{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T11:16:05Z","timestamp":1769080565151,"version":"3.49.0"},"reference-count":61,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2022,7,19]],"date-time":"2022-07-19T00:00:00Z","timestamp":1658188800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec><jats:title>Background and Aims<\/jats:title><jats:p>Adherence to the Mediterranean diet (MD) has been associated with a decreased risk of developing a variety of chronic diseases that are comorbidities in COVID-19 patients. However, its association to the severity and symptoms of COVID-19 are still unknown. This study aimed to examine the association between adherence to the MD pattern and COVID-19 severity and symptoms in Iranian hospitalized patients.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>In this cross-sectional study, 250 COVID-19 patients aged 18 to 65 were examined. We employed a food frequency questionnaire (FFQ) to obtain data on dietary intake of participants in the year prior to their COVID-19 diagnosis. COVID-19 severity was determined using the National Institutes of Health's Coronavirus Disease 2019 report. Additionally, symptoms associated with COVID-19, inflammatory markers, and other variables were evaluated. The scoring method proposed by Trichopoulou et al. was used to assess adherence to the MD.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>The participants' mean age was 44.1 \u00b1 12.1 years, and 46% of them had severe COVID-19. Patients who adhered more closely to the MD had lower serum C-reactive protein levels (7.80 vs. 37.36 mg\/l) and erythrocyte sedimentation rate (14.08 vs. 42.65 mm\/h). Those with the highest MD score were 77% less likely to have severe COVID-19 after controlling for confounding variables. The MD score was also found to be inversely associated with COVID-19 symptoms, including dyspnea, cough, fever, chills, weakness, myalgia, nausea and vomiting, and sore throat.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Higher adherence to the MD was associated with a decreased likelihood of COVID-19 severity and symptoms, as well as a shorter duration of hospitalization and convalescence, and inflammatory biomarkers.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fmed.2022.911273","type":"journal-article","created":{"date-parts":[[2022,7,19]],"date-time":"2022-07-19T05:06:43Z","timestamp":1658207203000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":21,"title":["Higher Adherence to the Mediterranean Dietary Pattern Is Inversely Associated With Severity of COVID-19 and Related Symptoms: A Cross-Sectional Study"],"prefix":"10.3389","volume":"9","author":[{"given":"Nikan","family":"Zargarzadeh","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kiana","family":"Tadbir Vajargah","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Armin","family":"Ebrahimzadeh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Seyed Mohammad","family":"Mousavi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hamidreza","family":"Khodaveisi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Camellia","family":"Akhgarjand","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fernando M. P.","family":"Toyos","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Henrique S.","family":"Cerqueira","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Heitor O.","family":"Santos","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohsen","family":"Taghizadeh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alireza","family":"Milajerdi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2022,7,19]]},"reference":[{"key":"B1","volume-title":"Features, Evaluation, and Treatment of Coronavirus (COVID-19)","author":"Cascella","year":"2022"},{"key":"B2","doi-asserted-by":"publisher","first-page":"792584","DOI":"10.3389\/fcimb.2021.792584","article-title":"Experimental models of COVID-19","volume":"11","author":"Caldera-Crespo","year":"2022","journal-title":"Front Cell Infect Microbiol"},{"key":"B3","doi-asserted-by":"publisher","first-page":"760795","DOI":"10.3389\/fpubh.2021.760795","article-title":"Accessibility to non-COVID health services in the world during the COVID-19 pandemic: review","volume":"9","author":"Tuczy\u0144ska","year":"2021","journal-title":"Front Public Health."},{"key":"B4","doi-asserted-by":"publisher","first-page":"293","DOI":"10.1016\/j.bpa.2020.11.009","article-title":"Economic impact of COVID-19 pandemic on healthcare facilities and systems: international perspectives","volume":"35","author":"Kaye","year":"2021","journal-title":"Best Pract Res Clin Anaesthesiol."},{"key":"B5","doi-asserted-by":"publisher","first-page":"55","DOI":"10.1016\/j.rceng.2020.03.001","article-title":"COVID-19, a worldwide public health emergency","volume":"221","author":"Palacios Cruz","year":"2021","journal-title":"Rev Clin Esp."},{"key":"B6","doi-asserted-by":"publisher","first-page":"601","DOI":"10.1038\/s41591-021-01283-z","article-title":"Post-acute COVID-19 syndrome","volume":"27","author":"Nalbandian","year":"2021","journal-title":"Nat Med."},{"key":"B7","doi-asserted-by":"publisher","first-page":"388","DOI":"10.1016\/j.medcle.2021.04.008","article-title":"Medical sequels of COVID-19","volume":"157","author":"Peramo-\u00c1lvarez","year":"2021","journal-title":"Med Clin."},{"key":"B8","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2021.0830","article-title":"Sequelae in adults at 6 months after COVID-19 infection","volume-title":"JAMA Network Open","author":"Logue","year":"2021"},{"key":"B9","doi-asserted-by":"publisher","first-page":"e00233","DOI":"10.1128\/mSystems.00233-21","article-title":"Identification and development of therapeutics for COVID-19","volume":"6","author":"Rando","year":"2021","journal-title":"Msystems."},{"key":"B10","doi-asserted-by":"publisher","first-page":"145","DOI":"10.3390\/jpm10040145","article-title":"Pharmaconutrition in the clinical management of COVID-19: a lack of evidence-based research but clues to personalized prescription","volume":"10","author":"Santos","year":"2020","journal-title":"J Pers Med."},{"key":"B11","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1007\/s13668-021-00380-2","article-title":"The nutrition-COVID-19 interplay: a review","volume":"10","author":"Antwi","year":"2021","journal-title":"Curr Nutr Rep."},{"key":"B12","doi-asserted-by":"publisher","first-page":"1152","DOI":"10.1001\/jamainternmed.2020.3313","article-title":"Is a \u201cCytokine Storm\u201d relevant to COVID-19?","volume":"180","author":"Sinha","year":"2020","journal-title":"JAMA Intern Med."},{"key":"B13","doi-asserted-by":"publisher","first-page":"250","DOI":"10.1002\/jmv.26232","article-title":"The cytokine storm and COVID-19","volume":"93","author":"Hu","year":"2021","journal-title":"J Med Virol."},{"key":"B14","doi-asserted-by":"publisher","first-page":"738","DOI":"10.1177\/0748233712462468","article-title":"Nutraceuticals of anti-inflammatory activity as complementary therapy for rheumatoid arthritis","volume":"30","author":"Al-Okbi","year":"2014","journal-title":"Toxicol Ind Health."},{"key":"B15","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1016\/j.ejphar.2018.07.019","article-title":"The effect of zinc supplementation on plasma C-reactive protein concentrations: A systematic review and meta-analysis of randomized controlled trials","volume":"834","author":"Mousavi","year":"2018","journal-title":"Eur J Pharmacol."},{"key":"B16","doi-asserted-by":"publisher","first-page":"e346","DOI":"10.1016\/j.clinthera.2021.10.002","article-title":"The effects of folic acid supplementation on pro-inflammatory mediators: a systematic review and dose\u2013response meta-analysis of randomized controlled trials","volume":"43","author":"Zargarzadeh","year":"2021","journal-title":"Clin Ther."},{"key":"B17","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2021.0369","article-title":"Effect of high-dose zinc and ascorbic acid supplementation vs usual care on symptom length and reduction among ambulatory patients with SARS-CoV-2 infection: the COVID A to Z randomized clinical trial","volume-title":"JAMA Network Open","author":"Thomas","year":"2021"},{"key":"B18","doi-asserted-by":"publisher","first-page":"1053","DOI":"10.1001\/jama.2020.26848","article-title":"Effect of a single high dose of Vitamin D3 on hospital length of stay in patients with moderate to severe COVID-19: a randomized clinical trial","volume":"325","author":"Murai","year":"2021","journal-title":"JAMA."},{"key":"B19","doi-asserted-by":"publisher","first-page":"2327","DOI":"10.3390\/nu12082327","article-title":"COVID-19 lockdown and changes of the dietary pattern and physical activity habits in a cohort of patients with type 2 diabetes mellitus","volume":"12","author":"Ruiz-Roso","year":"2020","journal-title":"Nutrients."},{"key":"B20","doi-asserted-by":"publisher","first-page":"257","DOI":"10.1136\/bmjnph-2021-000272","article-title":"Plant-based diets, pescatarian diets and COVID-19 severity: a population-based case\u2013control study in six countries","volume":"4","author":"Kim","year":"2021","journal-title":"BMJ Nutr Prev Health."},{"key":"B21","doi-asserted-by":"publisher","first-page":"837458","DOI":"10.3389\/fnut.2022.837458","article-title":"COVID-19 illness severity in the elderly in relation to vegetarian and non-vegetarian diets: a single-center experience","volume":"9","author":"Hou","year":"2022","journal-title":"Front Nutr"},{"key":"B22","doi-asserted-by":"publisher","first-page":"1389","DOI":"10.3390\/medicina57121389","article-title":"Mediterranean diet a potential strategy against SARS-CoV-2 infection: a narrative review","volume":"57","author":"Ferro","year":"2021","journal-title":"Medicina."},{"key":"B23","doi-asserted-by":"publisher","first-page":"1466","DOI":"10.3390\/nu12051466","article-title":"COVID-19: The inflammation link and the role of nutrition in potential mitigation","volume":"12","author":"Zabetakis","year":"2020","journal-title":"Nutrients."},{"key":"B24","doi-asserted-by":"publisher","first-page":"76","DOI":"10.3390\/diseases9040076","article-title":"The role of an anti-inflammatory diet in conjunction to COVID-19","volume":"9","author":"Ling","year":"2021","journal-title":"Diseases."},{"key":"B25","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1016\/j.maturitas.2019.12.002","article-title":"The mediterranean diet: a historical perspective on food for health","volume":"132","author":"Hidalgo-Mora","year":"2020","journal-title":"Maturitas."},{"key":"B26","doi-asserted-by":"publisher","first-page":"3837","DOI":"10.3390\/nu12123837","article-title":"Mediterranean diet adherence and subjective well-being in a sample of Portuguese adults","volume":"12","author":"Andrade","year":"2020","journal-title":"Nutrients."},{"key":"B27","doi-asserted-by":"publisher","first-page":"304","DOI":"10.1177\/0003319714532169","article-title":"Health benefits of the Mediterranean diet: an update of research over the last 5 years","volume":"66","author":"Gotsis","year":"2015","journal-title":"Angiology."},{"key":"B28","doi-asserted-by":"publisher","first-page":"154407","DOI":"10.1016\/j.metabol.2020.154407","article-title":"Mediterranean diet as a nutritional approach for COVID-19","volume":"114","author":"Angelidi","year":"2021","journal-title":"Metabolism."},{"key":"B29","doi-asserted-by":"publisher","first-page":"654","DOI":"10.1017\/S1368980009991698","article-title":"Reliability and relative validity of an FFQ for nutrients in the Tehran lipid and glucose study","volume":"13","author":"Mirmiran","year":"2010","journal-title":"Public Health Nutr."},{"key":"B30","doi-asserted-by":"publisher","first-page":"2599","DOI":"10.1056\/NEJMoa025039","article-title":"Adherence to a Mediterranean diet and survival in a Greek population","volume":"348","author":"Trichopoulou","year":"2003","journal-title":"N Engl J Med."},{"key":"B31","unstructured":"2021"},{"key":"B32","first-page":"317","article-title":"Erythrocyte sedimentation rate and C-reactive protein measurements and their relevance in clinical medicine","volume":"115","author":"Bray","year":"2016","journal-title":"WMJ."},{"key":"B33","doi-asserted-by":"publisher","first-page":"607","DOI":"10.1016\/j.jinf.2020.03.037","article-title":"The pathogenesis and treatment of the \u2018Cytokine Storm' in COVID-19","volume":"80","author":"Ye","year":"2020","journal-title":"J Infect."},{"key":"B34","doi-asserted-by":"publisher","first-page":"1195","DOI":"10.1001\/archinte.167.11.1195","article-title":"Effect of a traditional Mediterranean diet on lipoprotein oxidation: a randomized controlled trial","volume":"167","author":"Fit\u00f3","year":"2007","journal-title":"Arch Intern Med."},{"key":"B35","doi-asserted-by":"publisher","first-page":"577","DOI":"10.1016\/j.phrs.2012.03.006","article-title":"Virgin olive oil and nuts as key foods of the Mediterranean diet effects on inflammatory biomakers related to atherosclerosis","volume":"65","author":"Urpi-Sarda","year":"2012","journal-title":"Pharmacol Res."},{"key":"B36","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1016\/j.pcad.2015.04.003","article-title":"Benefits of the mediterranean diet: insights from the PREDIMED study","volume":"58","author":"Mart\u00ednez-Gonz\u00e1lez","year":"2015","journal-title":"Prog Cardiovasc Dis."},{"key":"B37","doi-asserted-by":"publisher","first-page":"624","DOI":"10.1016\/j.numecd.2017.05.004","article-title":"The PREDIMED trial, Mediterranean diet and health outcomes: how strong is the evidence?","volume":"27","author":"Guasch-Ferr\u00e9","year":"2017","journal-title":"Nutr Metab Cardiovasc Dis."},{"key":"B38","doi-asserted-by":"publisher","first-page":"e34","DOI":"10.1056\/NEJMoa1800389","article-title":"Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts","volume":"378","author":"Estruch","year":"2018","journal-title":"N Engl J Med."},{"key":"B39","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1038\/s41387-018-0025-1","article-title":"The antioxidant potential of the Mediterranean diet in patients at high cardiovascular risk: an in-depth review of the PREDIMED","volume":"8","author":"Billingsley","year":"2018","journal-title":"Nutr Diabetes."},{"key":"B40","doi-asserted-by":"publisher","first-page":"1","DOI":"10.7326\/0003-4819-145-1-200607040-00004","article-title":"Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial","volume":"145","author":"Estruch","year":"2006","journal-title":"Ann Intern Med."},{"key":"B41","doi-asserted-by":"publisher","first-page":"114","DOI":"10.1111\/bcp.12986","article-title":"Polyphenol intake from a Mediterranean diet decreases inflammatory biomarkers related to atherosclerosis: a substudy of the PREDIMED trial","volume":"83","author":"Medina-Rem\u00f3n","year":"2017","journal-title":"Br J Clin Pharmacol."},{"key":"B42","doi-asserted-by":"publisher","first-page":"462","DOI":"10.3390\/nu13020462","article-title":"Micronutrients, phytochemicals and Mediterranean diet: a potential protective role against COVID-19 through Modulation of PAF actions and metabolism","volume":"13","author":"Detopoulou","year":"2021","journal-title":"Nutrients"},{"key":"B43","doi-asserted-by":"publisher","first-page":"236","DOI":"10.3390\/ph13090236","article-title":"The role of adaptogens in prophylaxis and treatment of viral respiratory infections","volume":"13","author":"Panossian","year":"2020","journal-title":"Pharmaceuticals."},{"key":"B44","first-page":"1","article-title":"Cherry intake as a dietary strategy in sport and diseases: a review of clinical applicability and mechanisms of action","volume-title":"Crit Rev Food Sci Nutr","author":"Santos","year":"2020"},{"key":"B45","doi-asserted-by":"crossref","first-page":"102358","DOI":"10.1016\/j.ctim.2020.102358","article-title":"The effects of pomegranate supplementation on biomarkers of inflammation and endothelial dysfunction: A meta-analysis and systematic review","volume":"49","author":"Wang","year":"2020","journal-title":"Complement Ther Med"},{"key":"B46","doi-asserted-by":"publisher","first-page":"16683","DOI":"10.1074\/jbc.M011695200","article-title":"Saturated fatty acids, but not unsaturated fatty acids, induce the expression of cyclooxygenase-2 mediated through toll-like receptor 4","volume":"276","author":"Lee","year":"2001","journal-title":"J Biol Chem."},{"key":"B47","doi-asserted-by":"crossref","DOI":"10.3945\/an.114.006940","article-title":"The science of fatty acids and inflammation","volume-title":"Adv Nutr.","author":"Fritsche","year":"2015"},{"key":"B48","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.jnutbio.2015.12.007","article-title":"The relation of saturated fatty acids with low-grade inflammation and cardiovascular disease","volume":"36","author":"Ruiz-N\u00fa\u00f1ez","year":"2016","journal-title":"J Nutr Biochem."},{"key":"B49","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1093\/ajcn\/nqaa110","article-title":"Public health guidelines should recommend reducing saturated fat consumption as much as possible: YES","volume":"112","author":"Kris-Etherton","year":"2020","journal-title":"Am J Clin Nutr."},{"key":"B50","doi-asserted-by":"publisher","first-page":"1311","DOI":"10.3390\/nu9121311","article-title":"Nuts and human health outcomes: a systematic review","volume":"9","author":"de Souza","year":"2017","journal-title":"Nutrients"},{"key":"B51","doi-asserted-by":"publisher","first-page":"953","DOI":"10.1016\/j.numecd.2012.10.008","article-title":"Dietary intake and major food sources of polyphenols in a Spanish population at high cardiovascular risk: the PREDIMED study","volume":"23","author":"Tresserra-Rimbau","year":"2013","journal-title":"Nutr Metab Cardiovasc Dis."},{"key":"B52","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1515\/reveh-2021-0065","article-title":"The aflatoxin B1 content of peanut-based foods in Iran: a systematic review","volume":"37","author":"Sadighara","year":"2021","journal-title":"Rev Environ Health."},{"key":"B53","doi-asserted-by":"publisher","first-page":"S45","DOI":"10.1017\/BJN20061863","article-title":"Dietary fibre, nuts and cardiovascular diseases","volume":"96","author":"Salas-Salvad\u00f3","year":"2006","journal-title":"Br J Nutr."},{"key":"B54","doi-asserted-by":"publisher","first-page":"1012","DOI":"10.1016\/j.nutres.2013.08.010","article-title":"An acute intake of a walnut-enriched meal improves postprandial adiponectin response in healthy young adults","volume":"33","author":"Lozano","year":"2013","journal-title":"Nutr Res."},{"key":"B55","doi-asserted-by":"publisher","first-page":"703","DOI":"10.1038\/ejcn.2011.20","article-title":"Effect of walnut-enriched meat on the relationship between VCAM, ICAM, and LTB4 levels and PON-1 activity in ApoA4 360 and PON-1 allele carriers at increased cardiovascular risk","volume":"65","author":"Canales","year":"2011","journal-title":"Eur J Clin Nutr."},{"key":"B56","doi-asserted-by":"publisher","first-page":"577","DOI":"10.1016\/j.metabol.2011.09.008","article-title":"Short-term walnut consumption increases circulating total adiponectin and apolipoprotein A concentrations, but does not affect markers of inflammation or vascular injury in obese humans with the metabolic syndrome: data from a double-blinded, randomized, placebo-controlled study","volume":"61","author":"Aronis","year":"2012","journal-title":"Metabolism."},{"key":"B57","doi-asserted-by":"publisher","first-page":"682","DOI":"10.3390\/nu12030682","article-title":"Oxidative stress biomarkers, nut-related antioxidants, and cardiovascular disease","volume":"12","author":"Lorenzon Dos Santos","year":"2020","journal-title":"Nutrients"},{"key":"B58","doi-asserted-by":"publisher","first-page":"257","DOI":"10.1093\/ajcn\/nqab012","article-title":"Underreporting of energy intake in weight loss maintainers","volume":"114","author":"Dahle","year":"2021","journal-title":"Am J Clin Nutr."},{"key":"B59","first-page":"5","article-title":"Predicting basal metabolic rate, new standards and review of previous work","volume":"39","author":"Schofield","year":"1985","journal-title":"Hum Nutr Clin Nutr."},{"key":"B60","doi-asserted-by":"publisher","first-page":"833628","DOI":"10.3389\/fnut.2022.833628","article-title":"Formulation of the menu of a general hospital after its conversion to a \u201cCOVID Hospital\u201d: a nutrient analysis of 28-day menus","volume":"9","author":"Detopoulou","year":"2022","journal-title":"Front Nutr"},{"key":"B61","doi-asserted-by":"publisher","first-page":"e1005973","DOI":"10.1371\/journal.ppat.1005973","article-title":"IL-1\u03b2\/IL-6\/CRP and IL-18\/ferritin: distinct inflammatory programs in infections","volume":"12","author":"Slaats","year":"2016","journal-title":"PLoS Pathog."}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2022.911273\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,7,19]],"date-time":"2022-07-19T05:06:51Z","timestamp":1658207211000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2022.911273\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,7,19]]},"references-count":61,"alternative-id":["10.3389\/fmed.2022.911273"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2022.911273","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,7,19]]},"article-number":"911273"}}