Article

Adherence to the Mediterranean Diet and Carotid Intima-Media

Thickness in University Students: A Cross-Sectional Study
Sónia Mateus 1,2 , Ana Miguel Amaral 1 , Patrícia Coelho 1,2, * and Francisco Rodrigues 1,2

1 Polytechnic Institute of Castelo Branco, 6000-084 Castelo Branco, Portugal; soniaateus@ipcb.pt (S.M.);
a.amaral@ipcbcampus.pt (A.M.A.); franciscobrodrigues@ipcb.pt (F.R.)
2 Sport Physical Activity and Health Research & Innovation Center (Sprint), Polytechnic Institute of Castelo
Branco, 6000-084 Castelo Branco, Portugal
* Correspondence: patriciacoelho@ipcb.pt

Abstract
Introduction: Subclinical atherosclerosis is increasingly recognized in younger popula-
tions, often progressing silently until the onset of overt cardiovascular events. Carotid
intima-media thickness (CIMT) is a validated, non-invasive biomarker of early vascular
alterations. Although the Mediterranean diet (MD) is well established as cardioprotective,
its relationship with CIMT in young adults remains insufficiently studied. Objective: To
assess sex-specific adherence to the Mediterranean diet and its association with carotid
intima-media thickness in a cohort of university students. Methods: A cross-sectional study
was performed involving 60 university students (50% male, aged 17–25 years), selected
through stratified probabilistic sampling. Data were collected on sociodemographic charac-
teristics, vascular risk factors, MD adherence via the PREDIMED questionnaire, and CIMT
measured using a high-resolution carotid Doppler ultrasound. Statistical analyses included
chi-square tests and descriptive statistics, with significance set at ρ ≤ 0.05. Results: A no-
table 95% of participants showed low adherence to the Mediterranean diet. Significant sex
differences in dietary patterns were identified: males consumed more red meat (ρ = 0.023),
while females reported higher fish intake (ρ = 0.037). Despite behavioral risk factors, all
CIMT values remained within normal ranges (≤0.9 mm). No significant association was
found between MD adherence and CIMT (ρ = 0.554). Conclusion: This exploratory study
Academic Editor: Jürgen Vormann reveals a high prevalence of modifiable cardiovascular risk factors, including poor dietary
Received: 22 July 2025 adherence, among young adults, despite the absence of detectable vascular structural
Revised: 1 August 2025 changes. Although no significant association was found, the findings reflect the dietary
Accepted: 5 August 2025 and behavioral profiles of a young, low-risk population.
Published: 18 August 2025

Citation: Mateus, S.; Amaral, A.M.; Keywords: atherosclerosis; Mediterranean diet; cardiovascular risk factors; carotid intima-media
Coelho, P.; Rodrigues, F. Adherence to thickness; Doppler ultrasound; young adults; university students
the Mediterranean Diet and Carotid
Intima-Media Thickness in University
Students: A Cross-Sectional Study.
Obesities 2025, 5, 62. https://doi.org/
10.3390/obesities5030062
1. Introduction
Cardiovascular diseases (CVDs) remain the leading cause of morbidity and mortality
Copyright: © 2025 by the authors.
Licensee MDPI, Basel, Switzerland.
globally, representing a major public health burden across populations and health sys-
This article is an open access article tems [1–3]. Atherosclerosis is widely recognized as the primary pathological mechanism
distributed under the terms and underlying most CVD manifestations [4]. According to the World Health Organization
conditions of the Creative Commons (WHO), CVD accounted for approximately 17.9 million deaths in 2019, equating to 32%
Attribution (CC BY) license of all global deaths, with projections indicating an increase to 23 million annual deaths by
(https://creativecommons.org/
2030 [5,6]. In Portugal, CVD continues to be the leading cause of mortality, responsible for
licenses/by/4.0/).

Obesities 2025, 5, 62 https://doi.org/10.3390/obesities5030062

Obesities 2025, 5, 62 2 of 14

28% of all deaths in 2020—an increase of 2.9% compared to 2019 and the highest recorded
in the past decade [7,8]. Cerebrovascular disease, in particular, accounts for 9.2% of all
deaths (111 per 100,000 inhabitants), disproportionately affecting women and older adults,
with 93.9% of such deaths occurring in individuals aged ≥65 years [9].
Although traditionally associated with older adults, modifiable cardiovascular risk
factors are increasingly prevalent among younger populations, especially university stu-
dents [10,11]. While the etiology of CVD is multifactorial, atherosclerosis is universally
accepted as the central pathological process that initiates and drives disease progression [12].
Elevated adiposity—particularly pericardial fat—has been independently associated with
impaired left ventricular diastolic function [13], highlighting the need for the early screen-
ing of abdominal fat accumulation and waist circumference as key modifiable risk fac-
tors [12–14]. Although clinical manifestations of CVD typically emerge during middle
age, there is compelling evidence that atherosclerotic changes may begin in utero and
silently progress throughout life [15]. Atherosclerosis risk factors are broadly categorized
as modifiable or non-modifiable [16].
In this context, the eCOR study, “Prevalence of Cardiovascular Risk Factors in the
Portuguese Population” (2019), estimated the national burden of various risk factors,
identifying an inadequate diet (71.3%), pre-obesity/obesity (62.1%), hypertension (43.1%),
physical inactivity (29.2%), tobacco use (25.4%), and excessive alcohol consumption (18.8%)
as the most prevalent [10]. In response, the Portuguese National Program for the Promotion
of Healthy Eating (PNPAS 2022–2030) has outlined strategic interventions targeting these
risk factors to improve population-level cardiovascular health [17].
The early identification of reliable, non-invasive markers is crucial for CVD prevention.
The carotid intima-media thickness (CIMT) measurement has been widely validated as a
surrogate marker for subclinical atherosclerosis [18]. Although robust evidence supports
the cardiovascular benefits of the Mediterranean diet (MedDiet), its association with early
vascular changes, such as CIMT, in young and asymptomatic individuals remains less
well established.
Doppler ultrasonography has been used to assess vascular remodeling in response to
various physiological stimuli, including physical activity. Studies have reported significant
differences in the arterial velocity and vessel diameter between athletes and non-athletes,
suggesting that exercise-induced vascular adaptations may contribute to cardiovascular
protection [18]. Given its non-invasive nature and capacity to detect preclinical changes,
Doppler ultrasound is particularly suitable for evaluating vascular health in young adults,
where overt disease has not yet developed [4]. Carotid ultrasound allows for the quantifi-
cation of CIMT, detection of atheromatous plaques, and assessment of vascular remodeling
and functional changes, offering valuable insights into early subclinical pathology and
potential systemic implications [5,19]. For example, studies on futsal athletes have demon-
strated marked arterial and venous remodeling in the lower limbs, reflecting the vascular
impact of high-intensity, intermittent physical activity [20].
Against this background, preventing atherosclerosis is a critical public health priority.
Adopting healthy dietary patterns—particularly the Mediterranean diet—offers a compre-
hensive, evidence-based approach to mitigate modifiable risk factors and potentially slow
or prevent the development of atherosclerosis [21].
The Mediterranean diet has been extensively studied for its effects on CIMT and
carotid atherosclerosis. The NOMAS study demonstrated that long-term adherence to
the MedDiet was associated with reduced CIMT and a lower incidence of cardiovascu-
lar events [22]. Similarly, the PREDIMED-Navarra trial investigated the impact of the
MedDiet on subclinical atherosclerosis and found no significant short-term differences
between groups; however, participants with higher baseline CIMT experienced regression,
Obesities 2025, 5, 62 3 of 14

suggesting a potential benefit in higher-risk individuals [23]. Furthermore, recent evidence

(2021) indicates significant CIMT reductions after 5–7 years of sustained adherence to the
Mediterranean diet, reinforcing its long-term protective role [24]. Olive oil, a cornerstone
of the MedDiet, has also been inversely associated with CIMT, as shown by Buil-Cosiales
et al. [25]. Diets rich in fruits, vegetables, fish, and whole grains have similarly been linked
to lower CIMT values [26].
Taken together, these findings highlight the potential of the Mediterranean diet
to attenuate atherosclerotic progression, particularly in individuals at an elevated car-
diovascular risk, and emphasize the importance of dietary strategies in cardiovascular
disease prevention.
Accordingly, the primary aim of this study was to examine the relationship between
adherence to the Mediterranean diet and carotid intima-media thickness (CIMT) in a
sample of university students, with the consideration of sex-specific dietary differences.
Secondary objectives included evaluating CIMT values by sex and assessing the prevalence
of other vascular risk factors. While the main focus was the potential association between
MedDiet adherence and CIMT, sex-based dietary patterns were analyzed as possible
confounding variables.
We hypothesized that greater adherence to the Mediterranean diet would be associated
with lower CIMT values and that female participants would demonstrate higher dietary
adherence compared to their male counterparts.

2. Materials and Methods

2.1. Study Design
This cross-sectional study was conducted in September 2022 at a Higher School of
Health, following approval from the institutional ethics committee (approval number 65
CE-IPCB/2022). The study aimed to investigate the association between adherence to the
Mediterranean diet and carotid intima-media thickness (CIMT) among university students.

2.2. Participants and Setting

A total of 60 university students aged 17 to 25 years participated in the study. A
stratified probabilistic sampling method was employed to ensure demographic represen-
tativeness across sex and academic programs. The age range was selected to capture
individuals in a transitional phase between adolescence and adulthood, during which
significant lifestyle behaviors impacting cardiovascular health are often established.

2.3. Inclusion and Exclusion Criteria

Eligible participants were those enrolled at the institution, who provided informed
consent, completed the study questionnaire, and underwent a carotid Doppler ultrasound
assessment. Students from any academic discipline were considered eligible. Exclusion
criteria included refusal to participate or failure to complete the required procedures.

2.4. Initial Procedures

All participants were informed about the study’s objectives, procedures, and confiden-
tiality guarantees. Upon providing written informed consent, they completed a structured
questionnaire comprising sociodemographic and health-related sections. All participants
completed the questionnaires in a classroom setting under researcher supervision, follow-
ing standardized instructions to minimize response bias. The ultrasound operator was
blinded to the participants’ dietary information to minimize measurement bias.
Obesities 2025, 5, 62 4 of 14

2.5. Data Collection Instruments and Variables

• Sociodemographic Data:
Information regarding age, sex, and educational background was collected and used
to categorize participants for subgroup analyses.
• Anthropometric Measurements:
Weight and height were measured using standardized procedures. Body mass index
(BMI) was calculated as weight in kilograms divided by height in meters squared
(kg/m2 ) and categorized according to WHO criteria.
• Assessment of Vascular Risk Factors:
Participants reported on known cardiovascular risk factors, including smoking status,
history of hypertension, diabetes, dyslipidemia, and prior dietary counseling. Smoking
was categorized as current, former (cessation >12 months), or never. Hypertension
was defined as a previous medical diagnosis or the use of antihypertensive medication.
Dyslipidemia was considered present when participants reported a prior clinical
diagnosis or were on lipid-lowering therapy.
• Dietary Habits and Mediterranean Diet Adherence:
Adherence to the Mediterranean diet was assessed using the validated 14-item PRED-
IMED questionnaire [23,27,28]. Each affirmative response to a favorable dietary habit
scores one point, for a total score ranging from 0 to 14. A score of ≥10 indicates good
adherence; <10 indicates low adherence.
• Carotid Intima-Media Thickness (CIMT) Assessment:
CIMT was evaluated using a Philips HD7 ultrasound system equipped with a
5–12 MHz linear transducer. Bilateral measurements of the common carotid arteries
were performed with participants in the supine position and the neck slightly hyperex-
tended to optimize visualization. Three measurements were obtained on each side and
averaged to determine the mean CIMT. All measurements were performed manually
at the far wall of the distal 1 cm of the common carotid artery, approximately 10 mm
below the carotid bifurcation. CIMT values were classified as follows:
• ≤0.9 mm: normal;
• 1.0–1.4 mm: arterial wall thickening;
• ≥1.5 mm: presence of an atheromatous plaque.

2.6. Statistical Analysis

Data were analyzed using IBM SPSS Statistics, version 27. Descriptive statistics
included means, standard deviations, and frequencies. The Kolmogorov–Smirnov test
was applied to assess normality. Associations between categorical variables were tested
using the chi-square test. Given the limited sample size and the categorical nature of most
variables, no multivariate models were applied. Future studies with larger samples may
benefit from regression or multivariate analysis to adjust for potential confounding factors.
Each artery was measured three times independently, and the average value was used
for analysis. However, intra- and inter-observer variability were not formally assessed,
which is acknowledged as a methodological limitation.

3. Results
The selection of participants was conducted through probabilistic and stratified sam-
pling, ensuring an equitable and representative distribution. Confidence intervals (95%)
were calculated for all major findings to account for the sample size limitations. Com-
parisons of CIMT values by gender and dietary adherence were included to enhance the
visualization of results. The sample for this study consists of a total of 60 participants, with
an equal distribution between sexes: 50% (n = 30) are female and 50% (n = 30) are male.
Obesities 2025, 5, 62 5 of 14

Regarding age, Table 1 shows that the sample is predominantly composed of young adults,
with a mean age of 20.12 years and a standard deviation of ±1.91 years, ranging from 17
to 25 years (30 females sex and 30 males). In terms of body composition (Table 1), the
average body mass index (BMI) was 22.63 kg per square meter (kg/m2 ), with a standard
deviation of ±2.99 kg/m2 . The lowest recorded BMI was 16.8 kg/m2 , while the highest
was 30.8 kg/m2 . Overall, 95% of students exhibited low Mediterranean diet adherence,
with no significant association between adherence and CIMT (p = 0.554).

Table 1. Characterization of age and body mass index (n = 60).

Age Total (n = 60)

Average (mean value + standard deviation) 20.12 years ± 1.91 years
Minimum 17 years
Maximum 25 years
BMI (kg/m2 ) Total (n = 60)
Median (mean value + standard deviation) 22.63 kg/m2 ± 2.99 kg/m2
Minimum 16.8 kg/m2
Maximum 30.8 kg/m2
Legend: n = number of samples; BMI = body mass index (kg/m2 ).

3.1. Modifiable Vascular Risk Factors

As observed in Table 2, the results revealed an absence of hypertension and diabetes
mellitus among the participants. Dyslipidemia was present in only 1.7% (n = 1) of the
individuals studied. Regarding smoking habits, 21.7% (n = 13) of the participants were
smokers, and only 1.7% (n = 1) were former smokers. Additionally, obesity was observed
in just 3.3% (n = 2) of the sample. Physical inactivity stood out as the most prevalent
risk factor, with 43.3% (n = 26) of participants classified as physically inactive. Regarding
modifiable vascular risk factors, physical inactivity was the most prevalent risk factor
(43.3%), followed by smoking (21.7%).

Table 2. Prevalence of modifiable vascular risk factors among students (n = 60).

Doesn’t Know or Does

Risk Factors Yes No
not Answer
High blood pressure 0% (n = 0) 100% (n = 60) 0% (n = 0)
Diabetes mellitus 0% (n = 0) 100% (n = 60) 0% (n = 0)
Dyslipidemia 1.7% (n = 1) 93.3% (n = 56) 5% (n = 3)
Smoker 21.7% (n = 13) 78.3% (n = 47) 0% (n = 0)
Ex-smoker 1.7% (n = 1) 76.7% (n = 46) 0% (n = 0)
Obesity 3.3% (n = 2) 96.7% (n = 58) 0% (n = 0)
Physical inactivity 43,% (n = 26) 56.7% (n = 34). 0% (n = 0)
Legend: % = percentage; n = number of samples.

Modifiable Vascular Risk Factors by Sex

The comparative analysis of the presence of risk factors by sex (Table 3) revealed that
neither female nor male participants exhibited hypertension or diabetes mellitus, with a
prevalence of 0% (n = 0) in both cases. Regarding dyslipidemia, a prevalence of 3.3% (n = 1)
was observed in females, while no cases were noted in males. It is noteworthy that 3.3%
(n = 1) of females and 6.7% (n = 2) of males did not know or did not respond to the question
about dyslipidemia.
Obesities 2025, 5, 62 6 of 14

Table 3. Prevalence of modifiable vascular risk factors between sexes (n = 60).

Female Sex (n = 30) Male Sex (n = 30)

Does Not
Does Not Know or
Risk Factors Yes No Know or Does Yes No
Does Not Answer
Not Answer
High blood
0% (n = 0) 100% (n = 30) 0% (n = 0) 0% (n = 0) 100%(n = 30) 0% (n = 0)
pressure
Diabetes mellitus 0% (n = 0) 100% (n = 30) 0% (n = 0) 0% (n = 0) 100% (n = 30) 0% (n = 0)
Dyslipidemia 3.3% (n = 1) 93.3% (n = 28) 3.3% (n = 1) 0% (n = 0) 93.3 (n = 28) 6.7% (n = 2)
Smoker 16.7% (n = 5) 83.3% (n = 25) 0% (n = 0) 26.7% (n = 8) 73.3%(n = 22) 0% (n = 0)
Ex-smoker 3.3% (n = 1) 80% (n = 24) 0% (n = 0) 0% (n = 0) 73.3%(n = 22) 0% (n = 0)
Obesity 0% (n = 0) 100% (n = 30) 0% (n = 0) 6.7% (n = 2) 93.3 (n = 28) 0% (n = 0)
Physical inactivity 60% (n = 18) 40% (n = 12) 0% (n = 0) 26.7% (n = 8) 73.3%(n = 22) 0% (n = 0)
Legend: % = percentage; n = number of samples.

Concerning smoking habits, a higher prevalence was found in males, with 26.7% (n = 8)
identified as current smokers compared to 16.7% (n = 5) among females. Additionally,
3.3% (n = 1) of females were former smokers, while no male participants reported being
ex-smokers.
Regarding obesity, 6.7% (n = 2) of males were classified as obese, whereas no cases of
obesity were recorded among females. Lastly, physical inactivity was more prevalent in
females, with 60% (n = 18) compared to 26.7% (n = 8) in males (Table 3).

3.2. Mediterranean Diet

Regarding dietary habits, the responses obtained through the PREDIMED question-
naire (Table 4) revealed a heterogeneous adherence to the components of the Mediterranean
diet. Among the participants, positive behaviors with high adherence were noted: 90.2%
(n = 55) used olive oil as their main cooking fat; 50.8% (n = 31) consumed fewer than one
sugary or carbonated drink per day; 70.5% (n = 43) consumed seven or more glasses of wine
per week; 73.8% (n = 45) preferred chicken, turkey, or rabbit over beef, pork, hamburgers,
or sausages; and 96.7% (n = 59) regularly consumed vegetables, pasta, rice, or other dishes
made with a sauté of tomato, onion, leek, or garlic and olive oil at least twice a week.

Table 4. Interpretation of responses to PREvention with MEDiterránea Diet (n = 60).

Score
Question Answer % (n)
(1 = Adherent)
Yes 90.2% (55) 1
Do you use olive oil as your main cooking fat?
No 8.2% (5) 0
How many tablespoons of olive oil do you consume ≥4 tablespoons 6.6% (4) 1
daily (including cooking, salad dressing, etc.)? <4 tablespoons 91.8% (56) 0
≥2 servings (at least one
How many servings of vegetables do you eat per day? 34.4% (21) 1
raw)
(1 serving = 200 g, side dishes = ½ serving)
<2 servings 63.9% (39) 0
How many pieces of fruit (including natural juices) do ≥3 pieces 24.6% (15) 1
you consume per day? <3 pieces 73.8% (45) 0
How many servings of red meat, hamburgers or <1 serving 13.1% (8) 1
processed meats do you eat per day? (100–150 g) ≥1 serving 85.2% (52) 0
Obesities 2025, 5, 62 7 of 14

Table 4. Cont.

Score
Question Answer % (n)
(1 = Adherent)
How many servings of butter, margarine, or cream do <1 serving 34.4% (21) 1
you consume per day? (1 serving = 12 g) ≥1 serving 63.9% (39) 0
How many sugary or carbonated drinks do you drink <1 drink 50.8% (31) 1
per day? ≥1 drink 47.5% (29) 0
7 or more 70.5% (43) 1
How many glasses of wine do you drink per week?
<7 27.9% (17) 0
How many servings of legumes do you eat per week? ≥3 servings 44.3% (27) 1
(1 serving = 150 g) <3 servings 54.1% (33) 0
How many servings of fish or seafood do you eat per ≥3 servings 24.6% (15) 1
week? (100–150 g fish or 200 g seafood) <3 servings 73.8% (45) 0
How often do you eat commercial pastries or sweets <3 times per week 36.1% (22) 1
(cakes, cookies, biscuits)? ≥3 times per week 62.3% (38) 0
How many servings of nuts (e.g., walnuts, almonds, ≥3 servings 13.1% (8) 1
peanuts) do you consume per week? (30 g/serving) <3 servings 85.2% (52) 0
Do you prefer to eat poultry (chicken, turkey, rabbit) Yes 73.8% (45) 1
over red or processed meats? No 24.6% (15) 0
How many times per week do you eat dishes made ≥2 times/week 96.7% (59) 1
with sautéed tomato, onion, leek, garlic, and olive oil? <2 times/week 1.6% (1) 0
Legend: each response marked as “adherent” receives 1 point based on the original PREDIMED criteria. The total
score ranges from 0 to 14. BMI = body mass index; n = number of participants.

Conversely, negative behaviors with high adherence were also recorded among partic-
ipants: 91.8% (n = 56) consumed fewer than four tablespoons of olive oil per day; 63.9%
(n = 39) consumed fewer than two servings of vegetables per day or less than one serving
raw; 73.8% (n = 45) consumed fewer than three pieces of fruit per day; 85.2% (n = 52)
consumed one or more servings of red meat, hamburgers, or processed meats per day;
63.9% (n = 39) consumed one or more servings of butter, margarine, or cream per day;
54.1% (n = 33) consumed fewer than three servings of legumes per week; 73.8% (n = 45)
consumed fewer than three servings of fish or seafood per week; 62.3% (n = 38) consumed
pastries or commercial sweets three or more times per week; and 85.2% (n = 52) consumed
fewer than three servings of nuts per week.
The chi-square test indicated statistically significant differences in the use of olive oil
as the main cooking fat and in the daily amount consumed, both with ρ < 0.0001; in the
daily consumption of vegetables (ρ = 0.020) and fruits (ρ < 0.0001); in the intake of red meat,
hamburgers, or processed meats (ρ < 0.0001); and in the weekly consumption of butter,
margarine, or cream (ρ = 0.020), wine (ρ = 0.001), fish or seafood (ρ < 0.0001), pastries or
sweets (ρ = 0.039), and nuts (ρ < 0.0001). The preference for chicken, turkey, or rabbit over
red meats was also significant (ρ < 0.0001), as was the consumption of vegetables, pasta,
rice, or other dishes made with sauté (ρ < 0.0001).

Mediterranean Diet by Sex

The comparative analysis of dietary habits between sexes, based on responses from
the PREDIMED questionnaire, revealed several trends in positive and negative behaviors.
Positive behaviors included the following:
Obesities 2025, 5, 62 8 of 14

• 96.7% of females and 86.7% of males used olive oil as their main cooking fat.
• 60.0% of females and 56.7% of males consumed sugary or carbonated drinks less than
once a day.
• 100% of females and 96.7% of males regularly consumed vegetables, pasta, rice, or
sautéed dishes at least twice a week.
Negative behaviors included the following:
• 76.7% of females and 96.7% of males consumed one or more servings of red meat,
hamburgers, or processed meats daily.
• 50.0% of females and 60.0% of males consumed fewer than three servings of legumes
per week.
• 63.3% of both sexes consumed pastries or sweets three or more times per week.
The chi-square test identified statistically significant differences in consumption pat-
terns: males consumed significantly more red meat, hamburgers, or processed meats
(ρ = 0.023), while females consumed significantly more fish or seafood (ρ = 0.037) and
preferred chicken, turkey, or rabbit over red meats (ρ = 0.001) (Table 5).

Table 5. Interpretation of responses to PREvention with MEDiterránea Diet between sexes (n = 60).

p-
Questions Answers Female (n = 30) Male (n = 30)
Value
Yes 96.7% (n = 29) 86.7% (n = 26)
Do you use olive oil as your main cooking fat? 0.161
No 3.3% (n = 1) 13.3% (n = 4)
How much olive oil do you consume in a day < 4 < 4 tablespoons 96.7% (n = 29) 90.0% (n = 27)
(including use for frying, dressing salads, 0.301
eating out, etc.)? ≥ 4 ≥ 4 tablespoons 3.3% (n = 1) 10.0% (n = 3)
< 2 < 2 portions or < 1 < 1
How many servings of vegetables do you eat 66.7% (n = 20) 63.3% (n = 19)
raw portion
per day? (1 serving: 200 g; consider side 0.787
dishes as half a serving) ≥ 2 ≥ 2 portions or ≥ 1 ≥ 1
33.3% (n = 10) 36.7% (n = 11)
raw portion

How many pieces of fruit (including natural < 3 < 3 per day 80.0% (n = 24) 70.0% (n = 21)
fruit juices) do you consume per day? 0.371
≥ 3 ≥ 3 per day 20.0% (n = 6) 30.0% (n = 9)

How many servings of red meat, hamburgers < 1 portion per day 23.3% (n = 7) 3.3% (n = 1)
or meat products (ham, sausage, etc.) do you ≥1≥ 0.023
eat per day? (1 serving: 100–150 g) 76.7% (n = 23) 96.7% (n = 29)
1 portion per day portion per day

How many servings of butter, margarine, or < 1 portion per day 23.3% (n = 7) 46.7% (n = 14)
cream do you consume per day? (1 serving: ≥1≥ 0.058
12 g) 76.7% (n = 23) 53.3% (n = 16)
1 portion per day portion per day

How many sugary or carbonated drinks do < < 1 per day 60.0% (n = 18) 43.3% (n = 13)
you drink per day? 0.196
≥ 1 ≥ 1 per day 40.0% (n = 12) 56.7% (n = 17)

How many glasses of wine do you drink per < 7 < 7 glass per week 20.0% (n = 6) 36.7% (n = 11)
0.152
week? ≥ 7 ≥ 7 glass per week 80.0% (n = 24) 63.3% (n = 19)

How many servings of legumes do you eat < 3 < 3 per week 50.0% (n = 15) 60.0% (n = 18)
per week? (1 serving: 150 g) 0.436
≥ 3 ≥ 3 per week 50.0% (n = 15) 40.0% (n = 12)
How many portions of fish or seafood do you
< 3 < 3 per week 63.3% (n = 19) 86.7% (n = 26)
eat per week? (1 portion: 100–150 g of fish or 0.037
4–5 units or 200 g of seafood) ≥ 3 ≥ 3 per week 36.7% (n = 11) 13.3% (n = 4)
Obesities 2025, 5, 62 9 of 14

Table 5. Cont.

p-
Questions Answers Female (n = 30) Male (n = 30)
Value
How many times a week do you consume < 3 times per week 36.7% (n = 11) 36.7% (n = 11)
commercially available (not homemade) pastries 1.000
or sweets, such as cakes, cookies, biscuits? ≥ 3 ≥ 3 per week 63.3% (n = 19) 63.3% (n = 19)
How many servings of nuts (walnuts, almonds, < 3 < 3 per week 86.7% (n = 26) 86.7% (n = 26)
including peanuts) do you consume per week? (1 1.000
serving 30 g) ≥ 3 ≥ 3 per week 13.3% (n = 4) 13.3% (n = 4)

Do you prefer to eat chicken, turkey or rabbit Yes 93.3% (n = 28) 56.7% (n = 17)
instead of beef, pork, hamburgers or sausages? 0.001
No 6.7% (n = 2) 43.3% (n = 13)
How many times a week do you eat vegetables,
pasta, rice or other dishes made with a stir-fry < 2 < 2 per week 0% (n = 0) 3.3% (n = 1)
0.313
(sauce made with tomato, onion, leek or garlic
and olive oil)? ≥ 2 ≥ 2 per week 100% (n = 30) 96.7% (n = 29)
Legend: % = percentage; n = number of samples.

We observe that 95% (n = 57) of university students demonstrated poor adherence

to the Mediterranean diet, while only 5% (n = 3) showed good adherence. No female
participants reported receiving dietary counseling, while only one male participant (3.3%)
indicated having received such guidance.

3.3. Values of the Carotid Intima-Media Thickness

Regarding the CIMT, the average values were 0.626 mm (±0.1031 mm) in the right
common carotid artery and 0.613 mm (±0.0957 mm) in the left common carotid artery. The
minimum values were 0.4 mm and the maximum values were 0.9 mm, both observed in
both carotid arteries. The comparative analysis of CIMT values between genders revealed
that females recorded average values of 0.595 mm with a standard deviation of ±0.1025 mm
in the right common carotid artery and 0.602 mm with a standard deviation of ±0.0850 mm
in the left common carotid artery. In contrast, males not only exhibited higher average
values, with 0.657 mm and a standard deviation of ± 0.0957 in the right common carotid
artery and 0.625 mm with a standard deviation of ± 0.1056 mm in the left common carotid
artery, but also recorded higher maximum values, reaching 0.9 mm in both carotid arteries,
compared to 0.8 mm observed in females.

3.4. Adherence to the Mediterranean Diet and Carotid Intima-Media Thickness Values
Between Genders
According to the data presented in Table 6, it was observed that among females,
96.7% (n = 29) had low adherence to the Mediterranean Diet (MedDiet), while 3.3% (n = 1)
demonstrated high adherence. Regarding males, the results were similar, with 93.3%
(n = 28) showing low adherence to the MedDiet, while 6.7% (n = 2) exhibited high adherence.
In both genders, CIMT values remained equal to or below 0.9 mm, indicating that regardless
of the level of adherence to the MedDiet, the values stayed within the normal range. The chi-
square test indicated no statistically significant association between the degree of adherence
to the MedDiet and CIMT in both genders (ρ = 0.554).
Obesities 2025, 5, 62 10 of 14

Table 6. Correlation between adherence to the Mediterranean diet and carotid intima-media thickness
values between genders (n = 60).

CIMT (Right and Left) Low Adherence to the MedDiet High Adherence to the MedDiet
p-Value
Reference Values Female (n = 30) Male (n = 30) Female (n = 30) Male (n = 30)
≤0.9 mm 96.7% (n = 29) 93.3% (n = 28) 3.3% (n = 1) 6.7% (n = 2) 0.554
1 a 1.4 mm 0% (n = 0) 0% (n = 0) 0% (n = 0) 0% (n = 0) NA
≥1.5 mm 0% (n = 0) 0% (n = 0) 0% (n = 0) 0% (n = 0) NA
Legend: NA = not applicable; % = percentage; n = number of samples.

4. Discussion
4.1. Key Findings
To our knowledge, this is one of the few studies evaluating the association between
adherence to the Mediterranean diet (MedDiet) and carotid intima-media thickness (CIMT)
in a young university population. Despite 95% of students presenting low adherence to
the MedDiet, CIMT values remained within normal ranges, with no statistically significant
association between dietary adherence and subclinical atherosclerosis (ρ = 0.554).
Physical inactivity emerged as the most prevalent modifiable risk factor, especially
among females, confirming the gender-based disparities previously reported in similar
cohorts. Esteves et al. (2017) found that 35% of university students were physically inactive
due to barriers such as time constraints and financial limitations [29–32]. These results
are consistent with Sinclair [33] and Goje et al. (2014), who also reported lower physical
activity levels among females [34].
Smoking was the second most prevalent behavior, particularly among males—aligning
with the findings of Carvalho et al. (2017) and Pimentel et al. (2013), which docu-
mented increased smoking rates and initiation among university students upon entering
higher education [35,36].
In terms of body composition, only 3.3% of participants were classified as obese—
similar to the 7.7% prevalence reported by Odlaug et al. (2015) [37]. Males showed
slightly higher BMI values, consistent with findings of Vijayalakshmi [38]. Notably, no
participants had hypertension or diabetes mellitus, which differs from the studies by Silva
and Theodoropoulos [39] and Freitas et al. [40], as well as others [41–44] that reported low,
but measurable, rates of these conditions in similar populations.
Dietary analysis revealed marked differences by sex: males consumed significantly
more red and processed meats (ρ = 0.023), while females reported higher consumption
of fish (ρ = 0.037) and poultry (ρ = 0.001)—findings consistent with González-Sosa [44].
Although statistically significant, the clinical implications of these dietary differences
remain limited in the absence of corresponding vascular abnormalities.

4.2. Interpretation of CIMT Results

All CIMT values were below 0.9 mm, indicating no arterial wall thickening or plaque
formation. This likely reflects a floor effect, whereby the limited variability and normal
range of CIMT measurements in this low-risk, young population mask potential associ-
ations. Chehuen Neto et al. (2021) also noted that atherosclerotic changes detectable via
CIMT generally emerge after age 25, beginning with the progression from fatty streaks to
plaque formation [30].
The slightly higher CIMT values observed in males may be attributable to sex-specific
hormonal differences. Tan et al. (2009) and Meyer et al. (2006) suggest that estrogen plays a
protective role in premenopausal women by reducing lipid accumulation and promoting
vascular integrity [45,46].
Obesities 2025, 5, 62 11 of 14

4.3. Methodological Considerations and Limitations

Several limitations must be acknowledged. First, the relatively small sample size
(n = 60) may limit statistical power and generalizability. A formal sample size calculation
was not performed a priori. Second, the cross-sectional design precludes causal inference.
Third, while CIMT measurements were repeated three times per artery and averaged, inter-
and intra-observer variability were not formally assessed. The ultrasound operator was
blinded to dietary data, reducing the risk of measurement bias.
Dietary adherence was assessed using the PREDIMED questionnaire, which, although
validated in Mediterranean adult populations, was not specifically designed for young
adults. All participants completed the questionnaire under supervision, with standardized
instructions, yet recall and reporting biases cannot be excluded. The absence of biochemical
markers or objective dietary assessments (e.g., 24 h recalls, plasma carotenoids, or fatty
acid profiles) further limits the strength of dietary evaluation.
Finally, the exclusive use of chi-square tests to explore associations was driven by the
categorical nature of the data and limited sample size. Future studies with larger cohorts
should explore multivariate or regression models to adjust for confounders such as BMI,
smoking status, and physical activity.

4.4. Public Health Implications

Despite the limitations, this study highlights concerning trends in health behaviors
among university students, including poor dietary quality and sedentary lifestyles. While
CIMT values were within normal ranges, the presence of multiple modifiable risk factors
in this population suggests that early preventive strategies are warranted.
Universities represent an ideal setting for the implementation of targeted health-
promotion programs, including nutrition education, physical activity campaigns, and
collaborations with food providers to improve access to healthier options. Broader public
health strategies might include mandatory health modules, the integration of lifestyle
medicine into student services, and environmental changes that support healthy behaviors.

4.5. Future Perspectives

Future research should employ longitudinal designs to monitor the evolution of
vascular health over time and to assess whether early lifestyle patterns predict changes in
CIMT or cardiovascular outcomes later in life. The inclusion of validated tools for younger
populations, objective dietary biomarkers, and more sophisticated statistical modeling will
enhance the robustness of future findings.

5. Conclusions
This study highlights the alarmingly low adherence to the Mediterranean diet among
university students, alongside a high prevalence of modifiable cardiovascular risk factors,
particularly physical inactivity and smoking. Although no significant association was found
between dietary adherence and carotid intima-media thickness (CIMT), these findings
underscore the need for early, targeted public health interventions.
Nutrition education and lifestyle-modification programs should be integrated into
university health services as part of comprehensive cardiovascular-risk-prevention strate-
gies for young adults. Interventions focusing on promoting healthy dietary patterns and
increasing physical activity levels are critical to prevent the early establishment of risk
behaviors that contribute to future cardiovascular morbidity.
Although no significant association was observed between Mediterranean diet adher-
ence and CIMT, the high prevalence of modifiable risk behaviors highlights the importance
of early health promotion. However, given the cross-sectional design and the limited sam-
Obesities 2025, 5, 62 12 of 14

ple size, these findings should be interpreted with caution and further validated through
longitudinal studies.

Author Contributions: Conceptualization, A.M.A. and S.M.; methodology, A.M.A.; software, P.C.;
validation, S.M. and P.C.; formal analysis, P.C.; investigation, A.M.A.; resources, A.M.A.; data
curation, S.M.; writing—original draft preparation, A.M.A. and S.M.; writing—review and editing,
F.R.; visualization, P.C.; supervision, S.M.; project administration, S.M. All authors have read and
agreed to the published version of the manuscript.

Funding: This research received no external funding.

Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki, and approved by the Ethics Committee of Polytechnic Institute of Castelo Branco (number
65 CE-IPCB/2022).

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement: The datasets generated and/or analyzed during the current study are
not publicly available due to the fact that they are human health data, but they are available from the
corresponding author upon reasonable request.

Conflicts of Interest: The authors declare no conflicts of interest.

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