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Mediterranean Diet, Retinopathy, Nephropathy, and Microvascular Diabetes Complications: A Post Hoc Analysis of a Randomized Trial

Publicated to:Diabetes Care. 38 (11): 2134-2141 - 2015-11-01 38(11), DOI: 10.2337/dc15-1117

Authors: Diaz-Lopez, Andres; Babio, Nancy; Martinez-Gonzalez, Miguel A; Corella, Dolores; Amor, Antonio J; Fito, Montse; Estruch, Ramon; Aros, Fernando; Gomez-Gracia, Enrique; Fiol, Miquel; Lapetra, Jose; Serra-Majem, Lluis; Basora, Josep; Javier Basterra-Gortari, F; Zanon-Moreno, Vicente; Angel Munoz, Miguel; Salas-Salvado, Jordi

Affiliations

Centro de Investigacion Biomedica en Red de Fisiopatologia de la Obesidad y Nutricion, Instituto de Salud Carlos III, Madrid, Spain Department of Cardiology, University Hospital Araba, Vitoria, Spain - Author
Centro de Investigacion Biomedica en Red de Fisiopatologia de la Obesidad y Nutricion, Instituto de Salud Carlos III, Madrid, Spain Department of Clinical Sciences, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain - Author
Centro de Investigacion Biomedica en Red de Fisiopatologia de la Obesidad y Nutricion, Instituto de Salud Carlos III, Madrid, Spain Department of Family Medicine, Distrito Sanitario Atencion Primaria Sevilla, Centro de Salud San Pablo, Sevilla, Spain - Author
Centro de Investigacion Biomedica en Red de Fisiopatologia de la Obesidad y Nutricion, Instituto de Salud Carlos III, Madrid, Spain Department of Internal Medicine, IDIBAPS, Hospital Clinic, University of Barcelona, Barcelona, Spain - Author
Centro de Investigacion Biomedica en Red de Fisiopatologia de la Obesidad y Nutricion, Instituto de Salud Carlos III, Madrid, Spain Department of Preventive Medicine, University of Malaga, Malaga, Spain - Author
Centro de Investigacion Biomedica en Red de Fisiopatologia de la Obesidad y Nutricion, Instituto de Salud Carlos III, Madrid, Spain Department of Preventive Medicine, University of Valencia, Valencia, Spain - Author
Centro de Investigacion Biomedica en Red de Fisiopatologia de la Obesidad y Nutricion, Instituto de Salud Carlos III, Madrid, Spain Institute of Health Sciences, University of Balearic Islands and Son Espases Hospital, Palma de Mallorca, Spain - Author
Ctr Salud San Pablo, Dist Sanitario Atenc Primaria Sevilla, Dept Family Med, Seville, Spain - Author
Inst Hosp Mar Invest Med IMIM, Cardiovasc Risk & Nutr Regicor Study Grp, Barcelona, Spain - Author
Inst Invest & Recerca Atencio Primaria IDIAP Jord, Catalan Inst Hlth, Primary Care Div, Barcelona, Spain - Author
Inst Salud Carlos III, Ctr Invest Biomed Red Fisiopatol Obesidad & Nutr, Madrid, Spain - Author
Son Espases Hosp, Palma De Mallorca, Spain - Author
Univ Balearic Isl, Inst Hlth Sci, Palma De Mallorca, Spain - Author
Univ Barcelona, Dept Internal Med, Hosp Clin, IDIBAPS, Barcelona, Spain - Author
Univ Barcelona, Hosp Clin, Lipid Clin, Endocrinol & Nutr Serv,Inst Invest Biomed August, Barcelona, Spain - Author
Univ Hosp Araba, Dept Cardiol, Vitoria, Spain - Author
Univ Las Palmas Gran Canaria, Dept Clin Sci, Las Palmas Gran Canaria, Spain - Author
Univ Malaga, Dept Prevent Med, E-29071 Malaga, Spain - Author
Univ Navarra, Dept Prevent Med & Publ Hlth, Osasunbidea Inst Invest Sanitaria Navarra, E-31080 Pamplona, Spain - Author
Univ Rovira & Virgili, Dept Biochem & Biotechnol, Fac Med & Hlth Sci, Human Nutr Unit,Inst Invest Sanitaria Pere Virgil, E-43201 Reus, Spain - Author
Univ Valencia, Dept Prevent Med, Valencia, Spain - Author
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Abstract

To date no clinical trials have evaluated the role of dietary patterns on the incidence of microvascular diabetes complications. We hypothesized that a nutritional intervention based on the Mediterranean diet (MedDiet) would have greater protective effect on diabetic retinopathy and nephropathy than a low-fat control diet.This was a post hoc analysis of a cohort of patients with type 2 diabetes participating in the PREvención con DIeta MEDiterránea (PREDIMED) study, a multicenter randomized nutritional intervention trial conducted in a population at high cardiovascular risk. Individuals with type 2 diabetes who were free of microvascular complications at enrollment (n = 3,614, aged 55-80 years) were randomly assigned to one of three dietary interventions: MedDiet supplemented with extravirgin olive oil (MedDiet+EVOO), MedDiet supplemented with mixed nuts (MedDiet+Nuts), or a low-fat control diet. Two independent outcomes were considered: new onset of diabetic retinopathy and nephropathy. Hazard ratios (HRs) were calculated using multivariable-adjusted Cox regression.During a median follow-up of 6.0 years, we identified 74 new cases of retinopathy and 168 of nephropathy. Compared with the control diet, multivariable-adjusted HRs for diabetic retinopathy were 0.56 (95% CI 0.32-0.97) for the MedDiet+EVOO and 0.63 (0.35-1.11) for the MedDiet+Nuts. No between-group differences were found for nephropathy. When the yearly updated information on adherence to the MedDiet was considered, the HR for retinopathy in the highest versus the lowest quintile was 0.34 (0.13-0.89; P = 0.001 for trend). No significant associations were found for nephropathy.A MedDiet enriched with EVOO may protect against diabetic retinopathy but not diabetic nephropathy.© 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.

Keywords

AgedAged, 80 and overCardiovascular diseasesDiabetes mellitus, type 2Diabetic angiopathiesDiabetic nephropathiesDiabetic retinopathyDiet, mediterraneanFemaleHumansIncidenceMaleMicrovesselsMiddle agedNutsRisk factors

Quality index

Bibliometric impact. Analysis of the contribution and dissemination channel

The work has been published in the journal Diabetes Care due to its progression and the good impact it has achieved in recent years, according to the agency WoS (JCR), it has become a reference in its field. In the year of publication of the work, 2015, it was in position 7/133, thus managing to position itself as a Q1 (Primer Cuartil), in the category Endocrinology & Metabolism.

From a relative perspective, and based on the normalized impact indicator calculated from World Citations provided by WoS (ESI, Clarivate), it yields a value for the citation normalization relative to the expected citation rate of: 2.8. This indicates that, compared to works in the same discipline and in the same year of publication, it ranks as a work cited above average. (source consulted: ESI Nov 14, 2024)

This information is reinforced by other indicators of the same type, which, although dynamic over time and dependent on the set of average global citations at the time of their calculation, consistently position the work at some point among the top 50% most cited in its field:

  • Weighted Average of Normalized Impact by the Scopus agency: 3.28 (source consulted: FECYT Feb 2024)
  • Field Citation Ratio (FCR) from Dimensions: 19.36 (source consulted: Dimensions Jun 2025)

Specifically, and according to different indexing agencies, this work has accumulated citations as of 2025-06-22, the following number of citations:

  • WoS: 106
  • Scopus: 118
  • Europe PMC: 64
  • Google Scholar: 84
  • OpenCitations: 110

Impact and social visibility

From the perspective of influence or social adoption, and based on metrics associated with mentions and interactions provided by agencies specializing in calculating the so-called "Alternative or Social Metrics," we can highlight as of 2025-06-22:

  • The use, from an academic perspective evidenced by the Altmetric agency indicator referring to aggregations made by the personal bibliographic manager Mendeley, gives us a total of: 272.
  • The use of this contribution in bookmarks, code forks, additions to favorite lists for recurrent reading, as well as general views, indicates that someone is using the publication as a basis for their current work. This may be a notable indicator of future more formal and academic citations. This claim is supported by the result of the "Capture" indicator, which yields a total of: 272 (PlumX).

With a more dissemination-oriented intent and targeting more general audiences, we can observe other more global scores such as:

  • The Total Score from Altmetric: 49.35.
  • The number of mentions on the social network Facebook: 1 (Altmetric).
  • The number of mentions on the social network X (formerly Twitter): 32 (Altmetric).
  • The number of mentions in news outlets: 3 (Altmetric).

It is essential to present evidence supporting full alignment with institutional principles and guidelines on Open Science and the Conservation and Dissemination of Intellectual Heritage. A clear example of this is: