Mediterranean Diet Adherence and Sustainable Eating Behaviors in Type 2 Diabetes: A Cross-Sectional Analysis of Adiposity, Cooking and Food Skills, and Macrovascular Complications.

Aims: Although the Mediterranean diet (MD) is widely recognized as a sustainability-aligned dietary model, its relationship with sustainable eating behaviors and its cross-sectional associations with adiposity, cooking and food skills, and macrovascular complications in type 2 diabetes mellitus (T2DM) remain insufficiently characterized. Methods: This cross-sectional study included 120 adults with T2DM (median age, 60 years) consecutively recruited from an endocrinology outpatient clinic. Mediterranean diet adherence (MDA), Sustainable and Healthy Eating Behaviors (SHEB), and Cooking Skills and Food Skills (CSFS) were assessed using validated scales. Dietary intake was evaluated using a single 24-h dietary recall, and anthropometric and body composition measures were obtained using standardized procedures. Adjusted group differences were examined using ANCOVA. To account for multiplicity across prespecified families of exploratory outcomes, nominal p-values were corrected using the Benjamini-Hochberg false discovery rate (FDR) procedure. Results: Higher MDA was associated with a higher total SHEB score (primary outcome; p < 0.001) and with higher scores for quality labels, seasonal foods and food waste avoidance, local food, and reduced meat consumption, after FDR correction (all q < 0.05). Across SHEB tertiles, waist-to-hip ratio differed significantly after FDR correction (p = 0.001, q = 0.010), whereas the nominal difference in neck circumference did not remain significant (p = 0.046, q = 0.230). In analyses according to macrovascular complication status, lower adjusted protein intake remained significant after FDR correction (p = 0.002, q = 0.032). Nominal differences in food skills, total CSFS, MDA, total and saturated fat intake, monounsaturated fat intake, and dietary total antioxidant capacity did not remain significant after multiplicity correction (all q > 0.05). Conclusions: Greater adherence to the Mediterranean diet was cross-sectionally associated with more sustainable and healthier eating behaviors, whereas higher SHEB scores were associated with a lower waist-to-hip ratio. Most exploratory differences according to macrovascular complication status did not remain significant after correction for multiple testing, underscoring the need for cautious interpretation. Prospective studies are needed to establish temporal relationships, and intervention studies are required to determine whether modifying adherence to the Mediterranean diet, sustainable eating behaviors, or cooking and food skills affect subsequent cardiometabolic and vascular outcomes in T2DM.