Research Article| Volume 66, 104060, October 2022

Association of self-reported adherence to the Mediterranean diet with anthropometric indices, comorbidities, and degree of disability in patients with multiple sclerosis


      • Iranian patients with multiple sclerosis (MS) showed moderate compliance with the Mediterranean diet.
      • The score of adherence to the Mediterranean diet did not show significant relationship with varied levels of disability.
      • Low adherence to the Mediterranean diet in underweight, normal, and overweight patients was significantly higher than in obese patients.



      One of the important challenges in the treatment of patients with multiple sclerosis (MS) is determining the effective factors in the treatment of MS, including dietary adherence. The aim of this study was to investigate the relationship between adherence to the Mediterranean diet with anthropometric indices and the expanded disability status scale (EDSS) scores in patients with MS.

      Material and methods

      The present multicenter and cross-sectional study was conducted on patients with clinically definite MS (according to the 2017 revised McDonald criteria) who were referred to the MS clinics at medical centers affiliated to Shiraz and Tehran Universities of Medical Sciences during 2019. Disease phenotype, EDSS, waist circumference (WC), body mass index (BMI), and comorbidities were assessed. Adherence to the Mediterranean diet was measured with a 14-item modified Mediterranean Diet Adherence Questionnaire. In this questionnaire, a score of 0–5 indicates low adherence, a score of 6–9 shows moderate adherence, and a score of 10 and above demonstrates high adherence (healthy eating pattern).


      This study was performed on 478 patients with a mean age of 37.99 ± 9.60 years, out of which 352 patients (73.6%) were female. The percentage of low, medium, and high adherence to the Mediterranean diet in patients with MS was 26.4%, 64%, and 9.6%, respectively. The difference in the level of education between the groups based on adherence to the Mediterranean diet was statistically significant. Low adherence to the Mediterranean diet in underweight, normal, and overweight patients was, respectively, 1.31, 1.32, and 2.29 times higher than in obese patients. This increased risk was only significant in overweight patients (P = 0.019). The results revealed that the score of adherence to the Mediterranean diet had no significant relationship with mild (2.86 ± 2.18), moderate (2.76 ± 2.16), and severe (2.70 ± 2.02) levels of disability.


      The level of adherence to the Mediterranean diet in Iranian patients with MS was moderate. This level was associated with BMI, such that low adherence to the Mediterranean diet was higher in overweight patients than obese patients.


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        • Ali H.I.
        • Mohammed S.G.
        • Jafar Z.M.
        Study the resistant of probiotics bacteria in fermented dairy products for different concentrations of acidity and bile salts.
        Kufa J. Agric. Sci. 2016; 8: 274-290
        • Altowaijri G.
        • Fryman A.
        • Yadav V.
        Dietary interventions and multiple sclerosis.
        Curr. Neurol. Neurosci. Rep. 2017; 17: 28
        • Azizi F.
        • Hadaegh F.
        • Khalil D.
        • Esteghamati A.R.
        • Hosseinpanah F.
        • Delavari A.R.
        • Mirmiran P.
        • Zabetian A.
        • Mehrabi Y.
        • Kelishadi R.
        Appropriate definition of metabolic syndrome among Iranian adults: report of the Iranian National Committee of Obesity.
        Arch. Iran. Med. 2010; 13: 426-428
        • Baker K.
        • Figueroa R.
        Motivation, attitudes, and diet quality among US parents and adolescents.
        Am. J. Health Behav. 2021; 45: 125-137
        • Black L.J.
        • Baker K.
        • Ponsonby A.L.
        • Van Der Mei I.
        • Lucas R.M.
        • Pereira G.
        A higher Mediterranean diet score, including unprocessed red meat, is associated with reduced risk of central nervous system demyelination in a case-control study of Australian adults.
        J. Nutr. 2019; 149: 1385-1392
        • Bu T.
        • Tang D.
        • Liu Y.
        • Chen D.
        Trends in dietary patterns and diet-related behaviors in China.
        Am. J. Health Behav. 2021; 45: 371-383
        • Dalgas U.
        • Stenager E.
        • Ingemann-Hansen T.
        Multiple sclerosis and physical exercise: recommendations for the application of resistance-, endurance-and combined training.
        Mult. Scler. J. 2008; 14: 35-53
        • Dobson R.
        • Giovannoni G.
        Multiple sclerosis–a review.
        Eur. J. Neurol. 2019; 26: 27-40
        • Elhami S.R.
        • Mohammad K.
        • Sahraian M.A.
        • Eftekhar H.
        A 20-year incidence trend (1989–2008) and point prevalence (March 20, 2009) of multiple sclerosis in Tehran, Iran: a population-based study.
        Neuroepidemiology. 2011; 36: 141-147
        • Esposito S.
        • Sparaco M.
        • Maniscalco G.T.
        • Signoriello E.
        • Lanzillo R.
        • Russo C.
        • Carmisciano L.
        • Cepparulo S.
        • Lavorgna L.
        • Gallo A.
        Lifestyle and Mediterranean diet adherence in a cohort of Southern Italian patients with Multiple Sclerosis.
        Mult. Scler. Relat. Disord. 2021; 47102636
        • Fitzgerald K.C.
        • Tyry T.
        • Salter A.
        • Cofield S.S.
        • Cutter G.
        • Fox R.
        • Marrie R.A.
        Diet quality is associated with disability and symptom severity in multiple sclerosis.
        Neurology. 2018; 90: e1-e11
        • Galetta K.M.
        • Bhattacharyya S.
        Multiple sclerosis and autoimmune neurology of the central nervous system.
        Med. Clin. 2019; 103: 325-336
        • Gianfrancesco M.A.
        • Barcellos L.F.
        Obesity and multiple sclerosis susceptibility: a review.
        J. Neurol. Neuromed. 2016; 1: 1
        • Groves A.
        Understanding African-American women's low-sodium dietary practices: a qualitative perspective.
        Am. J. Health Behav. 2021; 45: 746-755
        • Herrán O.F.
        • Gamboa-Delgado E.M.
        Trends of adherence to dietary patterns in Colombian population, 2010-2015.
        Am. J. Health Behav. 2020; 44: 704-718
        • Jontony N.
        • Hill E.B.
        • Taylor C.A.
        • Boucher L.C.
        • O'Brien V.
        • Weiss R.
        • Spees C.K.
        Diet quality, carotenoid status, and body composition in NCAA division I athletes.
        Am. J. Health Behav. 2020; 44: 432-443
        • Keshani P.
        • Sharifi M.H.
        • Heydari M.R.
        • Joulaei H.
        The effect of genetically modified food on infertility indices: a systematic review study.
        Sci. World J. 2020; 2020
        • Kurtzke J.F.
        Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS).
        Neurology. 1983; 33: 1444
        • Mahdavi-Roshan M.
        • Salari A.
        • Soltanipour S.
        Reliability and Validity of the 14-point Mediterranean diet adherence screener among the Iranian high risk population.
        Med. J. Nutr. Metab. 2018; 11: 323-329
        • Meyer-Moock S.
        • Feng Y.S.
        • Maeurer M.
        • Dippel F.W.
        • Kohlmann T.
        Systematic literature review and validity evaluation of the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC) in patients with multiple sclerosis.
        BMC Neurol. 2014; 14: 1-10
        • Milo R.
        • Kahana E.
        Multiple sclerosis: geoepidemiology, genetics and the environment.
        Autoimmun. Rev. 2010; 9: A387-A394
        • Nathan J.
        • Kale D.K.
        • Naik V.D.
        • Thakker F.
        • Bailur S.
        Dietary therapy in secondary progressive multiple sclerosis: a case report.
        Cureus. 2019; 11
        • Nirooei E.
        • Kashani S.M.A.
        • Owrangi S.
        • Malekpour F.
        • Niknam M.
        • Moazzen F.
        • Nowrouzi-Sohrabi P.
        • Farzinmehr S.
        • Akbari H.
        Blood trace element status in multiple sclerosis: a systematic review and meta-analysis.
        Biol. Trace Elem. Res. 2021; 200: 13-26
        • Olsson T.
        • Barcellos L.F.
        • Alfredsson L.
        Interactions between genetic, lifestyle and environmental risk factors for multiple sclerosis.
        Nat. Rev. Neurol. 2017; 13: 25-36
        • Owji M.
        • Ashraf-Ganjouei A.
        • Sahraian M.A.
        • Bidadian M.
        • Ghadiri F.
        • Moghadasi A.N.
        The relationship between cognitive function and body mass index in multiple sclerosis patients.
        Mult. Scler. Relat. Disord. 2019; 32: 37-40
        • Pinhas-Hamiel O.
        • Livne M.
        • Harari G.
        • Achiron A.
        Prevalence of overweight, obesity and metabolic syndrome components in multiple sclerosis patients with significant disability.
        Eur. J. Neurol. 2015; 22: 1275-1279
        • Rasul T.
        • Frederiksen J.L.
        Link between overweight/obese in children and youngsters and occurrence of multiple sclerosis.
        J. Neurol. 2018; 265: 2755-2763
        • Sanchez J.M.S.
        • DePaula-Silva A.B.
        • Libbey J.E.
        • Fujinami R.S.
        Role of diet in regulating the gut microbiota and multiple sclerosis.
        Clin. Immunol. 2020; 108379
        • Sand I.K.
        The role of diet in multiple sclerosis: mechanistic connections and current evidence.
        Curr. Nutr. Rep. 2018; 7: 150-160
        • Sand I.K.
        • Benn E.K.T.
        • Fabian M.
        • Fitzgerald K.C.
        • Digga E.
        • Deshpande R.
        • Miller A.
        • Gallo S.
        • Arab L.
        Randomized-controlled trial of a modified Mediterranean dietary program for multiple sclerosis: a pilot study.
        Mult. Scler. Relat. Disord. 2019; 36101403
        • Sarihi S.
        • Niknam M.
        • Mahjour S.
        • Hosseini-Bensenjan M.
        • Moazzen F.
        • Soltanabadi S.
        • Akbari H.
        Toxic heavy metal concentrations in multiple sclerosis patients: a systematic review and meta-analysis.
        EXCLI J. 2021; 20: 1571
        • Saura-Calixto F.
        • Goni I.
        Definition of the Mediterranean diet based on bioactive compounds.
        Crit. Rev. Food Sci. Nutr. 2009; 49: 145-152
        • Schreiner T.G.
        • Genes T.M.
        Obesity and multiple sclerosis-a multifaceted association.
        J. Clin. Med. 2021; 10: 2689
        • Sedaghat F.
        • Jessri M.
        • Behrooz M.
        • Mirghotbi M.
        • Rashidkhani B.
        Mediterranean diet adherence and risk of multiple sclerosis: a case-control study.
        Asia Pac. J. Clin. Nutr. 2016; 25: 377-384
        • Stampanoni Bassi M.
        • Iezzi E.
        • Buttari F.
        • Gilio L.
        • Simonelli I.
        • Carbone F.
        • Micillo T.
        • De Rosa V.
        • Sica F.
        • Furlan R.
        Obesity worsens central inflammation and disability in multiple sclerosis.
        Mult. Scler. J. 2020; 26: 1237-1246
        • Thompson A.J.
        • Banwell B.L.
        • Barkhof F.
        • Carroll W.M.
        • Coetzee T.
        • Comi G.
        • Correale J.
        • Fazekas F.
        • Filippi M.
        • Freedman M.S.
        Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria.
        Lancet Neurol. 2018; 17: 162-173
        • Tobore T.O.
        Oxidative/nitroxidative stress and multiple sclerosis.
        J. Mol. Neurosci. 2021; 71: 506-514
        • Trajkovska Petkoska A.
        • Trajkovska-Broach A.
        Mediterranean diet: a nutrient-packed diet and a healthy lifestyle for a sustainable world.
        J. Sci. Food Agric. 2021; 101: 2627-2633
        • Trichopoulou A.
        • Vasilopoulou E.
        Mediterranean diet and longevity.
        Br. J. Nutr. 2000; 84: S205-S209