Reply to Alvarez Stehle, E. Comment on “Leone et al. Association between Mediterranean Diet and Fatty Liver in Women with Overweight and Obesity. Nutrients 2022, 14, 3771”

We thank Dr. Elvira Alvarez Stehle [1] for her interest in our work reporting the association between a Mediterranean diet and a fatty liver in women with overweight and obesity [2].

Although deviations from the original protocol were found in the PREDIMED trial, they do not affect the validation of the MEDAS questionnaire. Schröder et al. [3] did, in fact, validate MEDAS against a 137-item semiquantitative FFQ using baseline data from PREDIMED prior to randomization. Certainly, the validation of MEDAS against an FFQ has several limitations. As Schröder et al. stated in their work [3], the similar designs of FFQ and MEDAS may have caused an overestimation of the accuracy of MEDAS given the likely between-method correlation of the errors.

More recently, García-Conesa et al. [4] performed a validation study of MEDAS using small samples of subjects from different Mediterranean and non-Mediterranean countries. They compared the results obtained from MEDAS with those obtained from a 3 day dietary record. In addition to confirming the reliability of the MEDAS questionnaire, they found a good agreement between the two methods, with values similar to, and in some cases greater than, those reported by Schröder et al. [3]. They found low agreement between the two methods for some food items, but this could be due to the difficulty of quantifying a weekly consumption using a 3 day dietary record. This limitation can be overcome by using multiple 7 day dietary records.

We thus believe that the MEDAS questionnaire remains a useful and reliable tool for rapidly assessing adherence to the Mediterranean diet.