INTRODUCTION {#S5}
============

A dramatic increase in obesity in the United States has occurred over the past twenty years.^[@R1]^ In 2009--2010, 32% (95% CI: 29%--36%) of reproductive aged US women (20--39 y) were obese (body mass index \[BMI\]≥30kg/m^2^).^[@R2]^ Obesity among women of reproductive age carries its toll with the increased risks of infertility, pregnancy complications as well as adverse offspring outcomes.^[@R3];[@R4]^

Dietary intake plays a pivotal role in the rising obesity rates. In particular, examination of dietary patterns, rather than individual nutrients or foods, can capture interactions between separate dietary components.^[@R5]^ One dietary pattern that has been explored in studying obesity is the Mediterranean diet (MD). The traditional MD reflects food patterns found in Greece and Southern Italy in the early 1960s, and is characterized by an abundant intake of plant foods (vegetables, legumes, fruits, nuts, cereals) with olive oil as the main source of fat, a high to moderate intake of fish, a low to moderate consumption of eggs, dairy products (mainly cheese and yogurt) and poultry, a low intake of red meat, and a regular but moderate intake of alcohol (mainly wine during meals).^[@R6];[@R7]^

Previous studies examining the association between the MD and obesity have mainly assessed BMI and/or waist circumference, as surrogate measures of total and regional adiposity.^[@R8]^ Associations between the MD pattern and measured body fat, including regional adiposity however, have not been previously investigated among women of reproductive age. Regional adiposity, independent of overall obesity, is a well-recognized risk factor for cardiovascular disease, type 2 diabetes, gestational diabetes and mortality.^[@R9];[@R10]^ We thus examined the association between the MD, total and regional adiposity by dual-energy X-ray absorptiometry (DXA) and replicated previous findings of the associations between the MD and anthropometry measures using data from healthy premenopausal women participating in the BioCycle Study.

MATERIALS AND METHODS {#S6}
=====================

Study Participants {#S7}
------------------

The BioCycle Study was originally designed to study the association between endogenous sex hormones and oxidative stress.^[@R11]^ Between 2005 and 2006, 259 healthy premenopausal women 18--44 years of age from western New York were followed for 1 (n=9) or 2 (n=250) menstrual cycles and attended up to eight clinic visits per cycle (93.4% with 7--8 visits in cycle 1, 95.6% with 7--8 visits in cycle 2). The visits corresponded to specific menstrual cycle time points with the most hormonal variation, approximately days 2, 7, 12, 13, 14, 18, 22 and 27 of a 28-day cycle adjusted for cycle duration. Cycle visits were routinely scheduled in the morning and the study clinic was open 7 days per week. Main sources of recruitment included study flyers and friends or family referrals who knew about the study or were current study participants.

Participants were not eligible to participate if they were currently using oral contraceptives, vitamin and mineral supplements, or prescription medications; were pregnant or breastfeeding in the past 6 months; had a diagnosis of a chronic medical condition such as metabolic disorders or gastrointestinal diseases; reported a BMI of \<18 or \>35 kg/m^2^ at screening; or were on current dietary restrictions for weight loss or for medical reasons. Detailed study methods have been published elsewhere.^[@R11]^ Only participants who had body composition measurements by DXA during their final study visit are included in the current analyses (n=248; 96%). The University at Buffalo Health Sciences Institutional Review Board (IRB) approved the study and served as the IRB designated by the National Institutes of Health for this study under a reliance agreement. All participants provided written informed consent.

Adiposity Measures {#S8}
------------------

### Anthropometry {#S9}

Trained study personnel performed anthropometric measures at the baseline visit according to standardized protocols. Height was measured by a fixed Stadiometer while weight was measured on a calibrated balance scale. BMI was calculated by dividing weight in kilograms by height in meters squared (kg/m^2^). Waist, hip, and thigh circumferences were measured in centimeters to the nearest mm with an inelastic measuring tape. Waist circumference was measured at the end of normal expiration midpoint between the iliac crest and the lowest lateral portion of the rib cage. Hip girth was measured at the level of the symphysis pubis and the maximal protrusion of the gluteal muscles. Thigh circumference was measured at the midpoint between the inguinal crease and the proximal border of the patella. Skinfold thicknesses were measured at the triceps (mid-point between the acromion process of the scapula and the inferior margin of the olecranon process of the ulna), thighs (mid-point between the inguinal crease and the proximal border of the patella), subscapular (below the angle of the scapula) and suprailiac (midaxillary line above the iliac crest) to the nearest 1 mm using a Harpenden skinfold caliper. All the anthropometric measurements were done twice and the mean values were obtained from the two measurements.

### Body Composition {#S10}

Certified radiology technicians performed body composition assessments at the final clinic visit (n=248) using dual energy X-ray absorptiometry (Hologic Discovery Elite, Hologic, Waltham, MA, USA). Ongoing QC and daily phantoms were used to monitor any machine drift. Whole body assessment (distribution of bone, fat and lean mass) was performed. Total and regional (arms, trunk, and legs) bone mass, percent fat and regional fat mass were assessed. Trunk and leg fat were used to compute trunk-to-leg fat ratio (T/L), as a measure of upper to lower body fat. Percent leg fat was calculated as the average amount of fat in both legs divided by total body fat × 100.

Dietary Assessment {#S11}
------------------

### 24-hour Recall {#S12}

24-hr dietary recalls were administered on approximately days 2, 7, 14 and 22 of the menstrual cycle. As such, women could have up to eight 24-hr recalls if they completed 2 cycles. The 24-hr recalls were conducted by trained and certified staff through a computerized interview at the time of the morning clinic visit or after 8 pm the prior evening (after fasting has begun) and were administered either by telephone or in person. The Nutrition Data System for Research software (NDSR), version 2005 (Nutrition Coordinating Center of the University of Minnesota, Minneapolis, MN) was used to derive nutritional information. A validated two-dimensional visual aid helped participants estimate accurate information regarding portion sizes.^[@R12]^ 97.2% of the participants with DXA measures completed more than six 24-hr dietary recalls during the two cycles (7 recalls: 21.4%; 8 recalls: 75.8%). Energy intake was averaged across all available recalls per participant.

### Alternate Mediterranean Diet Score (aMED) {#S13}

The alternate Mediterranean Diet Score (aMED),^[@R13]^ a scale adapted from the traditional Mediterranean diet score developed by Trichopoulou et al.,^[@R14]^ is based on the dietary intake of 9 components including: vegetables (excluding potatoes), legumes, fruit, nuts, whole grains, red and processed meat, fish, alcohol, and the ratio of monounsaturated fat to saturated fat. The aMED ranges between 0 and 9 with higher scores implying greater adherence. Each dietary component receives a score of 1 if consumption exceeds the median intake except for: the red and processed meat component (a point is scored if consumption is less than the median intake) and the alcohol component (a point is scored if intake is between 5 and 15 grams per day). The median intake is derived from the distribution of the dietary intake components of the cohort under study.^[@R14]^

As each participant had more than one dietary recall (4--8 recalls), we calculated the average of each of the aMED dietary components across all available recalls per participant and subsequently calculated one aMED per subject.

Covariate Assessment {#S14}
--------------------

Participants reported demographic information including education, race and smoking by questionnaire. The International Physical Activity Questionnaire (IPAQ) was administered at baseline and was used to classify physical activity into high, moderate or low.^[@R15]^

Statistical Analyses {#S15}
--------------------

Descriptive analyses are presented as means ± standard deviations for normally distributed continuous variables, and as absolute numbers and frequencies for categorical variables by aMED category. Chi-square test or Fisher's exact test were used to examine the associations between categorical variables. Differences of mean aMED components and of mean adiposity measurements across the aMED categories (0--3, 4--5, 6--9) were evaluated with analysis of variance (ANOVA). ANOVA was also used to examine pairwise contrasts in mean adiposity measurements across the aMED categories. We then used multiple linear regression models to test the associations between the aMED and the different adiposity outcomes (percent body fat, percent trunk fat, percent leg fat, T/L, sum of skinfolds, waist circumference, hip circumference, waist-to-hip ratio \[WHR\], BMI) adjusting first for average energy intake across the dietary recalls (kcal) and in subsequent models additionally adjusting for age (continuous), physical activity (high, moderate, low), education (high school or less/GED, some college, associates or bachelor degree, graduate degree or higher) and race (white, black, other). The choice of covariates was based *a priori* on what was previously reported in the literature. Due to the increased risk of morbidities associated with regional obesity, we further examined the average intake of the individual aMED components by tertiles of T/L and evaluated the associations between each aMED component (independent) and T/L (dependent, continuous) using separate multiple linear regression models adjusting for average energy intake, age, physical activity, education and race. The homogeneity of variance and the independence of the errors assumptions for performing these tests were met. Additionally, our results are robust to the normality of errors assumption due to our large sample size.^[@R16]^ Results from the linear regression models are presented as β-coefficients and 95% confidence intervals (CI). All reported p-values are based on a two-sided test with a p-value \<0.05 considered statistically significant. SAS version 9.2 (SAS Institute Inc., Cary, NC, USA) was used for all analyses.

RESULTS {#S16}
=======

Overall, the mean age of this cohort was 27.5 years, 35% had a low aMED (score 0--3) while 22% had a high score (score 6--9). A larger proportion of white women reported a high aMED than women of other race (p=0.07) ([Table 1](#T1){ref-type="table"}). More than 50% of the participants reported high levels of physical activity with a larger proportion of these women reporting a low aMED (p=0.04). Energy intake increased with increasing aMED. Of the macronutrients, a higher aMED was associated with slightly greater carbohydrate intake but no difference in protein intake. The type of fat consumed significantly differed, with lower saturated and higher polyunsaturated fat among those with a high aMED. As expected, the individual aMED components were directly associated with the aMED in the hypothesized directions.

Women with moderate and high aMED had a significantly lower BMI, smaller waist and thigh circumferences measured at baseline than women with low aMED ([Table 2](#T2){ref-type="table"}). All of the examined DXA measures except for percent leg fat showed an inverse association with the aMED (p\<0.05). Hip circumference and leg fat mass were only significantly different when comparing the moderate aMED to the low aMED group ([Table 2](#T2){ref-type="table"}). Associations remained significant after adjusting for age, race, education, physical activity, and total energy intake ([Table 3](#T3){ref-type="table"}). An increment of 1-unit in the aMED was associated with a 0.67% (95% CI: −1.11,−0.24) lower percent body fat, a 0.85% (95% CI: −1.39,−0.32) lower percent trunk fat, and a 0.06% (95% CI: −0.09,−0.02) lower T/L ratio.

Intake of red and processed meat increased with the increase in tertiles of T/L (mean intake (SD)=1.3 servings/d (1.1) in the lowest tertile, 1.5 servings/d (1.2) in the moderate tertile, 1.8 servings/d (1.2) in the highest tertile of T/L). Significant differences were also noted for %SFA with the highest tertile of T/L having the highest %SFA intake ([Table 4](#T4){ref-type="table"}). When the associations between the individual dietary components of the aMED and regional adiposity as a measure of T/L were evaluated in linear regression models adjusting for age, race, education, physical activity and total energy intake, a high consumption of red and processed meat products and low intake of legumes were significantly associated with increased regional adiposity (p=0.04) (red and processed meat β=0.060, 95% CI:0.002, 0.117; legumes β=−0.280, 95% CI:−0.550, −0.010) ([Table 5](#T5){ref-type="table"}). Mutually adjusting for the other aMED dietary components reduced the associations with T/L (red and processed meat β=0.052, 95% CI: −0.011, 0.114; legumes β=−0.25, 95% CI: −0.57,0.08; p=0.1 data not shown).

As energy intake was significantly related to the aMED and given that the MD might be inherently positively associated with energy intake,^[@R17]--[@R19]^ we also conducted analyses without controlling for energy intake. No qualitative changes were noted in the results (data not shown).

DISCUSSION {#S17}
==========

In this cross-sectional analysis, following the principles of a Mediterranean dietary pattern was significantly associated with lower values of total and regional adiposity by DXA and by anthropometry. This association held even after adjusting for potential confounders including age, education, race, physical activity, and energy intake.

To our knowledge our findings represent the first demonstration examining the relationship between adherence to the alternate Mediterranean diet and a direct assessment of total and regional body fat distribution as measured by DXA. These findings are in agreement with previous studies, despite methodological differences (types of study designs, adiposity measurement methods, study populations), showing that following the aMED could potentially be associated with a favorable body weight. Nine cross-sectional studies, of which 6 examined BMI and 3 examined both BMI and WHR/waist circumference, have shown inverse associations with the above adiposity outcomes among study participants with better adherence to the MD.^[@R13];[@R18]--[@R25]^. Similarly, 3 of 5 cohort studies, with follow-up ranging between 2.4--9 years, showed that subjects with better adherence to the MD were less likely to gain weight or to develop overweight/obesity than were individuals with low adherence while the other two cohort studies did not demonstrate any significant weight change.^[@R26]--[@R30]^

The potential physiologic mechanisms explaining the protective role of the MD on obesity, the metabolic syndrome and its components as well as cardiovascular disease have been reviewed elsewhere. Briefly, the overall anti-inflammatory and anti-oxidant impact of the MD and the effects of its individual components including olive oil, fruits, vegetables, whole grains, and fish offer potential explanations for its protective effects.^[@R31]--[@R33]^ Particularly essential in the prevention of weight gain is the high consumption of dietary fiber with its satiation impact, coupled with a low degree of energy density of the MD overall.^[@R33]^ In a meta-analysis of over 500,000 subjects, a decrease of 0.42 cm (95% CI: −0.82,−0.02) in waist circumference has been reported among subjects with high adherence to the MD.^[@R33];[@R34]^ This is particularly important for the population under study. Women of reproductive age due to the childbearing process, are at high risk for obesity development and excessive weight gain during pregnancy with preferential centralized distribution of adipose tissue, a risk factor for a wide range of chronic diseases.^[@R35]--[@R37]^ Our study results support a strong inverse association between measured truncal adiposity and adherence to the aMED implying that not following such a pattern of dietary consumption may be potentially associated with a preference in fat distribution. In a randomized crossover study of overweight or obese men (aged 24--49 years, BMI 25.5--31.3 kg/m^2^), a significant loss of weight and fat mass resulted after 4 weeks when SFA-rich diet was substituted with predominantly MUFA-rich diet. Men on the SFA-rich diet accumulated fat mass predominantly on the trunk instead of the limbs.^[@R38]^ The aMED heavily reflects on the fatty acid component of this diet through mainly 4 categories including meat, nuts, fish and MUFA to SFA ratio. Interestingly, a food group analysis with T/L shows a difference in consumption for red and processed meat and consumption of legumes. High red and processed meat consumption have been previously associated with increased cardiometabolic risk independent of other dietary factors.^[@R39];[@R40]^ The lack of an appreciable association with the majority of the individual dietary components of the aMED, might be attributed to the inability of the individual components to capture the synergistic or interactive cumulative effects on adiposity detected through the diet score.^[@R14]^

The findings of this study should be interpreted in light of the study's strengths and limitations. As this study had a cross sectional design, we are restricted in terms of making an inference on the time sequence of all associations. The BioCycle study however, excluded women on a diet for weight loss or for other medical reasons rendering the likelihood of reverse causality less likely to occur. We also had strict inclusion criteria restricting the generalizability of our findings to all US women. While we used non-objective measurements in assessing physical activity, the instrument we used has previously demonstrated acceptable reliability and validity.^[@R15]^ Strengths of the current study include the use of the 24 h dietary recalls with repeated nutritional assessments (\>97% had ≥7 recalls) over a period of 2 months rendering misreporting of consumed food items unlikely.

In conclusion, we confirmed previous findings that showed an inverse relation between the aMED and anthropometric indices, including waist circumference, WHR and BMI, and expanded those findings to show the association with total and regional body fat distribution as measured by DXA. These results in addition to the mounting evidence of the health benefits of the Mediterranean diet raise awareness to promote such a lifestyle in dietary habits to combat the worldwide obesity epidemic.

This work was supported by the Intramural Research Program of the *Eunice Kennedy Shriver* National Institute of Child Health & Human Development, National Institutes of Health (Contract \#HHSN275200403394C). The authors thank the BioCycle working group for comments and feedback on this work.

**CONFLICT OF INTEREST**

The authors declare no conflict of interest.

aMED

:   Alternate Mediterranean Diet Score

BMI

:   Body Mass Index

DXA

:   Dual Energy X-ray Absorptiometry

MD

:   Mediterranean Diet

MUFA

:   Monounsaturated Fatty Acid

PUFA

:   Polyunsaturated Fatty Acid

SFA

:   Saturated Fatty Acid

T/L

:   Trunk-to-Leg Fat Ratio

WHR

:   Waist-to-Hip Ratio

###### 

Baseline and dietary characteristics according to adherence to the alternate Mediterranean Diet (aMED)

  aMED score                                                                                                       
  ---------------------------------------------- -------------- ---------------- ---------------- ---------------- ---------
  Demographic characteristics                                                                                      
   Age (y)                                       27.5 (8.2)     27.3 (8.4)       27.9 (8.1)       26.9 (8.3)       0.74
   Physical activity (n(%))                                                                                        0.04
    Low                                          22 (8.9)       10 (11.5)        6 (5.7)          6 (10.9)         
    Moderate                                     90 (36.3)      21 (24.1)        46 (43.4)        23 (41.8)        
    High                                         136 (54.8)     56 (64.4)        54 (50.9)        26 (47.3)        
   Race (n(%))                                                                                                     0.07
    White                                        147 (59.3)     46 (52.9)        60 (56.6)        41 (74.6)        
    Black                                        50 (20.2)      23 (26.4)        22 (20.8)        5 (9.1)          
    Other                                        51 (20.6)      18 (20.7)        24 (22.6)        9 (16.4)         
   Married or living together (n(%))             64 (25.8)      23 (26.4)        28 (26.4)        13 (23.6)        0.92
   Current smoker (n(%))                         10 (4.0)       3 (3.5)          5 (4.7)          2 (3.6)          0.92
   Education (n(%))                                                                                                0.44
    High school or less/GED                      32 (12.9)      14 (16.1)        15 (14.2)        3 (5.5)          
    Some college                                 95 (38.3)      34 (39.1)        39 (36.8)        22 (40.0)        
    Associates or Bachelor degree                93 (37.5)      33 (37.9)        38 (35.9)        22 (40.0)        
    Graduate school or higher                    28 (11.3)      6 (6.9)          14 (13.2)        8 (14.6)         
  Total energy (kcal)                            1613.0 (348)   1542.3 (345.6)   1635.4 (331.5)   1681.8 (368.9)   0.04
   Proteins (% of kcal)                          15.7 (3.0)     15.9 (3.0)       15.9 (3.1)       15.1 (2.7)       0.23
   Carbohydrates (% of kcal)                     50.9 (7.0)     49.9 (6.7)       50.9 (7.1)       52.7 (6.9)       0.06
   Fat (% of kcal)                               33.8 (5.3)     34.5 (5.1)       33.6 (5.6)       33.2 (5.0)       0.34
   SFA (% of kcal)                               11.5 (2.5)     12.3 (2.3)       11.4 (2.5)       10.5 (2.4)       \<0.001
   MUFA (% of kcal)                              12.6 (2.3)     12.6 (2.3)       12.4 (2.4)       12.6 (2.2)       0.80
   PUFA (% of kcal)                              7.0 (1.6)      6.6 (1.6)        7.1 (1.5)        7.6 (1.6)        0.002
  aMED components                                                                                                  
   Vegetables (excludes potatoes) (servings/d)   2.3 (1.1)      1.8 (0.7)        2.3 (1.0)        3.0 (1.3)        \<0.001
   Legumes (servings/d)                          0.1 (0.2)      0.1 (0.1)        0.1 (0.2)        0.3 (0.4)        \<0.001
   Fruits (servings/d)                           1.2 (0.9)      0.9 (0.9)        1.1 (0.9)        1.7 (0.8)        \<0.001
   Nuts (servings/d)                             0.3 (0.6)      0.1 (0.2)        0.3 (0.5)        0.7 (0.8)        \<0.001
   Whole grains (servings/d)                     0.8 (0.9)      0.5 (0.5)        0.9 (1.1)        1.3 (0.9)        \<0.001
   Red meat & products (servings/d)              1.5 (1.2)      1.8 (1.1)        1.6 (1.3)        1.0 (1.1)        0.001
   Fish and seafood (servings/d)                 0.4 (0.6)      0.2 (0.4)        0.6 (0.7)        0.5 (0.6)        \<0.001
   MUFA:SFA ratio                                1.2 (0.3)      1.1 (0.2)        1.2 (0.2)        1.3 (0.3)        \<0.001
   Alcohol (g/d)                                 2.8 (5.3)      2.3 (6.4)        2.7 (4.6)        3.7 (4.4)        0.29

Figures are means (SD) unless stated otherwise. SFA: saturated fatty acid; MUFA: monounsaturated fatty acid; PUFA: polyunsaturated fatty acid. Median values for calculating the aMED component scores: vegetables excluding potatoes (2.044 servings/d), legumes (0.031 servings/d), fruits (1.021 servings/d), nuts (0.065 servings/d), whole grains (0.607 servings/d), red meat & products (1.329 servings/d), fish and seafood (0.113 servings/d), MUFA:SFA ratio (1.146).

###### 

Anthropometric indices and body fat distribution according to adherence to the alternate Mediterranean Diet (aMED)

  aMED score                                                                                                                                                                                     
  -------------------------------------------------------- ------------ ------------- ------------------------------------------------------ --------------------------------------------------- ---------
  Anthropometry                                                                                                                                                                                  
   BMI (kg/m^2^)                                           24.1 (3.9)   25.4 (4.0)    23.2 (3.3)[\*\*\*](#TFN8){ref-type="table-fn"}^vlow^   23.7 (4.2)[\*](#TFN6){ref-type="table-fn"}^vlow^    \<0.001
   Hip circumference (cm)                                  99.6 (8.6)   101.9 (8.9)   98.1 (7.3)[\*\*](#TFN7){ref-type="table-fn"}^vlow^     98.9 (9.7)                                          0.006
   Waist circumference (cm)                                74.8 (8.8)   77.4 (9.3)    73.1 (7.5)[\*\*](#TFN7){ref-type="table-fn"}^vlow^     73.8 (9.5)[\*](#TFN6){ref-type="table-fn"}^vlow^    0.002
   Waist-to-hip ratio                                      0.8 (0.1)    0.8 (0.1)     0.7 (0.1)                                              0.7 (0.1)                                           0.22
   Sum of skinfolds (mm) [a](#TFN3){ref-type="table-fn"}   81.2 (22)    87.4 (23.0)   78.2 (20.8)[\*](#TFN6){ref-type="table-fn"}^vlow^      77.3 (20.8)[\*](#TFN6){ref-type="table-fn"}^vlow^   0.005
   Thigh circumference (cm)                                50.2 (7.0)   52.5 (7.5)    48.7 (5.7)[\*\*\*](#TFN8){ref-type="table-fn"}^vlow^   49.4 (7.6)[\*](#TFN6){ref-type="table-fn"}^vlow^    \<0.001
  DXA analysis                                                                                                                                                                                   
   Percent body fat                                        29.5 (6)     31.2 (6.4)    28.8 (4.9)[\*](#TFN6){ref-type="table-fn"}^vlow^       28.2 (6.7)[\*](#TFN6){ref-type="table-fn"}^vlow^    0.004
   Percent trunk fat                                       25.1 (7.4)   27.5 (7.7)    24 (6.2)[\*\*](#TFN7){ref-type="table-fn"}^vlow^       23.5 (8.1)[\*](#TFN6){ref-type="table-fn"}^vlow^    \<0.001
   Percent leg fat                                         35.2 (5.8)   36 (6.3)      34.9 (5.1)                                             34.1 (6.3)                                          0.15
   Trunk fat mass (kg)                                     7.7 (3.6)    8.9 (4.0)     6.9 (2.8)[\*\*\*](#TFN8){ref-type="table-fn"}^vlow^    7.2 (4.0)[\*](#TFN6){ref-type="table-fn"}^vlow^     \<0.001
   Leg fat mass (kg)                                       4.3 (1.3)    4.6 (1.5)     4.1 (1.1)[\*](#TFN6){ref-type="table-fn"}^vlow^        4.2 (1.5)                                           0.021
   Trunk-to-leg fat ratio                                  1.8 (0.5)    1.9 (0.5)     1.7 (0.5)[\*](#TFN6){ref-type="table-fn"}^vlow^        1.7 (0.5)[\*](#TFN6){ref-type="table-fn"}^vlow^     0.007

Figures are means (SD).

Includes the sum of subscapular, suprailiac, triceps and thigh skinfolds.

Overall p-value for any significant difference between the three groups: low, moderate and high aMED.

Pairwise comparisons were performed between low and high aMED, low and moderate aMED, and between moderate and high aMED. No significant pairwise differences were observed between moderate and high aMED scores. For each significant result, a "vlow" indicates the low aMED comparison group.

p≤0.05;

p≤0.001;

p≤0.0001 by ANOVA.

###### 

Multiple linear regression evaluating the association between adiposity outcomes and alternate Mediterranean Diet (aMED)

  Score                                              Difference per 1-unit increase in aMED   95% CI             p-value
  -------------------------------------------------- ---------------------------------------- ------------------ ---------
  **aMED**                                                                                                       
  DXA analysis                                                                                                   
   Percent body fat                                                                                              
    Energy adjusted                                  −0.73                                    (−1.16,−0.29)      0.001
    Fully adjusted [a](#TFN9){ref-type="table-fn"}   −0.67                                    (−1.11,−0.24)      0.003
   Percent trunk fat                                                                                             
    Energy adjusted                                  −0.96                                    (−1.49,−0.43)      \<0.001
    Fully adjusted [a](#TFN9){ref-type="table-fn"}   −0.85                                    (−1.39,−0.32)      0.002
   Percent leg fat                                                                                               
    Energy adjusted                                  −0.48                                    (−0.91,−0.06)      0.027
    Fully adjusted [a](#TFN9){ref-type="table-fn"}   −0.48                                    (−0.91,−0.05)      0.029
   Trunk-to-leg fat ratio                                                                                        
    Energy adjusted                                  −0.06                                    (−0.10,−0.02)      0.002
    Fully adjusted [a](#TFN9){ref-type="table-fn"}   −0.06                                    (−0.09, −0.02)     0.005
  Anthropometry                                                                                                  
   Sum of skinfolds                                                                                              
    Energy adjusted                                  −2.99                                    (−4.58,−1.39)      \<0.001
    Fully adjusted [a](#TFN9){ref-type="table-fn"}   −2.63                                    (−4.25, −1.00)     0.002
   Waist circumference                                                                                           
    Energy adjusted                                  −1.09                                    (−1.73,−0.46)      \<0.001
    Fully adjusted [a](#TFN9){ref-type="table-fn"}   −0.98                                    (−1.61,−0.36)      0.0023
   Hip circumference                                                                                             
    Energy adjusted                                  −0.87                                    (−1.49,−0.25)      0.006
    Fully adjusted [a](#TFN9){ref-type="table-fn"}   −0.88                                    (−1.50,−0.25)      0.006
   Waist-to-hip ratio                                                                                            
    Energy adjusted                                  −0.004                                   (−0.008,−0.0001)   0.043
    Fully adjusted [a](#TFN9){ref-type="table-fn"}   −0.003                                   (−0.007,0.001)     0.14
   BMI                                                                                                           
    Energy adjusted                                  −0.44                                    (−0.73,−0.16)      0.002
    Fully adjusted [a](#TFN9){ref-type="table-fn"}   −0.38                                    (−0.67,−0.10)      0.009

Adjusted for energy intake (kcal, continuous), age (continuous), race (white, black, other), physical activity (high, moderate, low) and education (high school or less/GED, some college, associates or bachelor degree, graduate degree or higher).

###### 

Dietary characteristics by trunk-to-leg fat ratio tertiles

  Trunk-to-leg fat ratio tertiles [a](#TFN11){ref-type="table-fn"}                                                      
  ------------------------------------------------------------------ ---------------- ---------------- ---------------- ------
  Total energy (kcal)                                                1632.8 (321.5)   1582.2 (345.1)   1624.1 (377.5)   0.61
   Proteins (%)                                                      15.4 (3.0)       15.6 (2.7)       16.1 (3.2)       0.28
   Carbohydrates (%)                                                 51.7 (6.3)       51.6 (6.8)       49.5 (7.7)       0.08
   Fat (%)                                                           33.7 (5.0)       32.9 (5.0)       34.9 (5.7)       0.05
   SFA (%)                                                           11.4 (2.5)       11.0 (2.3)       12.1 (2.6)       0.02
   MUFA (%)                                                          12.5 (2.1)       12.2 (2.3)       13.0 (2.5)       0.12
   PUFA (%)                                                          7.1 (1.7)        6.9 (1.4)        7.0 (1.6)        0.76
  Total dietary fiber                                                14.1 (6.0)       13.2 (5.1)       13.7 (5.7)       0.61
  aMED components                                                                                                       
   Vegetables (excludes potatoes) (servings/d)                       2.3 (1.2)        2.2 (0.9)        2.3 (1.2)        0.78
   Legumes (servings/d)                                              0.2 (0.2)        0.1 (0.2)        0.1 (0.2)        0.57
   Fruits (servings/d)                                               1.3 (0.8)        1.1 (1.0)        1.1 (0.9)        0.45
   Nuts (servings/d)                                                 0.4 (0.7)        0.2 (0.4)        0.3 (0.6)        0.05
   Whole grains (servings/d)                                         0.7 (0.7)        0.8 (0.8)        1.0 (1.2)        0.32
   Red meat & products (servings/d)                                  1.3 (1.1)        1.5 (1.2)        1.8 (1.2)        0.03
   Fish and seafood (servings/d)                                     0.5 (0.6)        0.4 (0.6)        0.4 (0.6)        0.54
   MUFA:SFA ratio                                                    1.2 (0.2)        1.2 (0.2)        1.2 (0.3)        0.84
   Alcohol (g/d)                                                     2.2 (5.0)        3.2 (5.7)        2.8 (5.1)        0.42

Figures are means (SD). SFA: saturated fatty acid; MUFA: monounsaturated fatty acid; PUFA: polyunsaturated fatty acid.

Mean (range) of trunk-to-leg fat ratio tertiles: Low: 1.2 (0.78--1.45), Moderate: 1.7 (1.46--1.88), High: 2.4 (1.89--3.86).

Overall p-value for any significant difference between the three groups: low, moderate and high trunk-to-leg fat ratio tertiles.

###### 

Results from multiple linear regression analysis that evaluated the association between trunk-to-leg fat ratio (dependent), dietary factors (independent), and other explanatory variables

                                                 Trunk-to-leg fat ratio β-coefficient   p-value [a](#TFN13){ref-type="table-fn"}
  ---------------------------------------------- -------------------------------------- ------------------------------------------
  Proteins (%)                                   0.021 (−0.002, 0.045)                  0.07
  Carbohydrates (%)                              −0.009 (−0.018, 0.001)                 0.08
  Fat (%)                                        0.007 (−0.006, 0.020)                  0.27
  SFA (%)                                        0.020 (−0.009, 0.048)                  0.18
  MUFA (%)                                       0.011 (−0.017, 0.040)                  0.43
  PUFA (%)                                       0.004 (−0.038, 0.046)                  0.85
  aMED components                                                                       
   Vegetables (excludes potatoes) (servings/d)   −0.025 (−0.091, 0.040)                 0.45
   Legumes (servings/d)                          −0.280 (−0.550, −0.010)                0.04
   Fruits (servings/d)                           0.0004 (−0.0739, 0.0746)               0.99
   Nuts (servings/d)                             −0.074 (−0.187, 0.039)                 0.20
   Whole grains (servings/d)                     −0.0001 (−0.0723, 0.0721)              1.0
   Red meat & products (servings/d)              0.060 (0.002, 0.117)                   0.04
   Fish and seafood (servings/d)                 −0.028 (−0.139, 0.082)                 0.61
   MUFA:SFA ratio                                −0.056 (−0.315, 0.203)                 0.67
   Alcohol (g/d)                                 0.002 (−0.011, 0.016)                  0.71

Adjusted for energy intake (kcal, continuous), age (continuous), race (white, black, other), physical activity (high, moderate, low) and education (high school or less/GED, some college, associates or bachelor degree, graduate degree or higher).
