Exploring the Perceived Barriers to Following a Mediterranean Style Diet in Childbearing Age: A Qualitative Study

Mediterranean Dietary Pattern for Healthy and Active Aging: A Narrative Review of an Integrative and Sustainable Approach

The global population is on a trajectory of continuous growth, with estimates projecting an increase from 7.7 billion in 2019 to approximately 9.7 billion by 2050. Longevity is also expected to rise rapidly, with advancements in healthcare contributing to increased life expectancies and an increase in the maximum lifespan. The aging process is accompanied by different changes, often leading to a decline in daily life activities and an increased susceptibility to disease. Age-related changes can cause cellular damage and subsequent cellular death. Oxidative stress and inflammation play significant roles in this process contributing to molecular damage and mitochondrial dysfunction. Active aging has been associated with improved quality of life and a reduced risk of morbidity and premature mortality. In this context, the Mediterranean diet has emerged as a promising approach to promoting healthy aging and sustainability. The phytochemical compounds within the Mediterranean diet have been linked to a lower risk of developing cardiovascular disease, type 2 diabetes, obesity, cancer and neurodegenerative diseases. The findings of peer-reviewed articles regarding the use of the Mediterranean diet as a healthy and sustainable dietary pattern written in Portuguese, Spanish or English were included in this narrative literature review. This dietary pattern's emphasis on the consumption of fresh and local food aligns with both health and environmental sustainability goals. This work provides a comprehensive review of the benefits of the Mediterranean diet and its components in a healthy aging process and highlights the importance of this dietary pattern as a sustainable approach.

Adherence and barriers to Mediterranean diet in Tunisian patients with nonalcoholic fatty liver disease

Aim: The burden of non alcoolic fatty liver disease (NAFLD) is globally increasing. While crucial for management, NAFLD patient adherence to the Mediterranean diet (MD) is underexplored, especially in Mediterranean countries such as Tunisia. Materials & methods: A prospective study (Nov 2022-Feb 2023) supervised MD introduction by a nutritionist, evaluated adherence with MEDAS scores (≥10 for good compliance), and explored barriers to good adherence. Results: Among 41 patients (11 male/30 female, mean age 56 [29-70]), 63% had low education and 51% had metabolic syndrome. Good MD adherence stood at 14.6%. Poor adherence tied to diet-induced higher costs (p = 0.021) and difficulty to new-diet adoption (p = 0.026). Conclusion: Tunisian NAFLD patients had low MD adherence due to financial constraints and dietary adaptation challenges.

The feasibility of an anti-inflammatory diet in endometriosis: barriers and facilitators perceived by endometriosis patients

RESEARCH QUESTION

What is the feasibility of an anti-inflammatory diet in women diagnosed with endometriosis?

DESIGN

Qualitative study using semi-structured focus groups and individual interviews among patients with endometriosis. Transcripts of the focus groups and interviews were thematically analysed using ATLAS.ti 9. To identify and structure the ideas and views from the focus groups and interviews, two behavioural change models were used. The Capability Opportunity Motivation Behaviour (COM-B) model and domains of the Theoretical Domains Framework (TDF) helped to identify factors that make adherence to an anti-inflammatory diet more or less feasible for women with endometriosis.

RESULTS

The study population consisted of 23 patients with endometriosis. Numerous perceived barriers and facilitators were identified from all COM-B components and 13 out of 15 TDF domains. Knowledge and social influences were the most prominent TDF domains. Key barriers were eating with others; disbelief in a patients' own capability regarding specific dietary guidelines; concerns about taste; lack of knowledge on how to follow the diet; lack of noticeable beneficial effect; and lack of intention to follow the diet to full extent. Key facilitators were receiving social support; general confidence in a participant's own capabilities; knowing how and why to follow the diet; noticing beneficial effect; and belief that the diet would alleviate symptoms.

CONCLUSION

Provision of knowledge, stimulating social support and enhancing self-efficacy should be emphasized. Overall, an anti-inflammatory diet in endometriosis patients, especially when identified barriers and facilitators are addressed in an intervention, is feasible.

Preconception knowledge, beliefs and behaviours among people of reproductive age: A systematic review of qualitative studies

BACKGROUND

The health of parents before pregnancy influences the short- and long-term health of their offspring. This systematic review explored the preconception knowledge, beliefs and behaviours held by women and men of childbearing age.

METHODS

Databases were searched from 2009 to 2022 (MEDLINE, CINAHL Full-text, PsycINFO, EMBASE). Inclusion criteria specified qualitative research papers which recruited individuals of reproductive age (16-45 years) without existing chronic illnesses. Data were quality assessed and analysed using thematic synthesis.

RESULTS

Twelve papers met inclusion criteria. Six themes were identified (cultural context, pregnancy planning, knowledge, gender roles and responsibility, information seeking, prior health behaviours) which relate to individual, social, psychological and cultural factors. Cultural context was related to all other themes. Pregnancy planners had greater motivation to optimise their health whereas those not actively planning were focused more on becoming financially stable. Women and men's knowledge of how and why to engage in health protective behaviours was limited, with health risks and behaviour change discussed in the context of pregnancy rather than preconception. Gender roles influenced individual responsibility for preparation for pregnancy, which in turn influenced information seeking behaviours and engagement in health behaviours. Online sources of support and information were seen as desirable, regardless of pregnancy planning stage.

CONCLUSIONS

Our findings indicate that behaviour change interventions designed to support people to optimise health before conception should address cultural, individual, social and psychological factors to facilitate behaviour change. Development of online resources may help to increase accessibility for people across different cultural contexts and stages of pregnancy planning.

A peer support dietary change intervention for encouraging adoption and maintenance of the Mediterranean diet in a non-Mediterranean population (TEAM-MED): lessons learned and suggested improvements

Peer support interventions for dietary change may offer cost-effective alternatives to interventions led by health professionals. This process evaluation of a trial to encourage the adoption and maintenance of a Mediterranean diet in a Northern European population at high CVD risk (TEAM-MED) aimed to investigate the feasibility of implementing a group-based peer support intervention for dietary change, positive elements of the intervention and aspects that could be improved. Data on training and support for the peer supporters; intervention fidelity and acceptability; acceptability of data collection processes for the trial and reasons for withdrawal from the trial were considered. Data were collected from observations, questionnaires and interviews, with both peer supporters and trial participants. Peer supporters were recruited and trained to result in successful implementation of the intervention; all intended sessions were run, with the majority of elements included. Peer supporters were complimentary of the training, and positive comments from participants centred around the peer supporters, the intervention materials and the supportive nature of the group sessions. Attendance at the group sessions, however, waned over the intervention, with suggested effects on intervention engagement, enthusiasm and group cohesion. Reduced attendance was reportedly a result of meeting (in)frequency and organisational concerns, but increased social activities and group-based activities may also increase engagement, group cohesion and attendance. The peer support intervention was successfully implemented and tested, but improvements can be suggested and may enhance the successful nature of these types of interventions. Some consideration of personal preferences may also improve outcomes.

Mid- and long-term changes in satiety-related hormones, lipid and glucose metabolism, and inflammation after a Mediterranean diet intervention with the goal of losing weight: A randomized, clinical trial

Background

Obesity is produced by the enlargement of the adipose tissue. Functioning as an endocrine organ, it releases and receives information through a complex network of cytokines, hormones, and substrates contributing to a low-chronic inflammation environment. Diet and healthy habits play key roles in the prevention of obesity and its related pathologies. In this regard, there is a need to switch to healthier and more appetizing diets, such as the Mediterranean one.

Objective

To compare the mid-and long-term effects of two Mediterranean diet (MedDiet) interventions, one energy-reduced plus physical activity promotion versus a non-restrictive diet, on peripheral satiety-related hormones, weight loss, glucose/lipid metabolism, and pro-inflammatory markers in subjects with obesity/overweight and metabolic syndrome.

Materials and methods

A randomized, lifestyle intervention was conducted in 23 Spanish centers, with a large cohort of patients presenting metabolic syndrome. Our study is a subproject set in IMIM (Hospital del Mar Research Institute). Participants were men and women, aged 55–75 and 60–75, respectively, who at baseline met at least three metabolic syndrome components. Subjects were assigned to two intervention groups: (1) an intensive lifestyle intervention with an energy-reduced MedDiet and physical activity promotion (intervention group) with the aim of weight loss; and (2) a normocaloric MedDiet (control). We quantified in a subsample of 300 volunteers from Hospital del Mar Research Institute (Barcelona), following analytes at baseline, 6 months, and 1 year: glucose, HbA1c, triglycerides, total cholesterol, high-density lipoprotein cholesterol, LDL cholesterol, C-peptide, ghrelin, GLP-1, glucagon, insulin, leptin, PAI-1, resistin, and visfatin. Anthropometric and classical cardiovascular risk factors were also determined. A multivariate statistical model was employed to compare the two groups. Linear mixed-effect models were performed to compare changes in risk factors and biomarkers between intervention groups and over time.

Results

Compared to participants in the control group, those in intervention one showed greater improvements in weight, waist circumference, insulin (P < 0.001), glucose metabolism-related compounds (P < 0.05), triglyceride-related lipid profile (P < 0.05), leptin, blood pressure, and pro-inflammatory markers such as PAI-1 (P < 0.001) at mid-and/or long-term. High-sensitivity C-reactive protein, resistin, and vifastin also decreased in both groups.

Conclusion

A weight loss intervention employing a hypocaloric MedDiet and physical activity promotion has beneficial effects on adiposity, glucose metabolism, lipid profile, leptin, and pro-inflammatory markers, such as PAI-1 in both mid-and long-term.

Barriers and Facilitators Associated with the Adoption of and Adherence to a Mediterranean Style Diet in Adults: A Systematic Review of Published Observational and Qualitative Studies

The Mediterranean diet (MedDiet) has been linked with physical and mental health benefits. Previous research, however, suggests that adoption and adherence to a Mediterranean diet might be difficult for people who live outside of the Mediterranean region. The aim of this systematic review was to investigate the factors that influence adoption and adherence to a Mediterranean style diet in adults aged 18 years old and over, as identified in published observational and qualitative studies. Following registration of our protocol on PROSPERO (ID: CRD42018116515), observational and qualitative studies of adults' perceptions and experiences relevant to following a Mediterranean style diet were identified using systematic searches of databases: MEDLINE, the Cochane Library, CINAHL, Web of Science and Scopus, over all years of records until February 2022. A narrative synthesis was then undertaken. Of 4559 retrieved articles, 18 studies fulfilled our inclusion criteria and were included. Factors influencing adoption and adherence to a MedDiet were identified and categorized as: financial, cognitive, socio-cultural, motivational, lifestyle, accessibility & availability, sensory & hedonic and demographic. Similar barriers and facilitators are often reported in relation to healthy eating or the consumption of specific healthy foods, with a few exceptions. These exceptions detailed concerns with specific components of the MedDiet; considerations due to culture and traditions, and concerns over a cooler climate. Suggestions for overcoming these barriers and facilitators specific to adoption and adherence to the Mediterranean diet are offered. These data will inform the development of future studies of robust methodology in eating behaviour change which offer pragmatic approaches for people to consume and maintain healthy diets.

Adherence to the Mediterranean diet and its association with environmental footprints among women of childbearing age in the United Arab Emirates

PURPOSE

To examine the association of adherence to the Mediterranean Diet (MD) with Environmental Footprints (EFPs) among women of childbearing age in the United Arab Emirates (UAE).

METHODS

Data belonging to a nationally representative sample of 482 women (19-50 years) were derived from a previous survey in the UAE. In face-to-face interviews, participants completed questionnaires addressing sociodemographic, physical activity, and dietary intake characteristics; the latter assessed using a multiple pass 24-h recall. The composite Mediterranean (c-MED) index was used to examine the adherence to the MD. Metrics for the EFPs (water use, energy use, and GHG emissions) were calculated using Life Cycle Analyses. Descriptive statistics and linear regressions were used in data analysis.

RESULTS

In the study sample, the distribution of the c-MED scores was skewed to the right, indicating a low adherence to the MD. The lowest contributions to the total c-MED score were observed for legumes (2.9%) and olive oil (1.8%). The EFPs associated with food consumption per 1000 kcal were: water use: 1256.89 ± 544.95 L/day; energy use: 18.01 ± 7.85 MJ/day, and GHG: 2.46 ± 1.46 kg CO_{2 eq}/day. After adjustment for age, energy intake, and potential confounders, being adherent to the MD was associated with 540.57 [95% CI (- 726.6; - 354.54)] units decrease in water use and 0.94 units decrease in GHG emissions [95% CI (- 1.45; - 0.43)].

CONCLUSIONS

The findings of this study revealed an inverse association between adherence to the MD and EFPs. As such, the MD may represent a promising dietary strategy to improve health outcomes and reduce the environmental impact. Public health programs addressing the low adherence to the MD among women of childbearing age in the UAE are warranted.

Effectiveness and Usability of Digital Tools to Support Dietary Self-Management of Gestational Diabetes Mellitus: A Systematic Review

Advice on dietary intake is an essential first line intervention for the management of gestational diabetes mellitus (GDM). Digital tools such as web-based and smartphone apps have been suggested to provide a novel way of providing information on diet for optimal glucose regulation in women with GDM. This systematic review explores the effectiveness and usability of digital tools designed to support dietary self-management of GDM. A systematic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Scopus using key search terms identified 1476 papers reporting research studies, of which 16 met the specified inclusion criteria. The quality of the included studies was assessed using the ErasmusAGE Quality Score or the Mixed Methods Appraisal Tool (MMAT) version 2018. The findings show that the adoption of digital tools may be an effective approach to support self-management relating to healthy diet, health behaviour, and adherence to therapy in women with GDM as a usable intervention. However, there is a lack of evidence concerning the effectiveness of tools to support the dietary management of GDM. Consideration for ethnic specific dietary advice and evidence-based frameworks in the development of effective digital tools for dietary management of GDM should be considered as these aspects have been limited in the studies reviewed.

Comparison of barriers and facilitators of MIND diet uptake among adults from Northern Ireland and Italy

Background

The aim of the study was to identify and compare components of the COM-B (capability, opportunity, motivation and behaviour) model, that influences behaviour to modify dietary patterns in 40–55-year olds living in Northern Ireland (NI) and Italy, in order to reduce the risk of cognitive decline in later life.

Methods

This was a qualitative study examining factors influencing Mediterranean-DASH (Dietary Approaches to Stop Hypertension) Intervention for Neurodegenerative Delay (MIND) diet behaviour. This study further elaborated the COM-B components into the 14 domains of the Theoretical Domains Framework to further understand behaviour. Twenty-five Northern Irish and Italian participants were recruited onto the study, to take part in either a focus group or an interview. Participants were both male and female aged between 40 and 55 years.

Results

Thematic analysis revealed that the main barriers to the uptake of the MIND diet were; time, work environment (opportunity), taste preference and convenience (motivation). Culture (motivation), seasonal foods and lack of family support (opportunity) to be a barrier to the Italian sample only. The main facilitators reported were; improved health, memory, planning and organisation (motivation) and access to good quality food (opportunity). Cooking skills, knowledge (capability) and heathy work lunch (opportunity) reported as a facilitator to the Italian sample only.

Conclusions

Cross-cultural differences in relation to psychosocial barriers and facilitators were found in both samples. More barriers than facilitators towards uptake of the MIND diet were found. There is a need for interventions that increase capability, opportunity, and motivation to aid behaviour change. The findings from this study will be used to design a behaviour change intervention using the subsequent steps from the Behaviour Change Wheel.

Understanding the Self-Perceived Barriers and Enablers toward Adopting a Mediterranean Diet in Australia: An Application of the Theory of Planned Behaviour Framework

The transferability of a Mediterranean diet (MedDiet) in non-Mediterranean populations is appealing. However, little is known about the perceived enablers or barriers toward adherence, particularly in Australia. This study aimed to investigate the perceived beliefs, barriers, and enablers toward adherence to a MedDiet in Australian adults. Barriers and enablers were assessed using a self-administered online questionnaire, which included questions aligned with the Theory of Planned Behaviour (TPB). The survey was completed by n = 606 participants. Barriers and enablers toward adherence to MedDiet were grouped under the three core constructs of the TPB: attitudes (suitability, taste, restrictive, food waste); social norms (food culture); and perceived behavioural control (PBC) (motivation, affordability, time/effort, food access, knowledge, food outlets, natural conditions, cooking skills). PBC emerged as the most prominent construct influencing intention to follow a MedDiet. Perceived health benefits (n = 445; 76.5%) and improved diet quality (n = 224; 38.5%) were identified as major advantages. In contrast, dietary adherence (n = 147; 39.7%) was perceived as an important disadvantage. Future MedDiet interventions, in both research and clinical settings, should consider adopting strategies aimed at improving self-efficacy to reduce self-perceived barriers and facilitate dietary adherence.

Creating Healthy Change in the Preconception Period for Women with Overweight or Obesity: A Qualitative Study Using the Information-Motivation-Behavioural Skills Model

Worldwide, half of women begin a pregnancy with overweight or obesity, which increases the risk of pregnancy and birth complications and adversely affects the lifelong health of the offspring. In order for metabolic changes to influence the gestational environment, research suggests that weight loss should take place before conception. This study aimed to understand women’s emotional and social contexts, knowledge, motivations, skills and self-efficacy in making healthy change. Semi-structured interviews conducted with twenty-three women with overweight or obesity, informed by the Information–Motivation–Behavioural Skills (IMB) model, were analysed using reflexive thematic analysis. Information-related themes identified included poor health risk knowledge, healthy food decisions and health versus convenience. The Motivation themes comprised taking responsibility, flexible options, social expectations, interpersonal challenges and accountability. Behavioural Skills entailed themes such as the mental battle, time management, self-care and inspiration. An environmental factor was identified in affordability—limiting access to healthier alternatives. Women wanted simple, flexible options that considered family commitments, time and budgetary constraints. Unprompted, several mentioned the importance of psychological support in managing setbacks, stress and maintaining motivation. Strategies for enhancing self-efficacy and motivational support are required to enable longstanding health behaviour change. Findings will inform intervention mapping development of an eHealth solution for women preconception.

Barriers to and facilitators for addressing overweight and obesity before conception: A qualitative study

BACKGROUND

Obesity is a significant global health issue, especially for reproductive-aged women. Women who enter pregnancy overweight or obese are at increased risk of a range of adverse reproductive, maternal, and child health outcomes. The preconception period has been recognised as a critical time to intervene to improve health outcomes for women and their children. Despite this recognition, adequate information is significantly lacking in relation to women's health experiences, behaviours, and information preferences to inform the development of high-quality preconception intervention strategies.

AIM

This study aimed to examine women's perspectives of barriers, enablers, and strategies for addressing overweight and obesity before conception.

METHOD

Using a qualitative research design, twelve multiparous women, aged between 32 and 43 years, who considered themselves to be overweight or obese were interviewed. Data were analysed using thematic analysis.

FINDINGS

Three themes were identified in relation to barriers: lack of information and knowledge, time constraints, and affordability. The following four themes emerged with respect to enablers and strategies: knowledge provision, accountability and motivation, regular contact, and habit formation.

CONCLUSION

Key factors to incorporate in women-centred interventions for preconception weight loss include multi-faceted knowledge provision and practical affordable methods for supporting healthy behaviours. Interventions should integrate techniques for ensuring regular contact with support networks, to enhance accountability, motivation, and facilitate habit formation. Further research is now being conducted by our team to co-design interventions and strategies informed by these findings.

A Priori and a Posteriori Dietary Patterns in Women of Childbearing Age in the UK

Poor diet quality is a major cause of maternal obesity. We aimed to investigate a priori and a-posteriori derived dietary patterns in childbearing-aged women in UK. An online survey assessed food intake, physical activity (PA), anthropometry and socio-demographics. An a priori defined diet quality was determined via Mediterranean diet (MD) adherence score and Exploratory Factor Analysis (EFA) derived dietary patterns (DPs). Multiple linear regression explored associations between DPs with anthropometric measures, PA and socio-demographics. Participants (n = 123) had low-to-medium MD adherence (average MD-score: 4.0 (2.0)). Age was positively associated with higher MD adherence (X2 (2) = 13.14, p = 0.01). EFA revealed three DPs: 'fruits, nuts, vegetables and legumes' ("Vegetarian-style" DP); 'sweets, cereals, dairy products and potatoes' ("Dairy, sweets and starchy foods" DP); and 'eggs, seafood and meats' ("Protein-rich" DP). "Vegetarian-style" DP was positively associated with higher maternal educational level (p < 0.01) and PA (p = 0.01), but negatively with white ethnicity (p < 0.01). "Dairy, sweets and starchy foods" DP was positively associated with white ethnicity (p = 0.03) and negatively with age (p = 0.03). "Protein-rich" DP was positively associated with age (p < 0.001) and negatively with PA (p = 0.01). A poor diet quality was found among childbearing-aged women; notably in the younger age category, those of white ethnicity, that were more physically inactive and with a lower socioeconomic background.

Perceived stress and diet quality in women of reproductive age: a systematic review and meta-analysis

BACKGROUND

Poor diet quality is associated with obesity-related morbidity and mortality. Psychological stress can increase unhealthy dietary choices, but evidence pertinent to women of reproductive age remains unclear. This paper systematically reviewed the literature to determine the association between psychological stress and diet quality in women of reproductive age.

METHODS

Medline, CINAHL, Scopus, Cochrane Library, Web of Science, and Sciencedirect were searched. Data extraction was determined by the PEO. Inclusion criteria consisted of: English language, stress (exposure) measured in combination with diet quality (outcome), healthy women of reproductive age (18-49 years old (population)). Observational studies, due to the nature of the PEO, were included. Quality assessment used the Risk of Bias in Non-randomised Studies from the Cochrane Handbook of Systematic Reviews of Interventions. Meta-analysis was conducted using random-effect model to estimate the Fisher's z transformed correlation between stress and diet quality with 95% confidence interval (CI).

RESULTS

From 139,552 hits, 471 papers were screened; 24 studies met the inclusion criteria and were conducted in different countries: 8 studies on diet quality and 16 on food intake and frequency of consumption. Studies of diet quality consisted of six cross-sectional and two longitudinal designs with a total of 3982 participants. Diet quality was measured with diverse indices; Alternate Healthy Eating Index (n = 2), Healthy Eating Index (n = 2), Dietary Approach to Stop Hypertension (DASH) Diet Index (n = 2), Dietary Quality Index- Pregnancy (n = 2), and Dietary Guideline Adherence Index (n = 1). Most studies used Cohen's perceived stress scale and no study measured biological stress response. After sensitivity analysis, only 5 studies (3471 participants) were included in the meta-analysis. Meta-analysis revealed a significant negative association between stress and diet quality with substantial heterogeneity between studies (r = - 0.35, 95% CI [- 0.56; - 0.15], p value < 0.001, Cochran Q test P < 0.0001, I2 = 93%). The 16 studies of food intake and frequency of consumption were very heterogeneous in the outcome measure and were not included in the meta-analysis. These studies showed that stress was significantly associated with unhealthy dietary patterns (high in fat, sweets, salt, and fast food and low in fruits, vegetables, fish, and unsaturated fats).

CONCLUSION

Future studies that explore diet quality/patterns should include both diet indices and factor analysis and measure biological markers of stress and dietary patterns simultaneously.

Using the COM-B model to identify barriers and facilitators towards adoption of a diet associated with cognitive function (MIND diet)

OBJECTIVE

The aim of the study was to identify components of the COM-B (capability, opportunity, motivation and behaviour) model that influences behaviour to modify dietary patterns in 40-55-year-olds living in the UK, in order to influence the risk of cognitive decline in later life.

DESIGN

This is a qualitative study using the COM-B model and theoretical domains framework (TDF) to explore beliefs to adopting the Mediterranean-DASH Intervention for Neurodegenerative delay (MIND) diet.

SETTING

Northern Ireland.

PARTICIPANTS

Twenty-five participants were recruited onto the study to take part in either a focus group or an interview. Participants were men and women aged between 40 and 55 years. Participants were recruited via email, Facebook and face to face.

RESULTS

Content analysis revealed that the main perceived barriers to the adoption of the MIND diet were time, work environment, taste preference and convenience. The main perceived facilitators reported were improved health, memory, planning and organisation, and access to good quality food.

CONCLUSIONS

This study provides insight into the personal, social and environmental factors that participants report as barriers and facilitators to the adoption of the MIND diet among middle-aged adults living in the UK. More barriers to healthy dietary change were found than facilitators. Future interventions that increase capability, opportunity and motivation may be beneficial. The results from this study will be used to design a behaviour change intervention using the subsequent steps from the Behaviour Change Wheel.