Association between adherence to the Mediterranean diet and the prevalence of cardiovascular risk factors

Objective: to determine the prevalence of cardiovascular risk factors in a cohort of workers and to quantify its association with compliance with the Mediterranean diet follow-up. Method: a cross-sectional descriptive study was carried out on a cohort of 23,729 workers. Clinical data from annual medical examinations and the Mediterranean Diet Adherence Screener were used to assess adherence to the Mediterranean diet. Results: 51.3% of the participants showed good adherence to the Mediterranean diet. The multivariate analysis showed an inverse and significant association between the follow-up of the Mediterranean diet and the prevalence of abdominal obesity (Odds Ratio = 0.64, 95% CI 0.56; 0.73), dyslipidemia (Odds Ratio = 0.55, 95% CI 0.42; 0.73), and metabolic syndrome (Odds Ratio = 0.76, 95% CI 0.67; 0.86). Conclusions: our results suggest that the Mediterranean diet is potentially effective in promoting cardiovascular health. Implementing the interventions promoting the Mediterranean diet in the working population seems justified.


Introduction
Cardiovascular (CV) diseases represent the leading cause of death worldwide. Every year more than 17 million people die from this cause, which represents more than 30% of the total deaths registered (1) . In Spain, these diseases rank third in terms of potential years of life lost, only behind tumors and external causes (2) . From the epidemiological point of view, it is estimated that the action of factors traditionally linked to them may lead to a significant reduction in morbidity and mortality (3)(4) . In particular, it is considered that diet may be the behavioral factor with the greatest impact in minimizing CV risk (5) .
Among the dietary patterns that reduce CV morbidity and mortality, the Mediterranean diet (MedDi) has been pointed out. This diet is based on a generous intake of fruits, vegetables, complex carbohydrates or monounsaturated fats and, on the contrary, a low intake of animal fats and sugars. Its preventive mechanism would be supported by its positive influence on blood pressure, body weight, glycemic control, vascular inflammation or arteriosclerosis, among others (6) .
Several studies have analyzed the prevalence of CV risk factors in the Spanish population (7)(8)(9) . However, these  (10) . Based on these deficiencies, the objectives of this investigation were to determine the prevalence of CV risk factors in a cohort of workers from Aragon (Spain) and to quantify its association with the MedDi follow-up.

Method
A cross-sectional descriptive study was carried out.  (11) was considered as risky alcohol consumption.
All the participants who did not comply with any of the activity recommendations described by the World Health Organization (WHO) for people aged 18 to 64 years old were considered inactive/sedentary (12) .
The Mediterranean Diet Adherence Screener (MEDAS-14) was used to assess the degree of adherence to the MedDi. This is a specific questionnaire of fourteen items validated in the general population (13) . To obtain your score, the value +1 is assigned to each item with a positive connotation with respect to the MedDi.
The degree of adherence is determined from the sum of the obtained values, establishing two levels: Acceptable MedDi adherence (score ≥9), and low adherence (<9). perimeter (central/abdominal obesity) was considered when the measurements were ≥88 cm in women and ≥102 cm in men (14) .
For the blood test, the participant must have respected a night fast of, at least, 10 hours. The samples were sent to the entity's laboratory (accredited by the National Accreditation Entity). All the participants with baseline blood glucose ≥126 mg/dl (or under antidiabetic treatment) were classified as diabetic, and those who reported being under pharmacological treatment for lipid alterations or met any of the diagnostic criteria of the Spanish Society of Arteriosclerosis were considered as dyslipidemic (15) . Finally and based on international consensus criteria (16) , the existence of metabolic syndrome was evaluated.
The descriptive analysis of the characteristics of the sample was carried out using the mean and standard deviation for the quantitative variables and the number and percentage for the qualitative ones.
The comparison by sex of these characteristics was performed using the Student's t-test on the quantitative variables and the Chi-square for the qualitative ones.  (17)(18)(19)(20) . All the calculations were performed with the SPSS Version 21.0 software, accepting the significance level of α≤0.05.

Results
The There were no significant differences between the sex in the prevalence of diabetes (Table 1).     (Table 3).

Discussion
The results of this research show a working population with a high prevalence of CV risk factors.
However, the figures obtained are below the bulk of those reported in other Spanish population-based studies (2,(7)(8)(9)17) . This difference may be related to the location of the different studies. The sample of this study lies in the northeast of Spain, far from the southern area of the country where higher prevalences of CV risk factors have traditionally been reported and, in general, a worse socioeconomic situation (21) . In any case, this comparison and its interpretation should be taken with caution, due to the differences in the baseline characteristics of the smoking and diabetes were reported, respectively (22) .
As for our participants, 51.3% reported acceptable adherence to the MedDi. At this point, the results of previous studies are very heterogeneous, with adherence ranges between 14% and 58.3% (23)(24)(25)(26)(27)(28) . The relatively privileged situation of this sample compared to that of previous studies could be due to the intense Worker Health Promotion strategy implemented by MAS-Prevención in the last 5 years. This strategy, fundamentally implemented by the institution's work nurses, is based on a powerful educational commitment to healthy lifestyles.
In any case, the comparison of the results of this study with the previous bibliography is complex given the differences in the populations analyzed and the use of different questionnaires to assess adherence to the MedDi. In this sense, a recent review study (29) identifies up to 28 screening tools for MedDi adherence and defends the need to develop a questionnaire with greater conceptual and methodological rigor.
The participants in this study evidenced a significant and inverse association between MedDi adherence and the prevalence of abdominal obesity, dyslipidemia, and metabolic syndrome. In the previous literature on the theme, a great variability was observed in the results in relation to this association. In order to clarify these divergences, several secondary studies have been carried out in recent years. In a Cochrane meta-analysis (30) of the MedDi-based intervention studies, significant  In 2016, a meta-analysis of studies based on MedDibased interventions also revealed inverse and significant associations between this dietary pattern and the levels of triglycerides, glycaemia, blood pressure, and abdominal circumference (31) . Finally, in a meta-analysis of observational studies from 2017, a lower probability of suffering central obesity, hypertension and metabolic syndrome was deduced in people with good adherence to the MedDi (32) .
This study presents several limitations that may and health programs.

Conclusion
The results of this study show an active population subjected to a high exposure to CV risk factors. This circumstance suggests that the incidence of CV morbidity and mortality will progressively increase in the population. In addition, the low adherence to the MedDi of the working population of Aragon and the inverse association observed between their follow-up and the prevalence of CV risk factors are noteworthy. Under this prism it seems necessary to implement new social and health policies aimed at promoting a balanced eating pattern such as the MedDi. In this sense, occupational nurses, health surveillance professionals with close proximity and ancestry over the workers, must remain natural leaders.