Does Adherence to Mediterranean Diet Mediate the Association Between Food Environment and Obesity Among Non-Hispanic Black and White Older US Adults? A Path Analysis

Am J Health Promot. 2020 Jul;34(6):652-658. doi: 10.1177/0890117120905240. Epub 2020 Feb 12.


Purpose: This study aims to test the hypothesis that in addition to a direct effect of food environment on obesity, food environment is indirectly associated with obesity through consuming Mediterranean diet (MD).

Design: Cross-sectional secondary data analysis.

Setting: Nationwide community-dwelling residency.

Sample: A total of 20 897 non-Hispanic black and white adults aged ≥45 years who participated in the REasons for Geographic and Racial Differences in Stroke study and completed baseline assessment during January 2003 and October 2007.

Measures: The Modified Retail Food Environment Index (mRFEI; 0-100) was used as food environment indicator. The MD score (0-9) was calculated to indicate the dietary pattern adherence. Body mass index (BMI; kg/m2) was used to estimate obesity.

Analysis: Path analysis was used to quantify the pathways between food environment, MD adherence, and obesity. Proper data transformation was made using Box-Cox power transformation to meet certain analysis assumptions.

Results: The participants were from 49 states of the United States, with the majority (64.42%) residing in the South. Most of the participants were retired, female, white, married, having less than college graduate education, having annual household income ≤75 000, and having health insurance. The means of mRFEI was 10.92 (standard deviation [SD] = 10.19), MD score was 4.36 (SD = 1.70), and the BMI was 28.96 kg/m2 (SD = 5.90). Access to healthy food outlets (β = .04, P < .0001) and MD adherence (β = .08, P < .0001) had significant and inverse relationships with BMI, respectively. Mediterranean diet adherence mediated the relationship between food environment and obesity among a subpopulation who had an annual household income of <$75 000 (β = -.02, P = .0391).

Conclusion: Population-tailored interventions/policies to modify food environment and promote MD consumption are needed in order to combat the obesity crisis in the United States.

Keywords: BMI; Mediterranean diet; built environment; dietary pattern; epidemiology; food environment; health disparities; obesity; path analysis; population health.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Black or African American
  • Body Mass Index
  • Cross-Sectional Studies
  • Diet, Mediterranean*
  • Female
  • Humans
  • Middle Aged
  • Obesity* / epidemiology
  • United States / epidemiology
  • White People