Components of the Mediterranean Diet and Risk of COVID-19
Rafael Perez-Araluce, Miguel Ángel Martínez-González, Alfredo Gea, Silvia Carlos
Frontiers in Nutrition, doi:10.3389/fnut.2021.805533
Adherence to the traditional Mediterranean diet has been customarily assessed with the Mediterranean diet score (MDS or Trichopolou Index), with values of 0 or 1 assigned to each of the nine elements, and with the use of the sex-specific median as the cutoff. The value of persons whose consumption of the six beneficial items (ratio of monounsaturated to saturated fatty acids, vegetables, legumes, fruits and nuts, cereal, and fish) is at or above the median and is assigned a value of 1. Otherwise they receive 0 points. For detrimental elements (meats and dairy products) persons whose consumption is below the median are assigned a value of 1. An additional ninth point is assigned to moderate ethanol intake. We assessed the effect of each of the nine components of the MDS (replacing the fats ratio with olive oil, the main source of monounsaturated fats in the Mediterranean diet) on the risk of COVID-19 infection, symptomatic and severe COVID-19. From March to December 2020, 9,699 participants of the "Seguimiento Universidad de Navarra" (SUN) cohort answered a COVID-19 questionnaire. After excluding doctors and nurses, 5,194 participants were included in the main statistical analyses. Among them, we observed 382 cases of COVID-19 based on symptoms and clinical diagnosis; 167 of them with test confirmation. For the two COVID-19 definitions used, we found a significant decrease in risk for a higher adherence to the Mediterranean diet (OR = 0.64, 95% CI: 0.42-0.98, p for trend = 0.040; and OR = 0.44, 95% CI: 0.22-0.88, p for trend = 0.020, for test-diagnosed cases). A protective effect was also found for symptomatic COVID-19 (OR = 0.64, 95% CI: 0.41-1.00, p for trend = 0.050). Among the different individual food groups, only the consumption of whole dairy products showed a harmful direct association. The Mediterranean diet as a whole seems more important than each of its components in preventing the infection and symptoms of COVID-19.
ETHICS STATEMENT The studies involving human participants were reviewed and approved by the Research Ethics Committee of the University of Navarra. The patients/participants provided their written informed consent to participate in this study.
AUTHOR CONTRIBUTIONS RP-A, MM-G, and SC participated in the design of the study. RP-A was involved in the data analysis, supervised by SC and MM-G. SC and RP-A participated in writing the original manuscript. Finally, the manuscript was reviewed by MM-G and AG. All authors contributed to the article and approved the submitted version.
FUNDING The SUN Project has received funding from the Spanish Government-Instituto de Salud Carlos III, and the European Regional Development Fund (FEDER) (RD 06/0045, CIBER-OBN, Grants PI10/02658, PI10/02293, PI13/00615, PI14/01668, PI14/01798, PI14/01764, PI17/01795, and G03/140), the Navarra Regional Government (27/2011, 45/2011, 122/2014), the Government Delegation for the National Drug Plan (2020/ 021), and the University of Navarra.
Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References
Abdulah, Hassan, Relation of dietary factors with infection and mortality rates of COVID-19 across the world, J Nutr Heal Aging,
doi:10.1007/s12603-020-1512-3Ahmadi, Huang, Inan-Eroglu, Hamer, Stamatakis, Lifestyle risk factors and infectious disease mortality, including COVID-19, among middle aged and older adults: evidence from a community-based cohort study in the United Kingdom, Brain Behav Immun,
doi:10.1016/j.bbi.2021.04.022Batiha, Alqarni, Awad, Algammal, Nyamota et al., Dairy-derived and egg white proteins in enhancing immune system against COVID-19, Front Nutr,
doi:10.3389/fnut.2021.629440Beck, Levandert, Handy, Tabari, Mohammadzadeh et al., Vitamin D in respiratory viral infections: a key immune modulator?, Crit Rev Food Sci Nutr,
doi:10.1080/10408398.2021.1972407Behzadipour, Gholampour, Pirhadi, Seradj, Khoshneviszadeh et al., Viral 3CLpro as a target for antiviral intervention using milk-derived bioactive peptides, Int J Pept Res Ther,
doi:10.1007/s10989-021-10284-yBennouar, Cherif, Kessira, Bennouar, Abdi, Vitamin D deficiency and low serum calcium as predictors of poor prognosis in patients with severe COVID-19, J Am Coll Nutr,
doi:10.1080/07315724.2020.1856013Carlos, La Fuente-Arrillaga, Bes-Rastrollo, Razquin, Rico-Campà et al., Mediterranean diet and health outcomes in the SUN cohort, Nutrients,
doi:10.3390/nu10040439Cunningham, Vaduganathan, Claggett, Jering, Bhatt et al., Clinical outcomes in young US adults hospitalized with COVID-19, JAMA Intern Med,
doi:10.1001/jamainternmed.2020.5313De, Morais, Aquino, Silva-Maia, Vale et al., Nutritional status, diet and viral respiratory infections: perspectives for severe acute respiratory syndrome coronavirus 2, Br J Nutr,
doi:10.1017/S0007114520003311De, Ruiz, Bes-Rastrollo, Sampson, Martinez-González, Reproducibility of an FFQ validated in Spain, Public Health Nutr,
doi:10.1017/S1368980009993065Deschasaux-Tanguy, Srour, Bourhis, Arnault, Druesne-Pecollo et al., Nutritional risk factors for SARS-CoV-2 infection: a prospective study within the NutriNet-Santé cohort, BMC Med,
doi:10.1186/s12916-021-02168-1Detopoulou, Demopoulos, Antonopoulou, Micronutrients, phytochemicals and mediterranean diet: a potential protective role against covid-19 through modulation of paf actions and metabolism, Nutrients,
doi:10.3390/nu13020462Dong, Du, Gardner, Coronavirus COVID-19 (2019-nCoV
Elfström, Blomqvist, Nilsson, Hober, Pin et al., Differences in risk for SARS-CoV-2 infection among healthcare workers, Prev Med Reports,
doi:10.1016/j.pmedr.2021.101518Filippo, Formenti, Rovere-Querini, Carlucci, Conte et al., Hypocalcemia is highly prevalent and predicts hospitalization in patients with COVID-19, Endocrine,
doi:10.1007/s12020-020-02383-5Gorji, Ghadiri, Potential roles of micronutrient deficiency and immune system dysfunction in the coronavirus disease 2019 (COVID-19) pandemic, Nutrition,
doi:10.1016/j.nut.2020.111047Gouda, Adbelruhman, Alenezi, Mégarbane, Theoretical benefits of yogurt-derived bioactive peptides and probiotics in COVID-19 patients -A narrative review and hypotheses, Saudi J Biol Sci,
doi:10.1016/j.sjbs.2021.06.046Grant, Lahore, Mcdonnell, Baggerly, French et al., Evidence that vitamin d supplementation could reduce risk of influenza and covid-19 infections and deaths, Nutrients,
doi:10.3390/nu12040988Haupt-Jorgensen, Buschard, Can a gluten-free diet be partly protective for COVID-19 infection?, APMIS,
doi:10.1111/apm.13075Iddir, Brito, Dingeo, Campo, Samouda et al., Strengthening the immune system and reducing inflammation and oxidative stress through diet and nutrition: considerations during the covid-19 crisis, Nutrients,
doi:10.3390/nu12061562James, Ali, Armitage, Bonell, Cerami et al., The role of nutrition in COVID-19 susceptibility and severity of disease: a systematic review, J Nutr,
doi:10.1093/jn/nxab059Khoury, Julien, Inverse association between the mediterranean diet and COVID-19 risk in Lebanon: a case-control study, Front Nutr,
doi:10.3389/fnut.2021.707359Kim, Rebholz, Hegde, Lafiura, Raghavan et al., Plantbased diets, pescatarian diets and COVID-19 severity: A population-based case-control study in six countries, BMJ Nutr Prev Heal,
doi:10.1136/bmjnph-2021-000272Louca, Murray, Klaser, Graham, Mazidi et al., Modest effects of dietary supplements during the COVID-19 pandemic: insights from 445 850 users of the COVID-19 Symptom Study app, BMJ Nutr Prev Heal,
doi:10.1136/bmjnph-2021-000250Majumder, Debnath, Sharma, Shekhawat, Prasad et al., Olive oil consumption can prevent non-communicable diseases and COVID-19 : Review, Curr Pharm Biotechnol,
doi:10.2174/1389201022666210412143553Meltzer, Best, Zhang, Vokes, Arora et al., Association of vitamin D status and other clinical characteristics with COVID-19 test results, JAMA Netw Open,
doi:10.1001/jamanetworkopen.2020.19722Menni, Valdes, Freidin, Sudre, Nguyen et al., Real-time tracking of self-reported symptoms to predict potential COVID-19, Nat Med,
doi:10.1038/s41591-020-0916-2Merino, Joshi, Nguyen, Leeming, Mazidi et al., Diet quality and risk and severity of COVID-19: a prospective cohort study, Gut,
doi:10.1136/gutjnl-2021-325353Merra, Noce, Marrone, Cintoni, Tarsitano et al., Influence of mediterranean diet on human gut microbiota, Nutrients,
doi:10.3390/nu13010007Mohseni, Amini, Abiri, Kalantar, Kaydani et al., Are history of dietary intake and food habits of patients with clinical symptoms of COVID 19 different from healthy controls? A case-control study, Clin Nutr ESPEN,
doi:10.1016/j.clnesp.2021.01.021Moludi, Alizadeh, Vayghan, Naemi, Rahimi et al., The relationship between dietary inflammatory index (DII) and disease severity and inflammatory status: a case-control study of COVID-19 patients, Br J Nutr,
doi:10.1017/S0007114521003214Moreiras, Cabrera, Carbajal, Cuadrado, Tablas de Composición de Alimentos: Guía de Prácticas
Norouzbeigi, Yekta, Vahid-Dastjerdi, Keyvani, Ranjbar et al., Stability of severe acute respiratory syndrome coronavirus 2 in dairy products, J Food Saf,
doi:10.1111/jfs.12917Paparo, Bruno, Ferrucci, Punto, Viscardi et al., Protective effects elicited by cow milk fermented with L. paracasei CBAL74 against SARS-CoV-2 infection in human enterocytes, J Funct Foods,
doi:10.1016/j.jff.2021.104787Peng, Vitamin C Infusion for the Treatment of Severe 2019-nCoV Infected Pneumonia -Full Text View -ClinicalTrials
Perdijk, Van Splunter, Savelkoul, Brugman, Van Neerven, Cow's milk and immune function in the respiratory tract: potential mechanisms, Front Immunol,
doi:10.3389/fimmu.2018.00143Perez-Araluce, Martinez-Gonzalez, Fernández-Lázaro, Bes-Rastrollo, Gea et al., Mediterranean diet and the risk of COVID-19 in the 'Seguimiento Universidad de Navarra' cohort, Clin Nutr,
doi:10.1016/j.clnu.2021.04.001Pollán, Pérez-Gómez, Pastor-Barriuso, Oteo, Hernán et al., Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study, Lancet,
doi:10.1016/S0140-6736(20)31483-5Polzonetti, Pucciarelli, Vincenzetti, Polidori, Dietary intake of vitamin d from dairy products reduces the risk of osteoporosis, Nutrients,
doi:10.3390/nu12061743Ponzo, Pellegrini, 'eusebio, Bioletto, Goitre et al., Mediterranean diet and sars-cov-2 infection: is there any association? A proof-of-concept study, Nutrients,
doi:10.3390/nu13051721Ps, Kodgire, Paul, Desai, Kushwaha et al., Therapeutic potential of olive's bioactive compounds in COVID-19 disease management, Acta Sci Microbiol,
doi:10.31080/ASMI.2021.04.0879Redondo-Bravo, Moros, Sanchez, Lorusso, Ubago et al., The first wave of the COVID-19 pandemic in Spain: characterisation of cases and risk factors for severe outcomes, as at 27, Eurosurveillance,
doi:10.2807/1560-7917.ES.2020.25.50.2001431Rizzo, Sciorsci, Magrone, Jirillo, Exploitation of some natural products for the prevention and/or nutritional treatment of SARS-CoV2 infection, Endocr Metab Immune Disord Drug Targets,
doi:10.2174/1871530320999200831231029Skrajnowska, Brumer, Kankowska, Matysek, Miazio et al., Covid 19: diet composition and health, Nutrients,
doi:10.3390/nu13092980Soy, Keser, Atagündüz, Tabak, Atagündüz et al., Cytokine storm in COVID-19: pathogenesis and overview of antiinflammatory agents used in treatment, Clin Rheumatol,
doi:10.1007/s10067-020-05190-5Suardi, Cazzaniga, Graci, Dongo, Palestini, Link between viral infections, immune system, inflammation and diet, Int J Environ Res Public Health,
doi:10.3390/ijerph18052455Tavakol, Ghannadi, Tabesh, Halabchi, Noormohammadpour et al., Relationship between physical activity, healthy lifestyle and COVID-19 disease severity; a cross-sectional study, J Public Heal,
doi:10.1007/s10389-020-01468-9Torres, Alcubilla, González-Cordón, Inciarte, Chumbita et al., Impact of low serum calcium at hospital admission on SARS-CoV-2 infection outcome, Int J Infect Dis,
doi:10.1016/j.ijid.2020.11.207Trichopoulou, Costacou, Bamia, Trichopoulos, Adherence to a mediterranean diet and survival in a Greek population, N Engl J Med,
doi:10.1056/NEJMoa025039Trujillo-Mayol, Guerra-Valle, Casas-Forero, Mm, Viegas et al., Western dietary pattern antioxidant intakes and oxidative stress: importance during the SARS-CoV-2/COVID-19 pandemic, Adv Nutr,
doi:10.1093/advances/nmaa171Villa-Etchegoyen, Lombarte, Matamoros, Belizán, Cormick, Mechanisms involved in the relationship between low calcium intake and high blood pressure, Nutrients,
doi:10.3390/nu11051112Vu, Rydland, Achenbach, Van Horn, Cornelis, Dietary behaviors and incident COVID-19 in the uk biobank, Nutrients,
doi:10.3390/nu13062114Walton, Gibson, Hunter, Mechanisms linking the human gut microbiome to prophylactic and treatment strategies for COVID-19, Br J Nutr,
doi:10.1017/S0007114520003980Zhou, Chen, Wang, Zhao, Wei et al., Low serum calcium: a new, important indicator of COVID-19 patients from mild/moderate to severe/critical, Biosci Rep,
doi:10.1042/BSR20202690
