{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T09:08:19Z","timestamp":1788858499637,"version":"build-2803163510"},"reference-count":28,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T00:00:00Z","timestamp":1788825600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background: The Mediterranean diet (MD) has well-established health benefits, yet modern food systems are driving a nutrition transition. Quantifying how Mediterranean countries have shifted relative to global trends is essential for evidence-based public health. Aim: Dietary changes between 1990 and 2018 were examined in Mediterranean coastline countries (MED) in comparison with high-income non-Mediterranean countries (HIC non-MED) and middle-\/low-income non-Mediterranean countries (MLIC non-MED). Methods: Using the Global Dietary Database, within-country changes (1990 vs. 2018) for 13 food categories were analysed across 185 nations in three groups: MED countries (n = 21), HIC non-MED (n = 18), and MLIC non-MED (n = 146). MED countries were further grouped into Southern Europe (SE), Western Asia (WA), and North Africa (NA). Paired unweighted country-level analyses were the primary analyses; population-weighted analyses were sensitivity checks. Benjamini\u2013Hochberg\u2019s false-discovery-rate correction and centred log-ratio compositional analysis were applied. Results: MED seafood intake rose from 20.5 to 33.8 g\/day (\u0394 = +13.3 g\/day; 95% CI: +6.2 to +18.4; q = 0.003), and non-starchy vegetables increased from 135.5 to 173.6 g\/day (\u0394 = +38.0 g\/day; q = 0.626). Refined\/starchy carbohydrate intake rose by 63.3 g\/day in MED countries while declining by 33.6 g\/day in HIC non-MED countries (between-group divergence +96.9 g\/day; q = 0.006). Nuts and seeds rose across all groups; legumes declined modestly in MED countries. Saturated fatty acids + omega-6 polyunsaturated fatty acids (% kcal) rose by +0.6 percentage points in MED countries but fell in HIC non-MED countries. Monounsaturated fatty acids were stable. MED-WA showed the greatest overall divergence from the SE 1990 pattern. Conclusions: These findings highlight a public health paradox: the MD is globally promoted as a model of healthy eating, yet adherence within its region of origin is declining. Targeted, region-specific strategies are urgently needed to preserve beneficial MD elements while addressing emerging diet-related risks.<\/jats:p>","DOI":"10.3390\/nu18182943","type":"journal-article","created":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T08:10:22Z","timestamp":1788855022000},"page":"2943","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Mediterranean Diet and Global Dietary Shifts, 1990\u20132018: Population-Level Analysis Using Global Dietary Database"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5222-2540","authenticated-orcid":false,"given":"Dana","family":"Popescu-Spineni","sequence":"first","affiliation":[{"name":"Department of Social Medicine, Faculty of Midwives and Nursing, \u201cCarol Davila\u201d University of Medicine and Pharmacy, \u201cFrancisc I. Rainer\u201d Institute of Anthropology, Romanian Academy, 050711 Bucharest, Romania"},{"name":"Mediterranean Lifestyle Medicine Institute, 85400 Leros, Greece"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5558-7131","authenticated-orcid":false,"given":"Leila","family":"Karimi","sequence":"additional","affiliation":[{"name":"Mediterranean Lifestyle Medicine Institute, 85400 Leros, Greece"},{"name":"School of Health and Biomedical Sciences, STEM College, RMIT University, Melbourne 3000, Australia"},{"name":"School of Medicine and Healthcare Management, Caucasus University, Tbilisi 0102, Georgia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"software","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"conceptualization","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5740-9662","authenticated-orcid":false,"given":"Laima","family":"Brazionis","sequence":"additional","affiliation":[{"name":"Mediterranean Lifestyle Medicine Institute, 85400 Leros, Greece"},{"name":"Diabetes and Vascular Medicine Laboratory, Baker Heart and Diabetes Institute, Australia and Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne 3004, Australia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0300-9572","authenticated-orcid":false,"given":"Elena","family":"Philippou","sequence":"additional","affiliation":[{"name":"Mediterranean Lifestyle Medicine Institute, 85400 Leros, Greece"},{"name":"School of Health and Biomedical Sciences, STEM College, RMIT University, Melbourne 3000, Australia"},{"name":"Department of Life Sciences, School of Life and Health Sciences, University of Nicosia, 2417 Nicosia, Cyprus"},{"name":"Department of Nutritional Sciences, King\u2019s College London, London SE1 9NH, UK"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"resources","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8562-2877","authenticated-orcid":false,"given":"Audrey","family":"Tierney","sequence":"additional","affiliation":[{"name":"Mediterranean Lifestyle Medicine Institute, 85400 Leros, Greece"},{"name":"School of Allied Health and Centre for Implementation Research, Health Research Institute, University of Limerick, V94 T9PX Limerick, Ireland"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4932-0251","authenticated-orcid":false,"given":"Jelena Helene","family":"Cveji\u0107","sequence":"additional","affiliation":[{"name":"Mediterranean Lifestyle Medicine Institute, 85400 Leros, Greece"},{"name":"Biomedical Sciences Group, Translational Research Center in Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium"},{"name":"Department of Pharmacy, Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"resources","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1375-0033","authenticated-orcid":false,"given":"Linda","family":"Errington","sequence":"additional","affiliation":[{"name":"Mediterranean Lifestyle Medicine Institute, 85400 Leros, Greece"},{"name":"Walton Library, School of Biomedical, Nutritional and Sport Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"resources","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0887-2156","authenticated-orcid":false,"given":"Labros","family":"Sidossis","sequence":"additional","affiliation":[{"name":"Mediterranean Lifestyle Medicine Institute, 85400 Leros, Greece"},{"name":"Department of Kinesiology and Health, School of Arts and Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ 08901, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1397-4149","authenticated-orcid":false,"given":"Catherine","family":"Itsiopoulos","sequence":"additional","affiliation":[{"name":"Mediterranean Lifestyle Medicine Institute, 85400 Leros, Greece"},{"name":"School of Health and Biomedical Sciences, STEM College, RMIT University, Melbourne 3000, Australia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"supervision","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"conceptualization","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,8]]},"reference":[{"key":"ref_1","unstructured":"UNESCO (2026, February 01). Mediterranean Diet. Representative List of the Intangible Cultural Heritage of Humanity. Available online: https:\/\/ich.unesco.org\/en\/RL\/mediterranean-diet-00884."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1591","DOI":"10.1017\/S1368980009990413","article-title":"Mediterranean heritage: An intangible cultural heritage","volume":"12","author":"Arbore","year":"2009","journal-title":"Public Health Nutr."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1038\/ejcn.2017.58","article-title":"Mediterranean diet and multiple health outcomes: An umbrella review of meta-analyses of observational studies and randomised trials","volume":"72","author":"Dinu","year":"2018","journal-title":"Eur. J. Clin. Nutr."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"L\u0103c\u0103tu\u0219u, C.M., Grigorescu, E.D., Floria, M., Onofriescu, A., and Mihai, B.M. (2019). The Mediterranean diet: From an environment-driven food culture to an emerging medical prescription. Int. J. Environ. Res. Public Health, 16.","DOI":"10.3390\/ijerph16060942"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2288","DOI":"10.1017\/S1368980011002539","article-title":"The Middle Eastern and biblical origins of the Mediterranean diet","volume":"14","author":"Berry","year":"2011","journal-title":"Public Health Nutr."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Romagnolo, D., and Selmin, O. (2016). Historical and behavioral perspectives of the Mediterranean diet. Mediterranean Diet, Humana Press.","DOI":"10.1007\/978-3-319-27969-5"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1402S","DOI":"10.1093\/ajcn\/61.6.1402S","article-title":"Mediterranean diet pyramid: A cultural model for healthy eating","volume":"61","author":"Willett","year":"1995","journal-title":"AM. J. Clin. Nutr."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"35","DOI":"10.2174\/1874944501508010035","article-title":"The Mediterranean diet: Socio-cultural relevance for contemporary health promotion","volume":"8","author":"Phull","year":"2015","journal-title":"Open Public Health J."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1079\/PHN2005932","article-title":"The Mediterranean diet in a world context","volume":"9","author":"Alexandratos","year":"2006","journal-title":"Public Health Nutr."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1111\/j.1753-4887.2011.00456.x","article-title":"Global nutrition transition and the pandemic of obesity in developing countries","volume":"70","author":"Popkin","year":"2012","journal-title":"Nutr. Rev."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"168","DOI":"10.1017\/S1368980007246592","article-title":"Trends in food availability determined by the Food and Agriculture Organization\u2019s food balance sheets in Mediterranean Europe in comparison with other European areas","volume":"10","author":"Balanza","year":"2007","journal-title":"Public Health Nutr."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1079\/PHN2005757","article-title":"Changes in food supply in Mediterranean countries from 1961 to 2001","volume":"9","author":"Berenguer","year":"2006","journal-title":"Public Health Nutr."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1676","DOI":"10.1017\/S1368980009990541","article-title":"Worldwide variation of adherence to the Mediterranean diet, in 1961\u20131965 and 2000\u20132003","volume":"12","author":"Buckland","year":"2009","journal-title":"Public Health Nutr."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2274","DOI":"10.1017\/S1368980011002515","article-title":"Mediterranean diet pyramid today. Science and cultural updates","volume":"14","author":"Berry","year":"2011","journal-title":"Public Health Nutr."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1130","DOI":"10.1017\/S1368980007668517","article-title":"Population health and Mediterranean diet in southern Mediterranean countries","volume":"9","author":"Belahsen","year":"2006","journal-title":"Public Health Nutr."},{"key":"ref_16","unstructured":"World Obesity Federation (2025). World Obesity Atlas 2025, World Obesity Federation. Available online: https:\/\/data.worldobesity.org\/publications\/."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"294","DOI":"10.1186\/s12967-024-05095-w","article-title":"Underrated aspects of a true Mediterranean diet: Understanding traditional features for worldwide application of a \u2018Planeterranean\u2019 diet","volume":"22","author":"Godos","year":"2024","journal-title":"J. Transl. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1080\/09637486.2021.1941804","article-title":"Mediterranean diet\u2014Promotion and dissemination of healthy eating: Proceedings of an exploratory seminar at the Radcliffe Institute for Advanced Study","volume":"73","author":"Drescher","year":"2022","journal-title":"Int. J. Food Sci. Nutr."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e003585","DOI":"10.1136\/bmjgh-2020-003585","article-title":"Global Dietary Database 2017: Data availability and gaps on 54 major foods, beverages and nutrients among 5.6 million children and adults from 1220 surveys worldwide","volume":"6","author":"Miller","year":"2021","journal-title":"BMJ Glob. Health"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1111\/j.2517-6161.1995.tb02031.x","article-title":"Controlling the false discovery rate: A practical and powerful approach to multiple testing","volume":"57","author":"Benjamini","year":"1995","journal-title":"J. R. Stat. Soc. Ser. B"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e13126","DOI":"10.1111\/obr.13126","article-title":"Ultra-processed foods and the nutrition transition: Global, regional and national trends, food systems transformations and political economy drivers","volume":"21","author":"Baker","year":"2020","journal-title":"Obes. Rev."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"797","DOI":"10.1080\/09637486.2023.2290439","article-title":"Decreasing adherence to the Mediterranean diet: Health and environmental foe","volume":"74","author":"Godos","year":"2023","journal-title":"Int. J. Food Sci. Nutr."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Ruggiero, E., Dinu, M., Angelino, D., Di Costanzo, G., Esposito, S., Godos, J., Grosso, G., Lotti, S., Martini, D., and Vitale, M. (2025). Ultra-processed foods consumption, Mediterranean diet adherence and sociodemographic correlates in an Italian adult population: The UFO Survey. Nutrients, 17.","DOI":"10.3390\/nu17233651"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Cardamone, E., Iacoponi, F., Di Benedetto, R., Lorenzoni, G., Di Nucci, A., Zobec, F., Gregori, D., and Silano, M. (2024). Adherence to Mediterranean diet and its main determinants in a sample of Italian adults: Results from the ARIANNA cross-sectional survey. Front. Nutr., 11.","DOI":"10.3389\/fnut.2024.1346455"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Giampieri, F., Rosi, A., Frias-Toral, E., Abdelkarim, O., Aly, M., Ammar, A., Zambrano-Villacres, R., Pons, J., V\u00e1zquez-Ara\u00fajo, L., and Decembrino, N. (2025). Unhealthy ultra-processed food, diet quality and adherence to the Mediterranean diet in children and adolescents: The DELICIOUS Project. Foods, 14.","DOI":"10.3390\/foods14152648"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Quarta, S., Massaro, M., Chervenkov, M., Ivanova, T., Dimitrova, D., Jorge, R., Andrade, V., Philippou, E., Zisimou, C., and Maksimova, V. (2021). Persistent Moderate-to-Weak Mediterranean Diet Adherence and Low Scoring for Plant-Based Foods across Several Southern European Countries: Are We Overlooking the Mediterranean Diet Recommendations?. Nutrients, 13.","DOI":"10.3390\/nu13051432"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e194","DOI":"10.1017\/S1368980025101432","article-title":"Determinants of adherence to the Mediterranean diet among adults in Mediterranean countries: A systematic literature review","volume":"28","author":"Obeid","year":"2025","journal-title":"Public Health Nutr."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"113189","DOI":"10.1016\/j.nut.2026.113189","article-title":"Adherence to the Mediterranean diet and all-cause mortality: A systematic review and meta-analysis within the Italian National Guidelines \u2018La Dieta Mediterranea\u2019","volume":"147","author":"Nucci","year":"2026","journal-title":"Nutrition"}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/18\/2943\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T08:19:36Z","timestamp":1788855576000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/18\/2943"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,8]]},"references-count":28,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["nu18182943"],"URL":"https:\/\/doi.org\/10.3390\/nu18182943","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,8]]}}}