Substitution Modeling Shows Simple Dietary Changes Increase Mediterranean-Style Diet Pattern Scores for US Adults

BACKGROUND: A Mediterranean-style diet pattern (MSDP) is a recommended diet pattern in the 2020–2025 Dietary Guidelines for Americans. Few studies report widespread adherence to the diet, which suggests Americans may benefit from strategies to help them improve alignment to an MSDP. OBJECTIVES: The purpose of this study was to assess the impact of isocaloric food substitutions on adherence to an MSDP in US adults. METHODS: Using data from NHANES (2007–2018), alignment to an MSDP was determined by calculation of a Mediterranean diet scoring index appropriate for non-Mediterranean populations (0–100 points for the total score, with higher scores indicating greater adherence). The sample was divided into 2 groups, a high-adherence group (HA) and a non-high-adherence group (nHA), to differentiate food groups to be used for isocaloric food substitution modeling. Substitution modeling via multiple regression analyses determined food selections that have the greatest impact on MSDP scores. Honey was added to the substitutions in recipe form and evaluated for its impact on MSDP scores. RESULTS: The study consisted of 19,978 adults, ages 25–65, with complete dietary data. The nHA had a lower mean total MSDP score (7.07 ± 0.04 points) compared to the HA (16.45 ± 0.09 points). Increasing olive oil from nonuse to partial use had the greatest impact (>+2 points) for both groups. Other isocaloric substitutions also improved adherence, albeit to a lesser degree, including substituting 1 oz of whole grains for 1 oz of refined grains, 4 oz of fish for 4 oz of red meat, and 4.9 cups of kale for 0.7 cups of starchy or root vegetables. Improved MSDP scores were sustained when honey was added to the substitutions. CONCLUSIONS: Simple dietary substitutions can help a diet more closely align with an MSDP. Adding honey to the simple substitutions may increase palatability without sacrificing nutritional benefits.