Exploring the Validity of the 14-Item Mediterranean Diet Adherence Screener (MEDAS): A Cross-National Study in Seven European Countries around the Mediterranean Region

María-Teresa García-Conesa, Elena Philippou, Christos Pafilas, Marika Massaro, Stefano Quarta, Vanda Andrade, Rui Jorge, Mihail Chervenkov, Teodora Ivanova, Dessislava Dimitrova, Viktorija Maksimova, Katarina Smilkov, Darinka Gjorgieva Ackova, Lence Miloseva, Tatjana Ruskovska, Georgia Eirini Deligiannidou, Christos A Kontogiorgis, Paula Pinto, María-Teresa García-Conesa, Elena Philippou, Christos Pafilas, Marika Massaro, Stefano Quarta, Vanda Andrade, Rui Jorge, Mihail Chervenkov, Teodora Ivanova, Dessislava Dimitrova, Viktorija Maksimova, Katarina Smilkov, Darinka Gjorgieva Ackova, Lence Miloseva, Tatjana Ruskovska, Georgia Eirini Deligiannidou, Christos A Kontogiorgis, Paula Pinto

Abstract

This study provides comprehensive validation of the 14-item Mediterranean Diet Adherence Screener (14-MEDAS) in an adult population from Greece (GR), Portugal (PT), Italy (IT), Spain (SP), Cyprus (CY), Republic of North Macedonia (NMK), and Bulgaria (BG). A moderate association between the 14-MEDAS and the reference food diary was estimated for the entire population (Pearson r = 0.573, p-value < 0.001; Intraclass Correlation Coefficient (ICC) = 0.692, p-value < 0.001) with the strongest correlation found in GR, followed by PT, IT, SP, and CY. These results were supported by kappa statistics in GR, PT, IT, and SP with ≥50% of food items exhibiting a fair or better agreement. Bland-Altman analyses showed an overestimation of the 14-MEDAS score in the whole population (0.79 ± 1.81, 95%Confidence Interval (CI) 0.61, 0.96), but this value was variable across countries, with GR, NMK, and BG exhibiting the lowest bias. Taking all analyses together, the validation achieved slightly better results in the Mediterranean countries but a definitive validation ranking order was not evident. Considering growing evidence of the shift from Mediterranean Diet (MD) adherence and of the importance of culture in making food choices it is crucial that we further improve validation protocols with specific applications to compare MD adherence across countries.

Keywords: Mediterranean Diet; Southern Europe; body mass index; diet adherence; diet quality; dietary assessment; dietary health benefits; food frequency questionnaire; survey instruments; validation.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Bland–Altman plots of the differences between the results of the 14-MEDAS questionnaire and those of the 3d-FD. Y axis: DIFFERENCE (14-MEDAS—3d-FD) vs. X axis: MEAN ((14-MEDAS + 3d-FD)/2). Results are presented for: (a) All countries together, (b) Spain (SP), (c) Italy (IT), (d) Portugal (PT), (e) Cyprus (CY), (f) Greece (GR), (g) Bulgaria (BG), (h) Republic of North Macedonia (NMK).

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