking, physical activity, alcohol and energy intake. Model 3:
additionally adjusted for changes in dietary habits (fruits, vegetables, meat/meat products, fish, olive oil and alcohol) and physical activity during follow-up. Weight
change: weight (kg) in Q_2 minus weight (kg) in Q_0. BMI: Body Mass Index (kg/m2). BMI change: Body Mass Index (kg/m2) in Q_2 minus Body Mass Index
(kg/m2) in Q_0.

Table 4 shows the joint exposure to baseline adherence to a
MDP (score_1) and to changes in the adherence during
follow-up (score_2). Participants with lower baseline adher-
ence to a MDP and with no improvement during follow-up
(score_2p4) were considered as the reference category. A
higher baseline adherence to a MDP together with an
increase in adherence during follow-up led to lower weight
gain ( 0.36 kg, whereas weight gain was 0.80 kg in the
reference category; P 0.02). The results were similar when
we assessed change in BMI ( 0.13 versus 0.28 kg/m2;
P 0.04). Nevertheless, the results were not statistically
significant after adjusting for relevant confounders.
We included 4556 subjects without prevalent overweight
or obesity at baseline to assess the association between
adherence to a MDP and the risk of incident overweight/
obesity during follow-up. During 2 years of follow-up, we
observed 353 new cases of overweight/obesity. No significant
association was observed when we fit either crude or
multivariate nonconditional logistic regression models with
quartiles of baseline adherence to a MDP (score_1) as the
exposure and incident overweight/obesity as the outcome
(Table 5).
We also assessed different interactions (effect modifica-
tion) in the association between adherence to a MDP and the
risk of overweight/obesity, but none of them was statistically
significant (gender*age; gender*baseline BMI, age*baseline
BMI; baseline BMI*MDP; gender*MDP, age*MDP and phy-
sical activity*MDP).
Discussion
To our knowledge, this is the first time that a prospective
cohort study analyses the effect of the adherence to a MDP
on weight or BMI change.
Although participants increased their average weight and
BMI during follow-up, crude increments were lower among
those with a higher adherence to an a priori defined MDP
and among those who increased their adherence to a MDP
during follow-up.
In any case, beyond controversies, the MDP did not show
an association with a higher likelihood of weight gain,
overweight or obesity in the SUN cohort.
Similarly, a recent study found a protective and statisti-
cally significant inverse association between the MDP and
obesity. However, the results reported from that study
acknowledged that they were not conclusive because of the
cross-sectional nature of the design. In addition, that study
did not include olive oil consumption in the Mediterranean
score.15
The scientific literature about this topic is not abundant,
but to our knowledge some small clinical trials are consistent
with our findings.1921 They found that the Mediterranean
diet is a good alternative diet for weight loss compared with a
low-fat diet, both controlled for energy.19 Fernandez de la
Puebla et al.20 found that an isocaloric replacement of a
saturated fat-rich diet by a Mediterranean diet decreases total
body fat in hypercholesterolemic males. Flynn et al.21
reported that a Mediterranean diet is at least as effective as
any diet published, in patients attending a weight-loss
programme.
The promotion of olive oil consumption has been a
notorious issue for public health nutrition. Although its
benefits on health have been largely tested, the composition
of this Mediterranean component (100% fat) has led to some
criticism about recommending virgin olive oil consumption
to protect from cardiovascular disease because it is presumed
to increase the risk of overweight/obesity. Furthermore,
Ferro-Luzzi et al.22 criticized the current nutritional advice
applied in Greece and based in the Mediterranean Diet
Pyramid.23 A crucial discussion matter was that the high

International Journal of Obesity

 Mediterranean dietary pattern and weight gain
A Sanchez-Villegas et al
356
prevalence of weight gain associated with excessive energy
Table 4 Joint association of baseline adherence to a Mediterranean diet pattern (score_1) and change in adherence to the MDP (No change/decrease versus increase in score_2) and body mass index and

+0.36 (0.016 to +0.74)

Model 1: crude. Model 2: adjusted for age and gender. Model 3: additionally adjusted for baseline BMI, smoking, physical activity, alcohol consumption and energy intake. BMI: Body Mass Index (kg/m2).
+0.45 (+0.06 to +0.84)
+0.52 (+0.13 to +0.90)

+0.16 (+0.02 to +0.29)

+0.18 (+0.04 to +0.32)
+0.14 (0.00 to +0.27)
intake and physical inactivity observed in the Mediterranean

Increase (44)
area in the last 30 years is a strong reason for concern

750
regarding the threating obesity epidemic. The high fat

BMI change: Body Mass Index (kg/m2) in Q_2 minus Body Mass Index (kg/m2) in Q_0. Weight change: weight (kg) in Q_2 minus weight (kg) in Q_0. 95% CI: 95% confidence interval.
content based on olive oil consumption of the Greek diet
Quartile 4 (X22)

(one of the most typical Mediterranean diets) could have

increased since the 1950s, leading to substantial weight gain
No change/decrease (p4)

+0.48 (+0.10 to +0.87)

+0.54 (+0.15 to +0.93)
+0.67 (+0.29 to +1.06)

+0.19 (+0.06 to +0.33)

+0.20 (+0.07 to +0.34)
+0.25 (+0.11 to +0.39)
in this Mediterranean region and, thus, increasing obesity
prevalence and, consequently, the risk of cardiovascular
disease, hypertension and diabetes.22
727

However, the presumption that olive oil increases the risk

of obesity in Mediterranean populations is not supported by
any reliable evidence.24,25 Recently, our group did not find a
+0.64 (+0.29 to +0.99)
+0.67 (+0.32 to +1.03)
+0.76 (+0.41 to +1.11)

+0.23 (+0.10 to +0.35)

+0.23 (+0.11 to +0.36)
+0.26 (+0.14 to +0.39)
significant association between olive oil consumption and
Increase (44)

the risk of obesity or weight gain in the SUN cohort (M Bes-

1059

Rastrollo et al. unpublished data). On the contrary, we

report here a moderate protection of the MDP on weight
Quartile 3 (2021)
Baseline adherence to Mediterranean dietary pattern quartiles (score_1)

gain.
The usual definition of MDP involves whole milk products
No change/decrease (p4)

as a negative item (i.e. a higher consumption, means a lower

+0.66 (+0.26 to +1.06)
+0.66 (+0.26 to +1.06)
+0.72 (+0.33 to +1.18)

+0.24 (+0.10 to +0.38)

+0.24 (+0.10 to +0.39)
+0.27 (+0.13 to +0.40)

adherence), but we have observed here that whole milk

products are associated with a lower likelihood of weight
609

gain. This finding is consistent with some recent evidence

claiming that dairy products consumption may act as a
possible protector factor against obesity. Some studies have
suggested an intracellular role of calcium or other compo-
+0.21 (+0.07 to +0.359
+0.56 (+0.16 to +0.96)
+0.64 (+0.24 to +1.04)
+0.66 (+0.26 to +1.06)

+0.23 (+0.09 to +0.37)

+0.23 (+0.09 to +0.38)

nents of dairy products in body weight regulation,26 a

Increase (44)

hypothesis supported by several observational and experi-

632

mental studies.2729 Our findings contribute to support this

hypothesis.
Quartile 2 (1819)

Another important feature of the MDP is a high consump-

tion of nuts. Nuts are high in fat. Their fat content can range
No change/decrease (p4)

+0.54 (+0.15 to +0.92)

+0.58 (+0.19 to +0.96)
+0.59 (+0.21 to +0.98)

+0.20 (+0.06 to +0.33)

+0.20 (+0.07 to +0.34)
+0.21 (+0.08 to +0.34)

from 45 to 75% of their total energy supply. However, the

available data from epidemiologic studies show an inverse
731

association or no association at all between nut consump-

tion and the likelihood of weight gain or of becoming
obese.30,31 In addition, dietary intervention studies have
failed to find a relationship between nut consumption and
+0.83 (+0.48 to +1.18)
+0.86 (+0.51 to +1.21)
+0.90 (+0.55 to +1.25)

+0.29 (+0.17 to +0.41)

+0.30 (+0.17 to +0.42)
+0.31 (+0.19 to +0.43)

any increment in body weight.32 Many reasons could

Increase (44)

explain the reported associations. Protective effect against

1084

weight gain could be attributed to the increased resting

energy expenditure of this type of food item rich in protein
Quartile 1 (o18)

and unsaturated fatty acids. Moreover, nuts could increase

satiety due to their high content in fiber and proteins.33
No change/decrease (p4)

+0.80 (+0.54 to +1.06)

+0.80 (+0.54 to +1.06)
+0.80 (+0.54 to +1.06)

+0.28 (+0.19 to +0.36)

+0.28 (+0.19 to +0.36)
+0.28 (+0.19 to +0.36)

Essentially, the high consumption of fruit and vegetables

weight change in two years of follow-up

in Mediterranean countries could better explain the ob-

served protective effect of the adherence to MDP against
727

BMI change (kg/m2) (mean (95% CI))

weight gain or against the development of obesity.34 A high

Weight change (kg) (mean (95% CI))

olive oil intake may help to consume plant foods in great

amounts, because this high consumption of vegetables
Number of participants

dressed and cooked with olive oil may contribute to decrease

Change in adherence

obesity associated with a higher intake of olive oil.24

to a MDP (score_2)

However, a potential limitation of our reported results

Model 1
Model 2
Model 3

Model 1
Model 2
Model 3

could be that a higher adherence to the MDP was in fact

associated with a lower total fat intake, thus raising doubts
about whether we properly assessed a true MDP. We

International Journal of Obesity

 Mediterranean dietary pattern and weight gain
A Sanchez-Villegas et al
357
Table 5 Association between baseline adherence to a Mediterranean dietary pattern (score_1) and the risk of overweight/obesity during follow-up in 4556
participants of the SUN Study

Logistic regression analysis Baseline adherence to Mediterranean dietary pattern (score_1)

Quartile 1 (o18) Quartile 2 (1819) Quartile 3 (2021) Quartile 4 (X22) P for trend

n 937 1555 1051 1013

Cases 72 128 89 64
Crude OR 1 (ref.) 1.08 1.11 0.81 0.259
(95% CI) (0.801.46) (0.801.54) (0.571.15)
Age- and gender-adjusted OR 1 (ref.) 1.23 1.35 0.92 0.741
(95% CI) (0.911.68) (0.961.89) (0.631.32)
Multivariatea OR 1 (ref.) 1.17 1.29 0.90 0.739
(95% CI) (0.821.66) (0.881.88) (0.591.38)

95% CI: 95% confidence interval. aAdditionally adjusted for baseline BMI, smoking, physical activity, alcohol and energy intake and change in dietary habits (fruits,
vegetables, meat/meat products, fish, olive oil and alcohol) and physical activity from Q_0 to Q_2.

acknowledge this potential limitiation. However, it is needed
to take also into account that the major fat-related feature
generally used to define a MDP is not the total fat intake
(which is still high in absolute terms in our overall sample)
but the ratio of monounsaturated to saturated fatty acids
(MUFA/SFA ratio), and we did find that the distribution of
the MUFA/SFA ratio monotonically increased from 1.1 to 1.5
across successive quartiles of the MDP.
One of the strengths of our study is its ability to adjust for
changes in dietary habits during follow-up to eliminate the
possible effect of reverse causality in the reported associa-
tions. The inclusion of changes in fruits, vegetables, alcohol,
fish, meat/meat products and olive oil consumption in the
models could be considered as a proxy of change in the
adherence to a MDP.
Additionally, we have to consider that Mediterranean
lifestyle includes the regular practice of physical activity.
Besides this, epidemiological evidence supports a detrimen-
tal role of sedentary lifestyles on increasing obesity epidemic
in Mediterranean countries.35,36 For that reason, we took
into account not only baseline physical activity but also
changes in physical activity patterns during follow-up. Thus,
we do not think this factor has confounded the reported
associations.
Among participants initially free of overweight/obesity, a
higher adherence to an MDP was not associated with a
higher likelihood of becoming overweight/obese. On the
other hand, when we restricted the analyses to either
subjects with a baseline BMIX25 kg/m2, the results regarding
the association between the adherence to an MDP and
weight gain did not change. Thus, it does not seem that a
previous status of overweight/obesity modifies the associa-
tion between adherence to an MDP and subsequent weight
change.
The results of this study do not support the hypothesis
that the reported increases of obesity rates in Mediterranean
countries are attributable to the adherence to an MDP. An
alternative explanation could be that the increasing obesity
rates may instead be related to declining physical activity in
the population and to the abandonment of MDP observed in
Mediterranean countries, particularly among younger gen-
erations.37
Acknowledgements
We are indebted to the participants of the SUN Study for
their continued cooperation and participation. The Depart-
ment of Health of the Navarre Regional Government and
Spanish Ministry of Health (Fondo de Investigaciones
Sanitarias, projects 01/0619 and 04/042241 and G03/140,
Red Tematica de Dieta y Enfermedad Cardiovascular) are
gratefully acknowledged for supporting the present study.
We would like to thank other members of the SUN Study
Group: M Segu-Gomez, A Alonso, RM Pajares, JA Martinez,
M Delgado-Rodrguez, M Serrano-Martnez, M Marques, A
Marti, M Munoz, F Guillen-Grima and I Aguinaga and our
advisors from the Department of Nutrition of the Harvard
School of Public Health: A Ascherio, W Willett and FB Hu,
who helped us to design the SUN cohort study.
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