A higher adherence to a Mediterranean diet has been shown to be protective against obesity in adults, but the evidence is still inconclusive in children at early ages. Our objective was to explore the association between adherence to Mediterranean Diet at the age of 4 and the prevalence of overweight, obesity, and abdominal obesity at 4 years of age, and incidence at the age of 8.
We analyzed data from children of the INMA cohort study who attended follow-up visits at age 4 and 8 years (n = 1801 and n = 1527, respectively). Diet was assessed at the age of 4 using a validated food frequency questionnaire. The adherence to MD was evaluated by the relative Mediterranean diet (rMED) score, and categorized as low (0–6), medium (7–10), and high (11–16). Overweight and obesity were defined according to the age-sex specific BMI cutoffs proposed by the International Obesity Task Force, and abdominal obesity as waist circumference >90th percentile. We used Poisson regression models to estimate prevalence ratios at 4 years of age, and Cox regression analysis to estimate hazard ratios (HR) from 4–8 years of age.
In cross-sectional analyses at the age of 4 no association was observed between adherence to MD and overweight, obesity, or abdominal obesity. In longitudinal analyses, a high adherence to MD at age 4 was associated with lower incidence of overweight (HR = 0.38; 95% CI: 0.21–0.67; p = 0.001), obesity (HR = 0.16; 95% CI: 0.05–0.53; p = 0.002), and abdominal obesity (HR = 0.30; 95% CI: 0.12–0.73; p = 0.008) at the age of 8.
This study shows that a high adherence to MD at the age of 4 is associated with a lower risk of developing overweight, obesity, and abdominal obesity at age 8. If these results are confirmed by other studies, MD may be recommended to reduce the incidence of obesity at early ages.
This is a preview of subscription content, access via your institution
Subscribe to this journal
Receive 12 print issues and online access
$259.00 per year
only $21.58 per issue
Rent or buy this article
Get just this article for as long as you need it
Prices may be subject to local taxes which are calculated during checkout
NCD-RisC. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: A pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. The Lancet. 2017;390:2627–42.
NCD-RisC. Evolution of BMI over time. http://www.ncdrisc.org/overweight-prevalence-map-ado.html (Accessed 30 March 2019).
Marcano Y, Torcat J, Ayala L, Verdi B, Lairet C, Maldonado M. et al. Endocrine functions of the adipose tissue. Rev Venez Endocrinol Metab. 2006;4:15–21.
Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel CW, et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. 2004;350:2362–74.
Lobstein T, Jackson-Leach R, Moodie ML, Hall KD, Gortmaker SL, Swinburn BA, et al. Child and adolescent obesity: part of a bigger picture. Lancet. 2015;385:2510–20.
van Vliet-Ostaptchouk JV, Nuotio M-L, Slagter SN, Doiron D, Fischer K, Foco L, et al. The prevalence of metabolic syndrome and metabolically healthy obesity in Europe: a collaborative analysis of ten large cohort studies. BMC Endocr Disord. 2014;14:9.
Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120:S164–192.
Agostoni C, Braegger C, Decsi T, Kolacek S, Koletzko B, Mihatsch W, et al. Role of dietary factors and food habits in the development of childhood obesity: a commentary by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr. 2011;52:662–9.
Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98:1084–102.
Dinu M, Pagliai G, Casini A, Sofi F. Mediterranean diet and multiple health outcomes: an umbrella review of meta-analyses of observational studies and randomised trials. Eur J Clin Nutr. 2018;72:30–43.
Willett WC, Sacks F, Trichopoulou A, Drescher G, Ferro-Luzzi A, Helsing E. et al. Mediterranean diet pyramid: a cultural model for healthy eating. Am J Clin Nutr. 1995;61:1402S–1406S.
Trichopoulou A, Vasilopoulou E. Mediterranean diet and longevity. Br J Nutr. 2000;84:S205–209.
Bulló M, Casas-Agustench P, Amigó-Correig P, Aranceta J, Salas-Salvadó J. Inflammation, obesity and comorbidities: the role of diet. Public Health Nutr. 2007;10:1164–72.
Schröder H. Protective mechanisms of the Mediterranean diet in obesity and type 2 diabetes. J Nutr Biochem. 2007;18:149–60.
Bullo M, Lamuela-Raventos R, Salas-Salvado J. Mediterranean diet and oxidation: nuts and olive oil as important sources of fat and antioxidants. Curr Top Med Chem. 2011;11:1797–810.
Buckland G, González CA, Agudo A, Vilardell M, Berenguer A, Amiano P, et al. Adherence to the mediterranean diet and risk of coronary heart disease in the spanish EPIC cohort study. Am J Epidemiol. 2009;170:1518–29.
Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr. 2010;92:1189–96.
Liyanage T, Ninomiya T, Wang A, Neal B, Jun M, Wong M, et al. Effects of the Mediterranean diet on cardiovascular outcomes—a systematic review and meta-analysis. PLoS ONE. 2016;11:e0159252.
Iaccarino Idelson P, Scalfi L, Valerio G. Adherence to the Mediterranean diet in children and adolescents: a systematic review. Nutr Metab Cardiovasc Dis. 2017;27:283–99.
Guxens M, Ballester F, Espada M, Fernández MF, Grimalt JO, Ibarluzea J, et al. Cohort profile: the INMA-INfancia y Medio Ambiente-(environment and childhood) project. Int J Epidemiol. 2012;41:930–40.
Vioque J, Gimenez-Monzo D, Navarrete-Muñoz EM, Garcia-De-la-hera M, Gonzalez-Palacios S, Rebagliato M, et al. Reproducibility and validity of a food frequency questionnaire designed to assess diet in children aged 4–5 years. PLoS ONE. 2016;11:e0167338.
Vioque J, Navarrete-Muñoz E-M, Gimenez-Monzó D, García-de-la-Hera M, Granado F, Young IS, et al. Reproducibility and validity of a food frequency questionnaire among pregnant women in a Mediterranean area. Nutr J. 2013;12:26.
USDA, Agricultural Research Service. USDA national nutrient database for standard reference, release 24. Whashington (DC): USDA; 2011.
Palma I, Farran A, Cantós D. Tablas de composición de Alimentos por medidas caseras de consumo habitual en España. Madrid: McGraw-Hill, Interamericana de E spaña; 2008.
Vicario IM, Griguol V, León-Camacho M. Multivariate characterization of the fatty acid profile of spanish cookies and bakery products. J Agric Food Chem. 2003;51:134–9.
Cole TJ. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ. 2000;320:1240–3.
Fernández JR, Redden DT, Pietrobelli A, Allison DB. Waist circumference percentiles in nationally representative samples of African-American, European-American, and Mexican-American children and adolescents. J Pediatr. 2004;145:439–44.
Espelt A, Mari-Dell’Olmo M, Penelo E, Bosque-Prous A. Applied Prevalence Ratio estimation with different Regression models: an example from a cross-national study on substance use research. Adicciones. 2017;29:105–12.
Barros AJD, Hirakata VN, Espelt A, Mari-Dell’Olmo M, Penelo E, Bosque-Prous A. Alternatives for logistic regression in cross-sectional studies: An empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21.
Deddens JA, Petersen MR. Approaches for estimating prevalence ratios. Occup Environ Med. 2008;65:501–6.
Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ Br Med J. 2003;327:557–60.
Kontogianni MD, Vidra N, Farmaki A-E, Koinaki S, Belogianni K, Sofrona S, et al. Adherence rates to the Mediterranean diet are low in a representative sample of Greek children and adolescents. J Nutr. 2008;138:1951–6.
Kontogianni MD, Farmaki A-E, Vidra N, Sofrona S, Magkanari F, Yannakoulia M. Associations between lifestyle patterns and body mass index in a sample of Greek children and adolescents. J Am Diet Assoc. 2010;110:215–21.
Tognon G, Moreno LA, Mouratidou T, Veidebaum T, Molnár D, Russo P, et al. Adherence to a Mediterranean-like dietary pattern in children from eight European countries. The IDEFICS study. Int J Obes. 2014;38:S108–114.
Aldridge VK, Dovey TM, Martin CI, Meyer C. Identifying clinically relevant feeding problems and disorders. J Child Heal Care. 2010;14:261–70.
Leventakou V, Sarri K, Georgiou V, Chatzea V, Frouzi E, Kastelianou A, et al. Early life determinants of dietary patterns in preschool children: Rhea mother–child cohort, Crete, Greece. Eur J Clin Nutr. 2016;70:60–5.
García-Fernández E, Rico-Cabanas L, Estruch R, Estruch R, Estruch R, Bach-Faig A. Mediterranean diet and cardiodiabesity: a review. Nutrients. 2014;6:3474–500.
Grosso G, Mistretta A, Frigiola A, Gruttadauria S, Biondi A, Basile F, et al. Mediterranean diet and cardiovascular risk factors: a systematic review. Crit Rev Food Sci Nutr. 2014;54:593–610.
Smith CE, Tucker KL. Health benefits of cereal fibre: a review of clinical trials. Nutr Res Rev. 2011;24:118–31.
Wanders AJ, van den Borne JJGC, de Graaf C, Hulshof T, Jonathan MC, Kristensen M, et al. Effects of dietary fibre on subjective appetite, energy intake and body weight: a systematic review of randomized controlled trials. Obes Rev. 2011;12:724–39.
Tarro L, Llauradó E, Albaladejo R, Moriña D, Arija V, Solà R, et al. A primary-school-based study to reduce the prevalence of childhood obesity—the EdAl (Educació en Alimentació) study: a randomized controlled trial. Trials. 2014;15:58.
Dong D, Bilger M, van Dam RM, Finkelstein EA. Consumption of specific foods and beverages and excess weight gain among children and adolescents. Health Aff. 2015;34:1940–8.
Babio N, Sorlí M, Bulló M, Basora J, Ibarrola-Jurado N, Fernández-Ballart J, et al. Association between red meat consumption and metabolic syndrome in a Mediterranean population at high cardiovascular risk: cross-sectional and 1-year follow-up assessment. Nutr Metab Cardiovasc Dis. 2012;22:200–7.
Rouhani MH, Salehi-Abargouei A, Surkan PJ, Azadbakht L. Is there a relationship between red or processed meat intake and obesity? A systematic review and meta-analysis of observational studies. Obes Rev. 2014;15:740–8.
Lu L, Xun P, Wan Y, He K, Cai W. Long-term association between dairy consumption and risk of childhood obesity: a systematic review and meta-analysis of prospective cohort studies. Eur J Clin Nutr. 2016;70:414–23.
Dougkas A, Reynolds CK, Givens ID, Elwood PC, Minihane AM. Associations between dairy consumption and body weight: A review of the evidence and underlying mechanisms. Nutr Res Rev. 2011;24:72–95.
Buckland G, Gonzalez CA. The role of olive oil in disease prevention: a focus on the recent epidemiological evidence from cohort studies and dietary intervention trials. Br J Nutr. 2015;113:S94–101.
Haro-Mora JJ, García-Escobar E, Porras N, Alcázar D, Gaztambide J, Ruíz-Órpez A, et al. Children whose diet contained olive oil had a lower likelihood of increasing their body mass index Z-score over 1 year. Eur J Endocrinol. 2011;165:435–9.
Romaguera D, Norat T, Vergnaud AC, Mouw T, May AM, Agudo A, et al. Mediterranean dietary patterns and prospective weight change in participants of the EPIC-PANACEA project. Am J Clin Nutr. 2010;92:912–21.
Grosso G, Galvano F. Mediterranean diet adherence in children and adolescents in southern European countries. NFS. NFS J. 2016;3:13–9.
We like to acknowledge Emily Felt for providing assistance with the English revision of the paper; she received compensation.
This study was funded by grants from Instituto de Salud Carlos III and the Spanish Ministry of Health (Red INMA G03/176; CB06/02/0041; FIS 97/0588; 00/0021-2; PI061756; PS0901958; FIS-FEDER 03/1615; 04/1509; 04/1112; 04/1931; 05/1079; 05/1052; 06/1213; 07/0314; 09/02647; FIS-FEDER 18/00909; FIS-PI041436; FIS-PI081151; FIS-PI06/0867; FIS-PS09/00090; FIS-PI04/2018; FIS-PI09/02311; FIS PI11/01007; FIS-PI13/02429; MS13/00054, CPII18/00018; PI12/01890; CP13/00054; PI18/00825) University of Oviedo, Conselleria de Sanitat Generalitat Valenciana, Generalitat de Catalunya-CIRIT 1999SGR 00241, Generalitat de Catalunya-AGAUR 2009 SGR 501 and 2014 SGR 822. Department of Health of the Basque Government (2005111093, 2009111069, and 201311089) the Provincial Government of Gipuzkoa (DFG06/004 and DFG08/001), annual agreements with the municipalities of the study area of Gipuzkoa (Zumarraga, Urretxu, Legazpi, Azkoitia y Azpeitia y Beasain), Fundació Marató TV3 (20162210 and 090430). ISGlobal is a member of the CERCA Programme, Generalitat de Catalunya. Spanish Ministry of Economy and Competitiveness (SAF2012-32991 incl. FEDER funds), Agence Nationale de Securite Sanitaire de l’Alimentation de l’Environnement et du Travail (1262C0010), EU Commission (261357, 308333, 603794, and 634453). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the paper; and decision to submit the paper for publication.
Conflict of interest
The authors declare that they have no conflict of interest.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Members of the INMA project researchers are listed in Supplementary File.
Rights and permissions
About this article
Cite this article
Notario-Barandiaran, L., Valera-Gran, D., Gonzalez-Palacios, S. et al. High adherence to a mediterranean diet at age 4 reduces overweight, obesity and abdominal obesity incidence in children at the age of 8. Int J Obes 44, 1906–1917 (2020). https://doi.org/10.1038/s41366-020-0557-z
This article is cited by
Children who sleep more may have longer telomeres: evidence from a longitudinal population study in Spain
Pediatric Research (2022)
The dietary inflammatory index is associated with anti- and pro-inflammatory adipokines in Brazilian schoolchildren
European Journal of Nutrition (2021)