Associations Among Food Security, Diet Quality, and Dietary Intake During Pregnancy in a Predominantly African American Group of Women from North Carolina

Abstract

Background

Low food security during pregnancy can negatively affect women’s physical and mental health. Although many women make a greater effort to eat a healthy diet during pregnancy, the influence of low food security during pregnancy on maternal diet is not well understood.

Objective

This study aimed to assess the association between adult food security and maternal diet during pregnancy in a sample from North Carolina.

Design

This was a cross-sectional, secondary data analysis of food security (marginal, low, and very low vs high) and maternal diet during pregnancy.

Participants and setting

This study included 468 predominantly Black/African American women during pregnancy from the Nurture cohort, enrolled through prenatal clinics in central North Carolina between 2013 and 2016.

Main outcome measure

Diet quality was assessed using the Alternate Healthy Eating Index-Pregnancy and the Mediterranean Diet Score. Dietary intake from seven food groups included in the Alternate Healthy Eating Index-Pregnancy and/or Mediterranean Diet Score was assessed as well.

Statistical analysis performed

Multiple linear regression models were used to examine the association between food security and diet quality and dietary intake during pregnancy, adjusting for race/ethnicity; participation in the Special Supplemental Nutrition Program for Women, Infants, and Children; education; prepregnancy body mass index; age; parity; and mean daily energy intake.

Results

In this study, there was no association between maternal food security status and diet quality during pregnancy. However, researchers observed an association between low and marginal food security and greater intake of red and processed meats (marginal: β = 2.20 [P = 0.03]; low: β = 2.28 [P = 0.04]), as well as an association between very low food security and decreased vegetable consumption (β = −.43; P = 0.03).

Conclusions

Very low food security was associated with reduced vegetable intake. In addition, low and marginal food security were associated with greater red and processed meat intake. Future research should focus on nationally representative populations and include longitudinal assessments to allow for the study of the influence of food security on health during pregnancy.

Household food insecurity is a major public health problem, both in the United States and around the world.¹ The US Department of Agriculture (USDA) defines household food insecurity as an uncertainty or inability to acquire enough food to meet the needs of all household members because of insufficient money or other resources.² Households with food insecurity include those labeled by the USDA as having low or very low food security.² Those with low food security report reduced quality, variety, or desirability of diet, but little or no indication of reduced food intake. Those with very low food security report multiple instances of disrupted eating and reduced food intake.³ In the United States, 10.5% of all US households and 13.6% of households with children were considered food insecure in 2019.² In addition, 28.7% of households with children and a woman as head of household experience food insecurity.²

Food insecurity in the United States is related to issues of food access, income, and inadequate social policies.⁴ Women are more susceptible to food insecurity because they generally take on caregiver roles, and often reduce their own intake to ensure family members are properly nourished.^5,6 Food insecurity may be heightened during pregnancy, due to potential changes in employment status⁷ and an increase in spending in preparation for the birth of an infant. Food insecurity during pregnancy can have negative ramifications that can last beyond childbirth.^8–10 Women who experience food insecurity during pregnancy are more likely to experience mental health disorders, which can extend to the postpartum period.⁸ In addition, food insecurity during pregnancy has been associated with higher gestational weight gain,¹⁰ higher levels of stress,⁹ greater dietary fat intake,⁹ and a greater weight and body mass index (BMI) during the postpartum period among those already overweight or obese before pregnancy.⁹

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)¹¹ was created to supplement the diets of women at risk of food insecurity. Through this program, women receive nutritious foods and nutrition education throughout pregnancy and the postpartum period. There is evidence suggesting that WIC participation may improve women’s diets¹² and pregnancy outcomes.¹³

In the United States, the Dietary Guidelines for Americans provides guidance on what constitutes a healthy diet.¹⁴ There is no single dietary pattern that has been associated with positive health outcomes; thus, multiple diet indices have been used to measure diet quality,¹⁵ including the Alternate Healthy Eating Index for Pregnancy (AHEI-P)¹⁶ and the Mediterranean Diet Score (MDS).¹⁷ The Mediterranean diet is associated with a number of health benefits, including reduced cardiovascular disease risk,¹⁸ lower inflammation,^19,20 and improved life expectancy.²¹ The Mediterranean diet pattern is characterized by a high consumption of plant-based foods, high consumption of olive oil, a moderate consumption of fish, poultry, and dairy, a low consumption of red and processed meats, and other foods high in saturated fats, and a moderate consumption of alcohol.²² The MDS^17,23 has been shown to be a reliable measure of individuals’ adherence to a Mediterranean diet pattern.²⁴ The AHEI-P has been used to measure diet quality in pregnancy.¹⁶ It is based on the Alternate Healthy Eating Index,²⁵ which has been associated with risk of chronic disease. The AHEI-P assesses intake of fruits, vegetables (excluding white potatoes), the ratio of white meat to red meat, dietary fiber, trans fat, the ratio of polyunsaturated fat to saturated fat, calcium, folate, and iron.¹⁶ Higher AHEI-P scores have been associated with a lower blood glucose levels during pregnancy and a lower odds of preeclampsia.¹⁶

Maternal diet during pregnancy has been associated with a number of maternal and infant health outcomes. Prior research shows that consuming a healthy diet during pregnancy is associated with appropriate gestational weight gain,^26,27 reduced risk of gestational diabetes,²⁸ and improved birth outcomes.²⁹ During pregnancy, women often choose to take better care of their health and diet.³⁰ The most recent report from the Dietary Guidelines for Americans¹⁴ suggests that diet quality is slightly higher for women during pregnancy compared with nonpregnant women.¹⁴ However, recent peer-reviewed evidence also suggests that women’s diet quality during pregnancy is generally low.^31,32 In addition, evidence suggests that women of lower income and African-American women generally have lower diet quality compared with women of higher income and White women, possibly due to historical disadvantage.³² It is unclear how food security is linked with women’s ability to follow a healthy diet pattern during pregnancy because very few studies have focused on the pregnancy period.^33–35

The objective of this study was to assess the association between maternal food security during pregnancy and maternal diet during pregnancy using the following primary outcomes: AHEI-P and MDS in a cohort of predominantly Black/African-American women. In addition, the researchers assessed the association between maternal food security during pregnancy and dietary intake of seven food groups assessed in the AHEI-P and/or modified MDS, including vegetables, red and processed meats, dairy, fruit, whole grains, nuts, beans, and legumes. The study hypothesis posited that women reporting low and very low food security would have lower diet quality and would consume lower amounts of healthful foods compared with women of high food security.

METHODS

This study is a secondary analysis using data from the Nurture study, an observational cohort of pregnant women and infants residing in central North Carolina,³⁶ which aimed to assess the relation between early child care, infant caregiving, and weight gain. The study team enrolled and followed 860 women between 20 and 36 weeks’ gestation from a private prenatal clinic and the local county health department prenatal clinic between 2013 and 2016. The inclusion criteria were as follows: having a singleton pregnancy with no known congenital anomalies, being aged at least 18 years, speaking English, intending to keep the infant, and planning to stay in the area until at least 12 months postpartum. Women self-reported sociodemographic and lifestyle information via telephone and paper or electronic surveys. Of the 860 women enrolled, 658 completed a food frequency questionnaire (FFQ) during pregnancy, and 519 women had complete data for the exposure, outcome, and covariates of interest. Thirty-four women were excluded from analysis based on implausible calorie intake (< 500 kcal/day [n = 4] and > 5,000 kcal/day [n = 30]), and an additional 17 women who had missing data on covariates of interest. The analysis includes 468 women who completed an FFQ during pregnancy, reported plausible caloric intake, and had no missing data on covariates. Women who were excluded did not differ from women included in the study on the parameters of race/ethnicity, education, maternal age, food security status, prepregnancy BMI. However, excluded participants had a higher average calorie intake (P < 0.05) compared with women who were included in the study. The research team followed procedures according to ethical standards. This study was approved by the Duke University Medical Center Institutional Review Board. All participants provided written informed consent.

Food Security

At enrollment, food security was measured using the 10-item USDA Adult Food Security Survey.³⁷ Participants were asked to consider the past 30 days in their responses, which reflected the second or third trimester. Women were also categorized by the USDA’s labels of food security status of high, marginal, low, and very low.³ Individuals with high food security reported no indications of food access problems or limitations, those with marginal food security reported one or two indications of decreased food security, those with low food security reported reduced quality, variety, or desirability of food, without actual reduced food intake, and those with very low food security report multiple indications of disrupted eating patterns and reduced food intake.³ The sum of responses to the 10-item questionnaire was categorized as follows: 0 affirmative responses = high, 1 to 2 = marginal, 3 to 5 = low, and 6 to 10 = very low food security.

Maternal Diet

Maternal diet was measured at study enrollment in the second or third trimester of pregnancy using the validated and widely used Block FFQ.^38,39 Women completed the Block 2005 FFQ in paper format at home, using a standard portion size handout and an instruction sheet, with no help from research staff. Women were asked to reference their dietary intake during the past 30 days. Women returned completed FFQs to study staff by mail. Study staff mailed all completed FFQs to NutritionQuest⁴⁰ for processing and analysis of FFQs using Nutrition Data System for Research software.⁴¹ Study staff received data files containing dietary intakes of foods and food groups, total energy intake, and information on intake of several macro- and micronutrients.

AHEI-P

Maternal diet was assessed using the AHEI-P,¹⁶ which excludes alcohol intake, as alcohol is not recommended during pregnancy.^42,43 Women’s diets were scored based on their reported intake of 9 dietary components: fruits, vegetables, ratio of white meat to red meat, fiber, trans fat, ratio of polyunsaturated fatty acids to saturated fatty acids, calcium, folate, and iron.¹⁶ Women received a score of zero to 10 for each food/nutrient component, based on how their consumption reflected recommendations from the literature on diet and chronic disease prevention.²⁵ Component scores were added, with a maximum possible total score of 90, representing the highest possible quality diet based on AHEI-P.¹⁶

MDS

Maternal diet was also assessed in comparison to a Mediterranean diet pattern, using MDS,¹⁷ which scores reported dietary intake using external cut points influenced by the 2010 Dietary guidelines for Americans.⁴⁴ For the current analysis, the alcohol category was excluded because alcohol consumption is not recommended during pregnancy. The MDS measures individuals’ intakes of vegetables (excluding white potatoes), fruit, whole grains, legumes, nuts, fish, dairy, red and processed meat, the ratio of monounsaturated fatty acids to saturated fatty acids. Based on reported intake of each category, women’s diets were given a score of 1 for consumption above cut points, and a 0 for consumption at or below cut points for each beneficial or healthy component (vegetables, fruit, whole grains, legumes, nuts, fish, dairy, and ratio of monounsaturated fat to saturated fat). For foods recommended to be reduced (red and processed meats) a score of 1 was given for consumption at or below recommended cutoffs, and a 0 for consumption above cutoffs. Women received a score of zero to nine, with nine representing the highest possible adherence to a Mediterranean diet pattern.

Maternal Food Groups

Maternal intake of the following seven food groups was also assessed: vegetables, red and processed meats, dairy, fruit, whole grains, nuts, and beans and legumes. Food groups were selected on the basis of potential associations with chronic disease and pregnancy health.

Statistical Analysis

In these analyses, multiple linear regression models were used to test the association of food security during the second or third trimester of pregnancy with maternal AHEI-P score, maternal MDS score, and dietary intake of select food groups assessed in the AHEI-P or MDS (vegetables, red and processed meats, dairy, fruit, whole grains, nuts, and beans and legumes). The interaction term for food security × WIC status was tested. There was no significant interaction between food security and WIC (P = 0.14); therefore, only main effect models, adjusted for WIC and other covariates are presented. Covariates for adjustment included race/ethnicity (non-Hispanic Black/non-Hispanic White/non-Hispanic Other/Hispanic), age, education (≤ high school, > high school), prepregnancy BMI, parity, WIC, mean daily energy intake (in kilocalories), and possible under-reporting of intake (−1 standard deviation [SD] of reported energy intake:predicted energy intake × 100). All analyses were conducted using SAS version 9.4 (SAS Institute, Inc, Cary, NC)⁴⁵ with a significance level of P < 0.05.

RESULTS

Sociodemographic characteristics of the study sample are displayed in Table 1. The study sample was predominantly non-Hispanic Black/African American (73.7%), with 15.6% reporting non-Hispanic White race/ethnicity, 4.5% reporting other races (non-Hispanic), including Native American, Asian, Alaskan Native, Hawaiian/Pacific Islander, or more than one race, and 6.2% reporting Hispanic ethnicity (including all races). The mean (SD) age was 27.1 (5.5) years, and approximately half had completed more than a high school diploma. The average prepregnancy BMI was 30.3 (9.3). More than one-third of women reported marginal, low, or very low food security (marginal: 12.2%, low: 12.6%, or very low: 15.2%). The mean (SD) AHEI-P score was 57.9 (14.3), and ranged from 18.2 to 87.4. For the MDS, the mean (SD) score was 1.7 (1.2), with a range from zero to six. Average intakes of select food groups, overall and by food security status, are presented in Table 2.

Table 1.

Sociodemographic characteristics of women who completed a food frequency questionnaire during pregnancy as part of the Nurture study, North Carolina 2013–2016

Characteristic	Result n (%)
Total sample	468
Maternal race/ethnicity
Non-Hispanic Black/African American	345 (73.7)
Non-Hispanic White	73 (15.6)
Non-Hispanic other or more than one race	21 (4.5)
Hispanic	29 (6.2)
Education
≤ High school diploma	231 (49.4)
> High school diploma	237 (50.6)
Food security
High	281 (60.0)
Marginal	57 (12.2)
Low	59 (12.6)
Very low	71 (15.2)
Parity
Primiparous	177 (37.8)
Multiparous	291 (62.2)
WICa participation
Recipient	295 (63.0)
Nonrecipient	173 (37.0)
	mean (standard deviation)
Age (y)	27.1 (5.5)
Prepregnancy BMIb	30.3 (9.3)
AHEI-Pc score	57.9 (14.3)
MDSd	1.7 (1.2)
Daily energy intake (kcal)	2174 (945)

^aWIC = Special Supplemental Nutrition Program for Women, Infants, and Children.

^bBMI = body mass index.

^cAHEI-P = Alternate Healthy Eating Index-Pregnancy.

^dMDS = Mediterranean Diet Score.

Table 2.

Mean intakes of select food groups among women in the Nurture study, North Carolina, 2013–2016 (N = 468)

Food group	Overall	High Food Security	Marginal Food Security	Low Food Security	Very Low Food Security
Mean (standard deviation)
Vegetables (servings/d)	1.7 (1.5)	1.8 (1.7)	1.4 (1.2)	1.7 (1.4)	1.6 (1.5)
Red and processed meats (servings/wk)	11.9 (9.4)	11.0 (9.0)	12.8 (9.7)	14.5 (11.8)	12.4 (8.2)
Dairy (servings/d)	1.8 (1.2)	1.7 (1.2)	1.5 (1.0)	2.1 (1.3)	2.0 (1.2)
Fruit (servings/d)	2.3 (2.1)	2.4 (2.3)	2.0 (1.6)	2.3 (1.9)	2.2 (1.8)
Whole grains (g/d)	30.6 (22.0)	29.3 (21.1)	32.4 (24.9)	30.2 (21.1)	34.4 (23.8)
Nuts (servings/wk)	2.7 (4.6)	2.7 (4.6)	2.2 (3.7)	3.3 (5.8)	2.7 (4.4)
Beans and legumes (servings/wk)	2.8 (5.5)	3.0 (6.2)	2.1 (3.1)	3.1 (5.0)	2.6 (4.6)

These analyses showed no significant difference in AHEI-P score among women (Table 3) based on their food security status (marginal: β = −2.32 [P = 0.10]; low: β = .09 [P = 0.95]; very low: β = −2.14 [P = 0.10]). There was also no significant association between maternal food security during pregnancy and MDS (marginal: β = .00 [P = 0.98]; low: β = .12 [P = 0.50]; very low: β = −.03 [P = 0.86]).

Table 3.

Adjusted^a linear regression of the association among maternal food security status^b and Alternate Healthy Eating Index-Pregnancy (AHEI-P) and Mediterranean Diet Score (MDS) based on the Nurture study, North Carolina, 2013–2016 (N = 468)

	β (95% CI)	P value
AHEI-P
Marginal	−2.32 (−5.11 to .46)	0.10
Low	.09 (−2.80 to 2.99)	0.95
Very low	−2.14 (−4.66 to .39)	0.10
MDS
Marginal	.00 (−.32 to .33)	0.98
Low	.12 (−.22 to .46)	0.50
Very low	−.03 (−.33 to .28)	0.86

^aAdjusted for maternal race/ethnicity; age; education; prepregnancy body mass index; parity; Special Supplemental Nutrition Program for Women, Infants, and Children participation; mean daily energy intake; and possible underreporting of intake.

^bReference category is High food security.

Results of adjusted linear regression models of the association between food security status during pregnancy and consumption from individual food groups (Table 4) suggested that women who reported very low food security reported consuming fewer vegetables compared with women of high food security (β = −0.43 [P = 0.03]). Women of marginal or low food security during pregnancy consumed more red and processed meats compared to women of high food security (marginal: β = 2.20 [P = 0.03]; low: β = 2.28 [P = 0.04]).

Table 4.

Adjusted^a linear regression of the association between maternal food security^b and intake of select food groups, including vegetables^c, red and processed meats^d, dairy^c, fruit^c, whole grains^e, nuts^d, and beans and legumes^d, in the Nurture study, North Carolina, 2013–2016 (N = 468)

	β (95% CI)	P value
Vegetables
Marginal	−.24 (−.65 to .17)	0.25
Low	−.21 (−.64 to .23)	0.35
Very low	−.43 (−.81 to −.05)	0.03
Red and processed meats
Marginal	2.20 (.20 to 4.19)	0.03
Low	2.28 (.17 to 4.39)	0.04
Very low	−.03 (−1.88 to 1.82)	0.98
Dairy
Marginal	−.07 (−.37 to .23)	0.64
Low	.28 (−.04 to .59)	0.09
Very low	.12 (−.16 to .40)	0.38
Fruit
Marginal	−.41 (−.98 to .17)	0.17
Low	−.33 (−.94 to .28)	0.42
Very low	−.40 (−.93 to .14)	0.15
Whole grains
Marginal	5.47 (.00 to 10.9)	0.05
Low	1.08 (−4.67 to 6.84)	0.71
Very low	2.64 (−2.40 to 7.68)	0.30
Nuts
Marginal	.03 (−1.21 to 1.26)	0.97
Low	.61 (−.68 to 1.91)	0.35
Very low	−.22 (−1.35 to .92)	0.71
Beans and legumes
Marginal	−.77 (−2.33 to .79)	0.33
Low	−.48 (−2.12 to 1.17)	0.57
Very low	−.93 (−2.37 to .52)	0.21

^aAdjusted for maternal race/ethnicity; age, education; prepregnancy body mass index; parity; Special Supplemental Nutrition Program for Women, Infants, and Children participation; mean daily energy intake; and possible underreporting of intake.

^bReference category is High food security.

^cServings per day.

^dServings per week.

^eGrams per day.

DISCUSSION

In this study, women of very low food security during pregnancy consumed a diet lower in vegetables compared to women of high food security. In addition, women of marginal and low food security consumed more red and processed meats compared with women of high food security. However, there were no associations between food security and overall maternal diet measured by the AHEI-P and MDS.

Despite evidence suggesting that low food security is associated with low diet quality in US adults,^46–48 this study did not find an association between food security and diet quality. However, study findings related to overall diet quality are consistent with those of the few studies that have focused on low food security and diet quality during pregnancy.^33,34 This study builds on previous literature by focusing on a predominantly Black/African-American population, and by narrowing the period in which food security was assessed. Diet and food security were assessed between 20 and 36 weeks’ gestation and women were asked to report on their food security status within the past 30 days rather than the past 3 or 12 months. The timing of diet reporting aligned with that of food security status reporting, allowing for a better assessment of the correlation between food security status and diet.

In this study, women reporting very low food security consumed fewer vegetables compared with women of high food security. These findings are consistent with previous studies that have reported similar findings with respect to vegetable consumption in US adults.^5,46,49,50 Women reporting marginal and low food security in this study consumed more red and processed meats than women of high food security, which is consistent with a previous study in US adults.⁴⁶ The Dietary Guidelines for Americans recommends a diet low in processed mea because diets high in processed meat have been associated with a greater risk of chronic disease.¹⁴ Consumption of red and processed meat has also been associated with a higher risk of obesity,⁵¹ chronic disease,⁵² and mortality⁵³ in US adults. A high intake of red and processed meat during pregnancy has been associated with an increased risk for gestational diabetes⁵⁴ and an increase in the likelihood of having a small for gestational age infant.⁵⁵ Previous research in nonpregnant adults has found that a 1 serving per day increase in red and processed meat is associated with risk of type 2 diabetes.⁵² Another study reported that an increase in as little as 0.5 serving per day of red and processed meat was associated with increased mortality risk among US adults.⁵³ The findings of this study refer to 2.20 and 2.28 increase in servings per week of red and processed meats among women of marginal and low food security, respectively, which is less than has been found to be clinically significant.^52,53

The results of this study should be interpreted with caution. Although no differences in overall diet quality were observed between women with high food security and those with low food security during pregnancy, these data do not imply that women experiencing low food security during pregnancy have adequate or high-quality diets. Overall, diet quality was low in the study cohort (mean [SD] AHEI-P score = 57.9 [14.3]). Therefore, a lack of association between food security and diet quality may reflect a lack of variation in diet quality in this cohort. In addition, it is possible that misreporting of food security influenced the results of this study. Food security is a sensitive topic and may be subject to underreporting^56,57—especially during pregnancy when women may be more vulnerable to dietary criticism. Therefore, in the case that women who were food insecure systematically misrepresented their status as food secure, and those women also had poorer diets, then this would bias the study findings toward null. Conversely, in the case that the women misrepresenting their status as food secure had higher quality diets on average, study findings would be biased away from the null. Diet is also subject to misreporting due to social desirability bias.⁵⁸ In the case that women of low food security misreported their diets to appear healthier, and a higher quality diet is associated with higher food security, then this could have also biased study results toward the null.

This study contributes information on overall diet among women who experience low food security using a racially diverse cohort of women during pregnancy and previously validated measures for food security status³⁷ and diet.³⁸ Although this study has many strengths, it also has limitations. This study drew on a localized sample of predominantly African-American women during pregnancy in central North Carolina. Given the link between race, culture, and diet,^59,60 the results of the study may only be generalizable to populations in similarly located areas with similar demographic characteristics; however, they do provide information on an underrepresented demographic in research. The analysis did not account for multiple testing and may have also been limited by unmeasured confounding. The authors were not able to control for environmental factors, such as geographical access to healthy food or local food prices, which may inhibit individuals’ ability to consume a high-quality diet. The use of an FFQ as a dietary assessment tool has its limitations compared with 24-hour recalls in obtaining information on usual daily intake.⁶¹ In validation studies using biomarkers, FFQs have been found to underestimate calorie intake by approximately 30%.⁶² Energy adjustment can help attenuate this underestimation.⁶² Despite this, FFQs are still considered an adequate tool to capture overall dietary patterns, and are widely used for their cost-effectiveness and low participant burden.⁶³ In addition, the use of the Block FFQ has been previously validated³⁹ and has been shown to perform as well as or better than other FFQs in assessing habitual intake.⁶⁴ Although the AHEI-P is widely used to assess diet quality during pregnancy, it fails to capture sources of added sugar other than beverages, and does not assess dairy intake. The MDS assesses adherence to a Mediterranean-like diet pattern by scoring intake of diet component groups; however, the MDS does not include some foods that may be detrimental to health, such as added sugars. A more comprehensive measure of diet quality that comprehensively assesses both healthy and unhealthy foods in the diet is recommended for future studies.

CONCLUSIONS

This study provides evidence suggesting that food security is not associated with overall diet quality as measured by the AHEI-P and MDS. In addition, this study suggests that women who experience low or marginal food security generally consume a diet higher in red and processed meats, and those who experience very low food security generally consume fewer vegetables compared with women who report high food security. Women during pregnancy are particularly vulnerable due to greater financial needs in anticipation of a new baby, and have heightened needs for nutritionally dense foods. Thus, diet quality during pregnancy is of great importance. Research assessing factors that directly affect food purchasing decisions and consumption among food-insecure women are needed to further understand the factors underlying study findings and develop appropriate policies and interventions to help women achieve a higher diet quality.

RESEARCH SNAPSHOT.

Research Question:

Is food security (marginal, low, or very low food security, compared with high food security) associated with maternal diet during pregnancy in a group of predominantly African American women in North Carolina?

Key Findings:

In this cross-sectional study of predominantly African American or Black women in their second or third trimester of pregnancy, there was no association between food security and diet quality measured by the Alternate Healthy Eating Index-Pregnancy or Mediterranean Diet Score.