@article{2987267,
    title = "Mediterranean diet is inversely associated with steatosis and fibrosis and decreases ten-year diabetes and cardiovascular risk in NAFLD subjects: Results from the ATTICA prospective cohort study",
    author = "Kouvari, M. and Boutari, C. and Chrysohoou, C. and Fragkopoulou, E. and Antonopoulou, S. and Tousoulis, D. and Pitsavos, C. and Panagiotakos, D.B. and Mantzoros, C.S. and the ATTICA study Investigators",
    journal = "Clinical Nutrition Open Science",
    year = "2021",
    volume = "40",
    number = "5",
    pages = "3314-3324",
    publisher = "Churchill Livingstone",
    doi = "10.1016/j.clnu.2020.10.058",
    keywords = "adipocytokine;  adiponectin;  leptin, adult;  Article;  cardiovascular risk;  clinical effectiveness;  cohort analysis;  diabetes mellitus;  female;  human;  liver fibrosis;  macronutrient;  major clinical study;  male;  Mediterranean diet;  nonalcoholic fatty liver;  observational study;  prospective study;  risk reduction;  scoring system;  cardiovascular disease;  comorbidity;  fibrosis;  Greece;  liver;  Mediterranean diet;  middle aged;  non insulin dependent diabetes mellitus;  nonalcoholic fatty liver;  pathology, Adult;  Cardiovascular Diseases;  Cohort Studies;  Comorbidity;  Diabetes Mellitus, Type 2;  Diet, Mediterranean;  Female;  Fibrosis;  Greece;  Humans;  Liver;  Male;  Middle Aged;  Non-alcoholic Fatty Liver Disease;  Prospective Studies",
    abstract = "Background and aims: We assessed the association of Mediterranean diet with NAFLD and their interaction in predicting ten-year diabetes onset and first fatal/non-fatal cardiovascular disease (CVD) incidence. Methods: The ATTICA prospective observational study in Athens, Greece included 1,514 men and 1,528 women (>18 years old) free-of-CVD at baseline. Liver steatosis and fibrosis indices were calculated. Mediterranean diet adherence was assessed through MedDietScore. At the ten-year follow-up visit, CVD evaluation was performed in an a priori specified subgroup of n = 2,020 participants and diabetes onset in n = 1,485 free-of-diabetes participants. Results: MedDietScore was inversely associated with steatosis and fibrosis; e.g. in the case of the TyG index the Odds Ratio (OR) of the 3rd vs. 1st MedDietScore tertile was = 0·53, [95% Confidence Interval (95% CI) (0·29, 0·95)] and the associations persisted in multi-adjusted models. NAFLD predicted incident diabetes prospectively over a ten year period [HR = 1·87, 95% CI (0·75, 4·61)] and the association remained significant only in subjects with low MedDietScore (below median) whereas diabetes onset among subjects with higher MedDietScore was not influenced by NAFLD. Similarly, NAFLD predicted CVD [Hazard Ratio (HR) = 3·01, 95%CI(2·28, 3·95)]; the effect remained significant only in subjects with MedDietScore below median [HR = 1·38, 95% CI (1·00, 1·93)] whereas it was essentially null [HR = 1·00,95% CI (0·38, 2·63)] among subjects with higher score. Mediation analysis revealed that adiponectin and adiponectin-to-leptin ratio were the strongest mediators. Conclusions: We report an inverse association between Mediterranean diet and NAFLD. Mediterranean diet protected against diabetes and CVD prospectively among subjects with NAFLD. © 2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism"
}