Bridging Knowledge and Adherence: A Cross-National Study of the Mediterranean Diet Among Tourism Students in Slovenia, Croatia, and Montenegro

Abstract

The Mediterranean Diet (MD), recognized for its significant health benefits and cultural value, has been inscribed by UNESCO as an Intangible Cultural Heritage of Humanity. This study explores the knowledge and adherence to the MD among undergraduate tourism students in the Mediterranean region of the Balkans, specifically in Slovenia, Croatia, and Montenegro. A total of 581 students completed a self-administered questionnaire assessing MD knowledge, and the KIDMED scale was used to evaluate adherence. The results revealed an average level of MD knowledge overall, with Slovenian students achieving the highest scores. By contrast, adherence was highest among Montenegrin students, who nevertheless scored the lowest in knowledge. No significant correlation was found between MD knowledge and adherence, suggesting that factors beyond formal education contribute to dietary behavior. Further analysis showed that academic performance and tourism-related work experience were associated with higher knowledge but not with adherence. Conversely, reliance on informal sources—such as family, friends, and cookbooks—was positively associated with adherence levels. These findings highlight the important role of informal learning in shaping students’ dietary practices. Given the potential influence of tourism students on the promotion of sustainable food practices, it is essential to integrate diverse educational approaches that bridge the gap between knowledge and actual adherence to the principles of the MD.

1. Introduction

The Mediterranean Diet (MD) is deeply rooted in the historical, cultural, and nutritional heritage of the Mediterranean basin. It represents a holistic dietary pattern characterized by a high intake of plant-based foods and healthy fats and a moderate consumption of animal products. The MD emphasizes fruits, vegetables, whole grains, legumes, nuts, and olive oil while limiting red meat and processed foods. Recognized by UNESCO as an Intangible Cultural Heritage of Humanity, it extends beyond nutrition, promoting social and cultural values tied to food consumption in Mediterranean regions. Additionally, the MD aligns with global sustainability goals, supporting biodiversity and environmentally friendly food systems [1].

Numerous studies highlight the MD’s health benefits, particularly in preventing chronic diseases such as cardiovascular conditions, type 2 diabetes, osteoporosis, obesity, and certain cancers due to its anti-inflammatory and antioxidant properties [2,3,4]. Despite its well-documented advantages, adherence to the MD varies significantly across different populations and is influenced by cultural, socioeconomic, and lifestyle factors [5,6,7]. In the European Union (EU), obesity is a growing public health concern, with approximately 50% of the population affected by weight issues. Childhood obesity is particularly alarming, with over 22 million children classified as overweight or obese, a number that increases by 400,000 annually [8,9,10]. Given the variability in dietary habits across EU member states [5,10,11], it is vital to explore MD adherence in different regions.

This study focuses on the Mediterranean region of the Balkans, particularly Slovenia, Croatia, and Montenegro, where significant tourism, amount of workforce, and student migration occur. Research suggests that MD adherence in this region is low (also see Section 2.5), particularly among children and students [12,13,14,15], also resulting in high obesity rates among the adult population: in Montenegro, 25.2% of women and 26.0% of men; in Croatia, 26.9% of women and 27.0% of men; and in Slovenia, 22.8% of women and 21.6% of men [16].

For tourism and hospitality students, adherence to the MD is particularly relevant, both from a health and lifestyle perspective and from a professional standpoint [11,16,17]. As future industry professionals, these students will play a crucial role in promoting healthy, authentic, and sustainable gastronomic experiences [18,19]. The Mediterranean culinary heritage in the Balkans has been influenced by various civilizations, including the Greeks, Ottomans, Habsburg Monarchy, and specifically the Venetian Republic, and remains a crucial element in the development of tourism [20]. Moreover, until the dissolution of Yugoslavia, Slovenia, Croatia, and Montenegro shared common regulatory and educational systems. Today, they remain prominent Mediterranean (Adriatic) tourist destinations, with their oldest and most notable public faculties for tourism and hospitality education located along the Mediterranean (Adriatic) coastline: the University of Primorska, Faculty of Tourism Studies (TURISTICA) in Portorož (Slovenia); the University of Rijeka, Faculty of Tourism and Hospitality Management in Opatija (Croatia); and the University of Montenegro, Faculty of Tourism and Hospitality in Kotor (Montenegro).

While previous studies [11,16,21] have examined various factors influencing MD adherence, including student lifestyle, demographics, social, environmental, cultural, and policy-related factors (also see Section 2.4), to the best of the authors knowledge, no comparative study has been conducted specifically on tourism and hospitality students in the EU or the wider Balkan region. However, recent research in Croatia [22,23,24] suggests poor adherence to the MD, which tends to decline during the university years, indicating the need for targeted interventions (for more details, also see Section 2.5). In light of the lack of comparative studies focused on tourism students in this geographical area, it is essential to assess both knowledge and adherence to the MD among tourism students to identify key facilitators and barriers to adopting this dietary pattern.

A useful framework for understanding these relationships is the Knowledge, Attitudes, and Practices (KAP) model [25,26]. Applying the principles of the KAP model in this study enables a structured analysis of the interplay between students’ awareness of the MD and their actual dietary behaviors. Since this research was conducted at tourism faculties where students are taught about MD principles, this study specifically focused on the relationship between knowledge and adherence, while attitudes were not assessed (also see Section 2.2). This approach helps determine whether potential gaps in adherence stem from a lack of knowledge [27] and provides insight into how factors related to tourism students (also see the research questions) influence both knowledge and dietary practices.

The primary aim of this study is to assess MD knowledge and adherence among undergraduate tourism students in Slovenia, Croatia, and Montenegro. Specifically, this study seeks to evaluate the level of MD knowledge among tourism students in these three countries and identify potential differences; measure the extent of MD adherence and explore variations between student groups; analyze the correlation between MD knowledge and adherence to determine whether higher knowledge translates to better dietary practices; and investigate how academic performance, information sources, and work experience in tourism influence both knowledge and adherence to the MD. By grounding this study on the KAP model and within the specific educational and professional context of tourism students, the following research questions (RQs) were developed to guide the empirical investigation and address identified gaps in the literature (also see Section 2.1, Section 2.2, Section 2.3, Section 2.4 and Section 2.5):

• RQ1: What is the level of knowledge about the MD among tourism students in Slovenia, Croatia, and Montenegro? Are there differences between the countries?
• RQ2: To what extent do tourism students in these countries adhere to the MD? Are there noticeable differences?
• RQ3: What is the correlation between knowledge and adherence to the MD among tourism students?
• RQ4: How do academic performance, information sources, and work in tourism influence students’ knowledge and adherence to the MD?

To better align the empirical component of this study with its theoretical foundation, this research is grounded in the premise that knowledge is a key determinant of dietary behavior, as proposed by the KAP model. By examining both MD knowledge and adherence—alongside selected academic and professional variables—this study enables a more integrated interpretation of the findings within established theoretical frameworks. This approach facilitates a deeper understanding of whether observed differences in adherence can be partially explained by variations in students’ knowledge levels and their exposure to MD-related content in educational and professional contexts.

By addressing these questions, this study aims to generate valuable insights into how tourism students’ education and work experiences shape their knowledge and dietary behaviors. The findings may serve as a foundation for enhancing MD-related education within tourism curricula and inform evidence-based curriculum reforms by identifying gaps between knowledge and practice. Strengthening the presence of MD-related content in academic programs could promote more sustainable, health-conscious, and professionally relevant practices in the hospitality and tourism sectors.

2. Literature Review

To support the development of the RQs, this section synthesizes existing research in five thematic areas that reflect this study’s focus: (1) MD education and its relevance for tourism students (RQ1 and RQ4), (2) theoretical models explaining the knowledge–behavior link (RQ3), (3) tools for measuring MD knowledge and adherence (RQ1, RQ2, and RQ3), (4) factors influencing adherence in EU students (RQ2 and RQ4), and (5) regional studies from the Balkans (RQ2 and RQ4).

2.1. Mediterranean Diet Education for Future Tourism Professionals

Following the MD can enhance students’ academic performance, mental and physical health, and overall quality of life, ultimately preparing them for careers in the hospitality sector. Studies show that better adherence correlates with lower levels of depression and stress, improving students’ ability to cope with academic pressures [28] and body weight management [29]. Moreover, the MD supports cognitive functions, which can lead to improved academic outcomes—an essential factor for future professionals in tourism and hospitality [30].

Second, in the tourism industry, knowledge of the MD is vital as it integrates cultural heritage, sustainability, and local gastronomy. Recognized by UNESCO, the MD attracts tourists seeking authenticity and a healthy lifestyle. Its focus on sustainable agriculture and local ingredients appeals to eco-conscious travelers and supports local farmers and food producers. This, in turn, fosters both economic development and enriched guest experiences [18,19].

However, the increasing popularity of the MD raises concerns regarding potential misinterpretations and distortions that may undermine its cultural significance. When promoted without the proper context, the MD risks becoming a superficial representation of its traditional values, leading to over-commercialization and commodification at the expense of its cultural and health benefits [19]. Issues such as the loss of authenticity, the proliferation of ultra-processed products labeled as “Taste of the Mediterranean”, and the marginalization of local producers may ultimately erode the diet’s original essence [31].

To mitigate these issues, future tourism professionals must acquire both knowledge and professionalism to promote the MD in authentic and meaningful ways.

These findings underline the importance of assessing MD knowledge among tourism students (RQ1) and exploring how education and professional exposure may influence their awareness and practices (RQ4).

2.2. Theoretical Models for Studying the Relationship Between Knowledge and Adherence

Understanding the relationship between nutritional knowledge and adherence in academic settings requires examining the factors influencing students’ dietary habits. Theoretical models such as Knowledge-to-Action (KTA) [32], the Theory of Planned Behavior (TPB) [33], Capability–Opportunity–Motivation–Behavior (COM-B) [34], and the KAP model [35] provide different perspectives on this relationship. While adherence is shaped by multiple factors (see Table 1), knowledge is widely considered the foundation for informed decision-making [26]. For example, the KTA model explains how knowledge is translated into practice while recognizing barriers that hinder adherence. TPB emphasizes beliefs, social influences, and perceived behavioral control, showing that knowledge can shape attitudes and perceived control. The COM-B model considers capability, opportunity, and motivation, wherein knowledge contributes significantly to one’s behavioral capability. The KAP model, on the other hand, assumes a linear relationship between knowledge, attitudes, and behavior and serves as a starting point for understanding dietary adherence [26,32,33,34,35].

Although psychological, social, and environmental influences play a role [16,36,37], nutrition education remains a fundamental first step toward promoting healthy behaviors [25,38]. This theoretical foundation supports the examination of whether higher MD knowledge among students leads to greater adherence (RQ3).

2.3. Scales for MD Knowledge and Adherence Measurement

To the best of the authors’ knowledge, there are no generic questionnaires for assessing students’ knowledge of the MD. However, specific scales have been developed to measure MD-related knowledge in particular contexts. For instance, the Med-NKQ scale assesses knowledge related to cardiovascular disease [39], while the KomPAN scale evaluates MD knowledge among medical students [40]. In previous studies, researchers have primarily developed tailored, self-administered questionnaires to assess dietary literacy within specific populations [36,41]. This approach was also adopted in the present study (see Section 3.1).

By contrast, adherence to the MD has been assessed using various validated questionnaires tailored to different populations. Examples include the MedQ-Sus, which was designed for the Turkish population [42], and the MEDOC, which evaluates adherence to both the Mediterranean and Western diets [43]. Among student populations, the KIDMED questionnaire is a widely used tool for assessing adherence to the MD, though it has often been modified to suit specific populations [44].

The KIDMED questionnaire consists of 16 items, with 4 questions reflecting negative dietary habits and 12 questions reflecting positive adherence to the MD (see Appendix B). Negative items are scored −1, while positive items are scored +1. Based on the KIDMED index, adherence to the MD is categorized as follows: poor adherence (0–3 points), average adherence (4–7 points), and good adherence (8–12 points) [45,46]. These thresholds are later used to categorize students’ adherence levels in this study.

This review supports the study’s use of appropriate instruments to assess MD knowledge (RQ1) and adherence (RQ2) and to analyze their correlation (RQ3).

2.4. Factors Influencing Student Adherence to the MD in the EU Studies

In this section, we analyze key findings from the EU studies over the last decade. Regardless of measurement instruments, we focus on the main factors influencing adherence to the MD (dependent variable). Understanding these influences is essential for designing interventions to promote healthier dietary habits among students.

Table 1 presents a thematic grouping of key factors primarily influencing low adherence to the MD, ensuring clarity by categorizing similar influences together. Interestingly, no studies reporting high adherence levels were found. In this view, [16] reported that only 15.5% of Spanish students met the adherence criteria. Similarly, Badicu et al. [46] found that 90.3% of Romanian students had low adherence. A study on nursing students in Spain found that only 35.6% reported good adherence [47]. Abreu et al. [36] reported that university students in Lisbon showed low adherence to the MD, despite 84.1% demonstrating adequate nutritional literacy—particularly those in health-related fields. This knowledge–adherence gap was also noted among Polish dietetics students [37] and young Italians [48].

In their study, Daliens et al. [49] identified four key levels influencing students’ eating behaviors: individual, social, environmental, and policy. These factors interact to shape dietary choices, highlighting the complexity of MD adherence. Studies from the last decade confirm that adherence is rarely determined by a single factor (Table 1).

Table 1. Main factors influencing low adherence to MD in the EU studies (2015–present).

Category	Main Factors	Authors
Age and Gender	Younger students and males generally show lower adherence.	[50,51,52,53,54,55,56,57]
Physical Activity and Lifestyle	Low physical activity, sedentary habits, excessive internet use, night shifts, smoking, and limited engagement with dietary tools.	[51,54,55,56,58]
Dietary Habits	Low fruit/vegetable intake, fast food, sugary drinks, skipping breakfast, and unbalanced diet.	[59,60,61,62,63]
Body Composition and Health	Higher Body Mass Index (BMI), increased body fat, unfavorable HDL/cholesterol ratio, depression and anxiety, and muscle strength.	[21,63,64]
Psychological Factors	Stress, anxiety, depression, low self-esteem, sleep disorders, emotional eating, psychological adjustment, and health perception.	[4,29,54,56,60,62,65]
Socioeconomic Status and Living Conditions	Lower-income, living away from family, loneliness, and food insecurity.	[5,16,30,54,55,56,63,65]
Impact of COVID-19	Dietary changes and reduced meal preparation.	[36,52]
Knowledge, Attitudes, and Motivation	Lack of knowledge, negative attitudes, picky eating, motivational factors.	[5,16,30,36,65,66]
Academic and Cultural Influences	Health-related students adhere more; university life leads to poorer habits.	[5,36,46,55,62,63]
Routine and Environmental Factors	Worse dietary habits on weekends and lack of social support.	[65,67]

Table 1. Main factors influencing low adherence to MD in the EU studies (2015–present).

Category	Main Factors	Authors
Age and Gender	Younger students and males generally show lower adherence.	[50,51,52,53,54,55,56,57]
Physical Activity and Lifestyle	Low physical activity, sedentary habits, excessive internet use, night shifts, smoking, and limited engagement with dietary tools.	[51,54,55,56,58]
Dietary Habits	Low fruit/vegetable intake, fast food, sugary drinks, skipping breakfast, and unbalanced diet.	[59,60,61,62,63]
Body Composition and Health	Higher Body Mass Index (BMI), increased body fat, unfavorable HDL/cholesterol ratio, depression and anxiety, and muscle strength.	[21,63,64]
Psychological Factors	Stress, anxiety, depression, low self-esteem, sleep disorders, emotional eating, psychological adjustment, and health perception.	[4,29,54,56,60,62,65]
Socioeconomic Status and Living Conditions	Lower-income, living away from family, loneliness, and food insecurity.	[5,16,30,54,55,56,63,65]
Impact of COVID-19	Dietary changes and reduced meal preparation.	[36,52]
Knowledge, Attitudes, and Motivation	Lack of knowledge, negative attitudes, picky eating, motivational factors.	[5,16,30,36,65,66]
Academic and Cultural Influences	Health-related students adhere more; university life leads to poorer habits.	[5,36,46,55,62,63]
Routine and Environmental Factors	Worse dietary habits on weekends and lack of social support.	[65,67]

While some factors presented in Table 1 (e.g., age, gender, smoking, alcohol consumption, income, housing type, degree program, and BMI) have been identified as significant, some studies found no consistent association [51,61,64].

Importantly, none of the reviewed studies specifically focused on tourism students, despite their potential role in promoting the MD within sustainable tourism frameworks [68]. In this context, several authors [16,54,69] have emphasized the need for targeted interventions to address key barriers influencing healthier eating habits.

These insights are essential for understanding factors that influence MD adherence among students in different countries (RQ2) and how contextual and personal variables may affect knowledge and adherence (RQ4).

2.5. MD Student Studies in the Mediterranean Region of the Balkans

To provide specific study insights, we analyzed research on student populations in the Mediterranean region of the Balkans (ex-Yugoslav). As Detopoulou et al. [11] argue, region-specific data are essential due to the dietary diversity across EU countries.

All studies presented in Table 2 were conducted in Croatia. Interestingly, no studies have been conducted on the student population in Slovenia or Montenegro, nor have comparative studies been performed across the broader Balkan region. The findings consistently show low (poor to medium) levels of adherence to the MD.

Table 2. MD adherence among students in Croatia (chronologically descending).

Authors	Study Area	Sample (n)	Questionnaire	Main Findings
[24]	Association between MD and advanced glycation end products	1016 students from the University of Split	MD Serving Score (MDSS)	Low overall compliance to the MD among students (8.3% in women and 3.8% in men).
[23]	Impact of two COVID-19 lockdowns in Croatia on diet quality and mental state	751 and 1188 students, respectively	KIDMED	Poor to average adherence. Diet quality improved during the lockdown. Poorer mental health during lockdown correlated with lower diet quality.
[52]	MD among Lithuanian and Croatian students during the COVID-19 pandemic	1388 students, with 66.4% Lithuanians and 33.6% Croatians	MEDAS	Low MD adherence. No significant difference between the two groups. Higher adherence is linked to physical activity and non-smoking.
[70]	MD among children and youth in the Mediterranean region in Croatia	2722 individuals aged 2 to 24 years old, of whom 173 were students	KIDMED	Poor adherence increased with the higher education stage. The lowest adherence was observed for students.
[71]	MD adherence	455 students from Rijeka University	MD Quality Index and the Med. Diet Score	Medium to poor diet score. Women and non-smokers showed better adherence.
[45]	The reliability of the KIDMED questionnaire	276 students	KIDMED	Good reliability of the KIDMED. Poor to average adherence. Women had better adherence.

Table 2. MD adherence among students in Croatia (chronologically descending).

Authors	Study Area	Sample (n)	Questionnaire	Main Findings
[24]	Association between MD and advanced glycation end products	1016 students from the University of Split	MD Serving Score (MDSS)	Low overall compliance to the MD among students (8.3% in women and 3.8% in men).
[23]	Impact of two COVID-19 lockdowns in Croatia on diet quality and mental state	751 and 1188 students, respectively	KIDMED	Poor to average adherence. Diet quality improved during the lockdown. Poorer mental health during lockdown correlated with lower diet quality.
[52]	MD among Lithuanian and Croatian students during the COVID-19 pandemic	1388 students, with 66.4% Lithuanians and 33.6% Croatians	MEDAS	Low MD adherence. No significant difference between the two groups. Higher adherence is linked to physical activity and non-smoking.
[70]	MD among children and youth in the Mediterranean region in Croatia	2722 individuals aged 2 to 24 years old, of whom 173 were students	KIDMED	Poor adherence increased with the higher education stage. The lowest adherence was observed for students.
[71]	MD adherence	455 students from Rijeka University	MD Quality Index and the Med. Diet Score	Medium to poor diet score. Women and non-smokers showed better adherence.
[45]	The reliability of the KIDMED questionnaire	276 students	KIDMED	Good reliability of the KIDMED. Poor to average adherence. Women had better adherence.

This regional research gap highlights the need for broader comparative studies across Balkan countries (RQ2), as well as for targeted interventions aimed at increasing MD knowledge and adherence among tourism students (RQ4).

3. Materials and Methods

3.1. Literature Review and Study Scope

To establish a theoretical foundation, we conducted a systematic search of major academic databases, including Scopus, Web of Science, PubMed, ScienceDirect, EBSCOhost, and ProQuest. The search used combinations of the following keywords: ‘Mediterranean Diet’, ‘students’, ‘hospitality & tourism’, and ‘faculty & university’, focusing on studies published from 2015 onward. This process yielded 178 initial results.

Upon screening, we found that none of the identified studies focused exclusively on hospitality and tourism students, indicating a research gap. We therefore refined our focus to studies from EU and Mediterranean countries, excluding African and Asian Mediterranean regions due to notable cultural and dietary differences—particularly regarding alcohol (red wine) consumption, a principle of the MD. Ultimately, our scope was narrowed to the Balkan Mediterranean countries within the EU, aligning with our study’s geographic and cultural context.

3.2. Questionnaire Development

In the first step, a questionnaire (knowledge test) was developed to measure tourism students’ knowledge of the MD. An expert panel consisting of six gastronomy and food-related researchers from the three collaborating tourism faculties designed and tested a 14-item multiple-choice instrument, with each question having one correct answer. The questionnaire was based on the gastronomy-related curricula taught at the respective faculties and was initially pretested with 10 students from each institution. It included a variety of questions related to the MD and is presented in Appendix A. Since the influence of various factors on students’ adherence to the MD has already been reported (see Table 1 and Table 2), we focused specifically on those that may affect tourism students’ knowledge and adherence. These include different sources of information about the MD, academic performance, and work experience in the tourism industry. Additionally, basic demographic data and information for calculating BMI were collected, following the approach by Štefan et al. [45].

To assess MD adherence, we used the KIDMED index, a validated tool adapted for young adults (see Appendix B). This two-pronged approach enabled us to examine the potential discrepancy between students’ knowledge and their actual dietary behavior, as highlighted in previous studies such as that by Elmskini et al. [27].

3.3. Data Collection

The survey was conducted over two academic years (2023–2025) using the 1KA web platform. Lecturers at three partner faculties, all offering tourism-related study programs, distributed the survey link to undergraduate students enrolled in gastronomy, food and nutrition, and food and beverage management courses. Students were invited to participate during regular classes, ensuring high response rates and enabling the use of a census sampling approach. Each student could complete the questionnaire only once. Participation was anonymous and voluntary, and no incentives were provided. On average, the survey took approximately 7 to 8 min to complete. Informed consent was obtained at the beginning of the survey, following an explanation outlining this study’s purpose, data confidentiality, and participants’ rights.

A total of 581 completed responses were collected using a census sampling approach. While enrollment numbers may include students not actively engaged in coursework (inactive enrolled students), this approach ensured the inclusion of the full accessible student population across the three participating faculties, thereby supporting the representativeness of the sample within its practical boundaries.

3.4. Statistical Analysis

All responses were stored in a central database and analyzed using IBM SPSS Statistics, version 29.0. In the first phase, descriptive statistics—including the frequency, mean (M), median, and standard deviation (SD)—were used to summarize the demographic profile, MD knowledge scores, and KIDMED adherence scores.

To explore the relationships between variables and address our research questions, we applied the following statistical tests:

• The Kruskal–Wallis H test was used to compare the means of more than two independent groups (e.g., a comparison of MD knowledge across the three countries) when the data did not meet normality assumptions.
• The Mann–Whitney U test was applied to compare the means between two independent groups (e.g., pairwise comparisons between countries) when the data were not normally distributed.
• Pearson’s correlation coefficient was used to assess linear relationships between two continuous variables when both variables were normally distributed.
• Spearman’s rank correlation was applied to assess correlations between two variables when normality assumptions were violated.
• The independent samples t-test was used for comparing means between two independent groups when the assumptions of normality and homogeneity of variance were met.

All the statistical tests were conducted at a 5% significance level (p < 0.05). In addition, effect sizes (e.g., r for Mann–Whitney U tests, Cohen’s d for independent samples t-tests, and eta squared (η²) for the Kruskal–Wallis test) were calculated and are reported alongside p-values to improve interpretability and assess the magnitude of observed effects. Prior to conducting parametric tests, the normality of continuous variables was assessed using the Shapiro–Wilk test, as well as a visual inspection of histograms and Q–Q plots. Where assumptions of normality or homogeneity of variance were not met, appropriate non-parametric alternatives were applied. The results are presented in Section 4.

4. Results

First, descriptive statistics were conducted to analyze basic demographics. A total of 581 students participated, mostly from Opatija (n = 322), Kotor (n = 142), and Portorož (n = 117). The sample was predominantly female (74%), with an average age of 21 years. Regarding the year of study, 39% were in the first year, 29% in the second, and 32% in the third. Most students reported an average grade of good or very good (75%) and lived with their parents or grandparents (40%) or in dormitories (26%), while only 4% lived in their own apartment. In terms of employment, 26% worked regularly, 10% often, 22% occasionally, 14% rarely, and 28% did not work while studying. The calculated BMI showed that most students had a normal weight (72%), 18% were overweight, 5% were underweight, and 5% were obese. Students primarily obtained information about MD from (multiple responses were allowed) family and friends (62%) and social media (61%), followed by school (30.5%) and cookbooks (18.4%).

Normality testing was performed using the Shapiro–Wilk test for the two main continuous variables—MD knowledge and MD adherence. The distribution of MD knowledge scores significantly deviated from normality in all three institutional groups (e.g., Portorož: W = 0.949, p < 0.001; Kotor: W = 0.962, p < 0.001; and Opatija: W = 0.971, p < 0.001). Adherence scores showed mixed results: approximately normal in Portorož (W = 0.978, p = 0.051) but non-normal in Kotor (W = 0.978, p = 0.020) and Opatija (W = 0.975, p < 0.001). Normality test results guided the choice of non-parametric methods for group comparisons between countries. For independent samples t-tests, normality was considered acceptable due to the large sample size and supporting visual assessments. Levene’s test results were used to select the appropriate version of the t-test (see RQ3 and RQ4).

To answer RQ1, MD knowledge was assessed based on 14 possible correct answers (see

Table 3. MD knowledge scale.

No.	Questions	% of Correct Answers
1	How would you define the MD?	74.4
2	Which food group is a staple of the MD?	41.3
3	How is olive oil used in Mediterranean cuisine?	75.2
4	How often is red meat consumed in the MD?	15.3
5	What is the role of legumes in the MD?	33.9
6	How often is fish recommended in the MD?	58.5
7	What is the primary protein source in the MD?	19.6
8	How is wine included in the MD?	76.6
9	Which characteristic best describes Mediterranean recipes?	70.7
10	Which health benefits are associated with the MD?	83.1
11	The MD encourages a high intake of dairy products.	71.8
12	Which food is NOT typically part of a traditional MD?	58.3
13	UNESCO has recognized the MD as an Intangible Cultural Heritage.	67.8
14	Which statement about the MD is correct?	27.9

Note: See Appendix A.

). The highest average score was recorded in Portorož (8.25), followed by Opatija (7.79) and Kotor (7.24). Most students (65%) answered between 6 and 9 questions correctly, indicating an average level of MD knowledge. The best-known topics included the health benefits of the MD (83.1%), red wine (76.6%), and olive oil consumption (75.2%). Conversely, students showed the least knowledge about red meat consumption (15.3%), protein sources (19.6%), and the role of legumes in the MD (33.9%). Notably, 68% knew that the MD is recognized by UNESCO. When asked about misconceptions about the MD, 30% believed that the MD guarantees perfect health outcomes; only 28% knew that the MD also includes societal factors (the right answer), while 21% of students indicated that the MD is outdated and irrelevant to modern nutrition science.

Next, differences among faculties were analyzed using non-parametric tests due to heterogeneous variances and deviations from a normal distribution. The Kruskal–Wallis test (H = 19.625, df = 2, p < 0.001, and η² = 0.0338) revealed statistically significant overall differences among the three countries. Pairwise comparisons using the Mann–Whitney U test further confirmed that Slovenia exhibited the highest level of knowledge, which was statistically significantly greater than that of Montenegro (U = 5958.000; p < 0.001; r = 0.36). Croatia’s scores fell between the two but remained statistically significantly different from both Slovenia (U = 15,513.500; p = 0.004; r = 0.41) and Montenegro (U = 19,069.000; p = 0.004; r = 0.42). These effect sizes indicate medium and small effects, respectively. The presented findings provide a clear answer to RQ1.

In the next step, we proceeded to answer RQ2. The results of the KIDMED questionnaire presented in

Table 4. KIDMED scale.

No.	Cat.	Questions	% Yes
1	+	Do you have a fruit or fruit juice every day?	67.8%
2	+	Do you have a second fruit every day?	45.1%
3	+	Do you include fresh or cooked vegetables in your meals daily?	70.4%
4	+	Do you include fresh or cooked vegetables more than once daily?	43.0%
5	+	Do you consume fish regularly (at least 2–3 times per week)?	22.0%
6	−	Do you visit a fast-food restaurant more than once a week?	29.4%
7	+	Do you enjoy pulses more than once a week?	48.7%
8	+	Do you consume pasta or rice almost every day?	47.0%
9	+	Do you have cereals or grains for breakfast?	75.6%
10	+	Do you consume nuts regularly (at least 2–3 times per week)?	42.9%
11	+	Do you use olive oil at home?	81.6%
12	−	Do you skip breakfast?	46.0%
13	+	Do you have a dairy product for breakfast?	71.1%
14	−	Do you have commercially baked goods or pastries for breakfast?	61.6%
15	+	Do you consume two yoghurts and/or some cheese daily?	32.7%
16	−	Do you consume sweets and candy several times every day?	37.7%

Note: Positive (+) answers indicate the reverse meaning for negative (−) questions.

, which assesses adherence to the MD, indicate that the majority of respondents regularly consume healthy foods. Specifically, 81.6% regularly consume olive oil, and 75.6% have cereals or grains and dairy products (71.1%) for breakfast. In addition, a smaller proportion of students reported visiting fast-food restaurants more than once a week (29.4%).

However, there are some concerning trends among students: Only 22.0% consume fish regularly. A total of 32.7% meet the recommended daily consumption of dairy products, and 61.6% have commercially baked goods or pastries for breakfast. Overall, dietary adherence to the MD is moderate (M = 4.70), with the highest adherence reported in Montenegro (M = 4.98), followed by Croatia (4.75), and the lowest was in Slovenia (4.38).

Again, differences among institutions were analyzed using non-parametric tests. The Kruskal–Wallis test (H = 4.692, df = 2, p = 0.096, and η² = 0.0047) did not reveal statistically significant differences in mean ranks across the groups, and the overall effect size indicates a small effect. Nevertheless, pairwise comparisons were conducted using the Mann–Whitney U test. The results of pairwise comparisons indicate that Slovenia and Montenegro differed statistically significantly (U = 7072.5; p = 0.038; r = 0.43), suggesting a medium effect. The difference between Slovenia and Croatia was not statistically significant (U = 16,822.5; p = 0.084; r = 0.45), nor was the difference between Montenegro and Croatia (U = 21,787.0; p = 0.416; r = 0.48), although effect sizes suggest potentially meaningful differences. These findings respond to RQ2.

Next, we analyzed the correlation between knowledge scores and adherence to the MD (RQ3). The Pearson correlation (r = 0.065, p = 0.117) showed no statistically significant correlation. Separate analyses by country confirmed the absence of statistically significant correlations (Slovenia: r = 0.011, p = 0.908; Montenegro: r = 0.135, p = 0.108; and Croatia: r = 0.070, p = 0.207). These results suggest that higher knowledge of the MD does not necessarily lead to better adherence among tourism students.

Finally, the analysis explored the influence of academic performance, information sources, and work in tourism on students’ knowledge and adherence (RQ 4). Pearson’s correlation was used to assess relationships between numerical variables, while Spearman’s correlation was applied for ordinal and a combination of ordinal and numerical variables.

The results indicate a statistically significant positive correlation between the number of information sources and both knowledge (r = 0.127, p = 0.002) and adherence to the MD (r = 0.103, p = 0.013). This suggests that students who engage with more (different) sources of dietary information tend to have better knowledge and adherence. This is the only variable with a statistically positive correlation to both knowledge and adherence, while all other variables had no or a selective influence on either knowledge or adherence. For example, academic performance (grade) shows a small but statistically significant positive correlation with knowledge (r = 0.112, p = 0.007) but no influence on adherence (r = 0.039, p = 0.348). Similarly, working in tourism while studying has a weak, statistically significant positive correlation with knowledge (r = 0.093, p = 0.026) but no statistical relationship with adherence (r = −0.016, p = 0.705).

Further analysis using independent samples t-tests specifically examined differences in higher knowledge and adherence scores based on specific information sources. Statistically significant differences were found in higher knowledge scores for students who used social media (t = −3.237; df = 579; p = 0.001; d = 0.275), indicating a small effect, though it did not influence adherence. On the contrary, in terms of higher adherence scores, statistically significant differences were observed among students who relied on their family and friends (t = −2.065; df = 415.013; p = 0.040; d = 0.19), indicating a small effect, and cookbooks (t = −3.829; df = 579; p = 0.001; d = 0.41), suggesting a small-to-moderate effect, while these sources of information, surprisingly, did not influence their knowledge level (t = −1.148, df = 377.913, p = 0.252, and d = 0.099, and t = −1.759, df = 579, p = 0.079, and d = 0.19, indicating a small effect despite a marginally non-significant p-value, respectively). Additionally, t-test results indicate that there are no statistically significant differences in the average number of correct answers (t = 0.080; df = 579; p = 0.936; d = 0.009) nor the adherence score (t = −0.192; df = 579; p = 0.850; d = 0.015) between students who selected the school as their main source of information and those who did not. This suggests that primarily obtaining information from the faculty is not associated either with greater knowledge or better adherence to the MD.

Additionally, statistical relationships were investigated between basic demographic variables, knowledge, and adherence. Results indicate that female students (t = 4.547; df = 579; p = 0.001; d = 0.44) demonstrated higher knowledge than males, although no statistically significant relationship was found between gender and adherence. Moreover, a positive correlation was observed between age and adherence (r = 0.146; p = 0.001), while no significant correlation was found between age and MD knowledge. In terms of BMI, it was not correlated either to knowledge or adherence.

To facilitate a clearer overview of the main findings, a summary table (

Table 5. Summary of main study findings by RQs.

RQs	Main Findings	Statistical Evidence
RQ1: What is the level of MD knowledge among tourism students, and how does it differ by institution?	Moderate knowledge overall (avg. 6–9 correct answers); highest in Slovenia and lowest in Montenegro.	Kruskal–Wallis H = 19.625, with p < 0.001; Mann–Whitney pairwise comparisons: Slovenia > Croatia > Montenegro
RQ2: What is the level of adherence to the MD, and how does it differ by institution?	Moderate adherence (M = 4.70); highest in Montenegro and lowest in Slovenia.	Kruskal–Wallis H = 4.692, with p = 0.096; Mann–Whitney: Slovenia < Montenegro (p = 0.038)
RQ3: Is there a relationship between knowledge and adherence to the MD?	No significant correlation between knowledge and adherence.	Pearson r = 0.065, with p = 0.117 (overall); also non-significant by country
RQ4: Which factors influence MD knowledge and adherence?	The No. of information sources correlates positively with both knowledge and adherence. Academic performance and tourism work experience relate only to knowledge. Female students show higher knowledge; age is positively associated with adherence.	Multiple correlations; t-tests confirm the role of specific sources (e.g., social media on knowledge and family/cookbooks on adherence)

) was created, organizing key results by each RQ.

5. Discussion

This study provides valuable insights into the relationship between knowledge and adherence to the MD among tourism students in Slovenia, Croatia, and Montenegro. The findings reveal significant gaps in both knowledge and behavior, challenging the assumption that greater knowledge leads to higher adherence. While theoretical models, such as KAP and KTA [25,35], suggest that knowledge is a foundation for behavior change (see Section 2.2), our results, consistent with prior studies [16,36,48], indicate that knowledge does not necessarily reflect MD adherence. Surprisingly, in our study, knowledge was not even statistically correlated with dietary practice.

In this view, several other factors discussed below may play a more decisive role in shaping adherence. Notably, this is the first study to analyze MD knowledge and adherence among tourism students, as well as the first cross-national study in the former Yugoslav member states, offering a novel perspective on the intersection of education and dietary behavior.

In addressing RQ1, statistically significant differences in MD knowledge were observed among the three countries, with Slovenian students achieving the highest scores, followed by Croatian and Montenegrin students. These variations may stem from differences in educational curricula or cultural influences and socioeconomic factors, as further discussed below. Despite a moderate overall knowledge level (M = 7.75), our results indicate notable dietary knowledge gaps, such as a limited understanding of red meat consumption recommendations—possibly reflecting traditional Balkan dietary patterns [20]. Furthermore, only about three-quarters of students knew that the MD is recognized by UNESCO, suggesting limited awareness of its cultural significance. This is particularly relevant to the subject of this study, as these students will play a professional role in promoting the Mediterranean food culture within sustainable tourism contexts. Strengthening their cultural understanding of the MD could enhance its representation in the industry.

In relation to RQ2, adherence to the MD followed a reversed trend: Montenegrin students reported the highest adherence despite scoring the lowest on knowledge tests, while Slovenian students, with the highest MD knowledge, exhibited the lowest adherence. Notably, statistically significant differences were observed between Slovenian and Montenegrin students. This result further aligns with the response to RQ3.

RQ3 revealed one of the most striking findings of this study: the absence of a statistically significant correlation between knowledge and adherence. Although students demonstrated moderate knowledge of the MD, this did not translate into higher adherence rates (M = 4.70). This finding is consistent with prior research, which suggests that awareness of MD health benefits [30,36,37] does not necessarily lead to improved adherence. Most likely contributing to this disconnect are practical barriers, such as convenience, accessibility, and financial constraints, which affect students’ capacity to make informed dietary choices [5,16,49,55]. Additionally, entrenched dietary patterns and socio-cultural influences often outweigh knowledge in the decision-making process, underscoring the need for behavioral interventions that extend beyond education alone [36,48].

To better explain this disconnect, behavioral change models such as the COM-B model and the TPB provide valuable frameworks. According to COM-B, behavior is a result of capability, opportunity, and motivation. Even if students have the psychological capability (knowledge), they may lack social opportunity (supportive environments) or reflective motivation (belief in benefits). Similarly, the TPB emphasizes the role of attitudes, perceived behavioral control, and subjective norms in shaping intentions, which mediate actual behavior. These models suggest that knowledge alone is rarely sufficient; it must be accompanied by supportive contexts and motivational drivers [33,34].

Accordingly, Slovenian students may exhibit more “Westernized” dietary habits due to Slovenia’s higher GDP and closer integration with Central EU markets, which exposes them to non-Mediterranean food choices. Conversely, in Montenegro, where local food production (particularly subsistence farming) plays a more significant role [15], adherence to MD principles may occur more naturally. These findings suggest that local food accessibility may also have a significant impact on MD adherence, potentially shaping dietary traditions in ways that could outweigh formal MD education. Unlike previous research in Croatia, which has primarily examined individual determinants [24,45,71], our study underscores the importance of considering broader external influences on dietary adherence patterns, as highlighted by Donini and Berry [72].

Future research should also focus on the role of tourism students’ attitudes toward the MD in shaping dietary behavior. Understanding whether students have positive perceptions of the MD but face barriers to adherence could provide deeper insights into the intention–action gap. Addressing some of the student-reported misconceptions which were identified in our study—such as the belief that the MD is outdated and not relevant to modern nutrition science—may help refine dietary interventions by targeting specific motivational and psychological factors. In this context, applying behavioral models such as the TPB or COM-B in future studies could help identify which specific mechanisms (e.g., a lack of intention and motivational conflict) contribute most to the observed disconnect between knowledge and behavior. This would also enable more targeted and theoretically grounded intervention strategies. It is therefore recommended that future studies explore the relative contributions of individual-level determinants (e.g., emotions and beliefs) versus broader structural factors (e.g., economic conditions, social norms, and food access) in explaining the variability in MD adherence. Such an approach is especially important for understanding regional dietary patterns, particularly given persistently high obesity rates in the Western Balkans [15].

In response to RQ4, students ranked the school as only the third most relevant source of information, after family and friends, and social media. Statistical analyses indicate that academic performance correlates positively with knowledge levels; however, school grades were not relevant for MD adherence. Similarly, students who identified their school as their primary source of information did not exhibit higher knowledge or adherence. Social media and work in tourism significantly influenced knowledge but had no impact on adherence, while family, friends, and cookbooks were statistically associated with higher adherence but did not impact knowledge. The only variable positively correlated with both knowledge and adherence was the number of information sources, suggesting that exposure to multiple sources is crucial in shaping both knowledge and behavior.

These findings emphasize the critical role of informal learning pathways in both knowledge acquisition and behavioral practice. While formal education remains essential, it appears insufficient on its own to foster meaningful adherence to the MD. This has important implications for the focus of this study—namely, how future tourism professionals can be better prepared to internalize and promote the MD in both personal and professional contexts.

To address this, educational strategies should incorporate experiential and culturally contextualized learning approaches, such as field visits, culinary workshops, and engagement with local food producers. These methods may include guided study visits to MD-certified (best practice example) destinations, collaboration with local agritourism providers, or short courses co-organized with dietitians and chefs specialized in Mediterranean cuisine. Such initiatives can provide students with immersive exposure to MD values and strengthen the link between theory and practice. These approaches may offer more effective ways to bridge the gap between knowledge and behavior, fostering deeper understanding and long-term commitment.

The differences between MD knowledge and adherence may also reflect the gap between explicit and tacit knowledge. While formal education conveys explicit knowledge (facts and guidelines), adherence often depends on tacit knowledge (e.g., personal experience, cultural habits, and daily food-related practices). This may explain why informal sources like family or cookbooks were more strongly linked to adherence. Recent cross-national research also emphasizes the role of tacit, experience-based knowledge in shaping sustainable dietary practices beyond formal instruction [5]. Introducing more tacit learning opportunities into tourism education could also help bridge this gap (also see the Section 6).

Overall, our results indicate that informal learning channels play an important role in students’ MD knowledge and adherence. This aligns with previous research [36,73,74], emphasizing the potentials of dietary applications, digital storytelling, and interactive learning materials in bridging the gap between knowledge and behavior.

6. Conclusions

This study is the first cross-national investigation of both knowledge and adherence to the MD among tourism students and the first such study in the Balkan Mediterranean region, specifically in the ex-Yugoslav countries of Slovenia, Croatia, and Montenegro. The findings reveal notable discrepancies in MD knowledge and adherence despite shared historical and geographical contexts. Most strikingly, this study identifies an inverse relationship between these two factors: Slovenian students demonstrated the highest MD knowledge, while Montenegrin students had the highest adherence rates despite reporting the lowest knowledge scores. These results indicate that factors beyond formal education play a crucial role in shaping dietary behaviors.

One of the most significant findings is the absence of a statistically significant correlation between MD knowledge and adherence. This challenges the long-standing assumption that increasing knowledge alone is sufficient to drive dietary change and highlights the limitations of traditional educational interventions in promoting MD adoption. Nevertheless, this study identifies distinct factors influencing MD knowledge and adherence separately: while social media, academic performance, and tourism-related work experience positively impact knowledge, adherence is more strongly shaped by informal sources such as family, friends, and cookbooks. The only variable positively associated with both knowledge and adherence is the number of different information sources, suggesting that diversified exposure is key. These insights underscore the need for a multifaceted, context-sensitive approach to MD promotion among students.

The lack of correlation between MD knowledge and adherence supports more comprehensive frameworks like COM-B and the TPB, which highlight the importance of motivation, opportunity, and context alongside knowledge. This suggests that effective interventions should move beyond information delivery and actively address the conditions and drivers that enable behavioral change. This is particularly relevant in the transitional context of the Western Balkans, where socioeconomic changes, cultural shifts, and evolving food environments may further complicate the translation of knowledge into practice.

The tourism industry presents a unique opportunity to promote the MD as a sustainable and health-conscious dietary pattern aligned with global food trends. To ensure its preservation for future generations, efforts should focus on both education and encouraging adherence among employees, students, and guests. Tourism students, in particular, represent a strategically important group, as their future professional roles combine cultural mediation, knowledge transfer, and direct interaction with guests. Equipping them with a deeper and more practical understanding of the MD could have ripple effects across the tourism sector.

6.1. Limitations and Future Research Directions

Despite its contributions, this study has certain limitations. The cross-sectional design prevents causal inferences, necessitating longitudinal studies to explore how MD knowledge and adherence evolve over time. The reliance on self-reported data may introduce recall bias and social desirability effects. Additionally, the sample was predominantly female (74%), which may limit the generalizability of the findings, particularly regarding dietary preferences and BMI scores. Another limitation is the exclusion of attitudes from the analysis, as they could provide a deeper understanding of the disconnect between knowledge and behavior.

Accordingly, future research should investigate culturally adapted interventions that integrate both formal and informal learning approaches and conduct longitudinal studies to assess the long-term impact of MD-focused education. Qualitative methods, such as in-depth interviews and focus groups, could offer deeper insights into students’ dietary behaviors and decision-making processes. Researchers should also explore how students’ attitudes, motivations, and perceived barriers interact with their dietary choices. Furthermore, studies should examine the role of campus food environments and institutional policies, particularly whether the increased availability of Mediterranean-style meals leads to better adherence. Comparative studies between tourism students and students from other disciplines could also provide valuable perspectives on how the educational context influences MD-related outcomes.

6.2. Practical Implications

In the educational sector, integrating MD principles into the tourism curricula through experiential learning, such as cooking workshops, farm visits, and industry partnerships, could help students develop a stronger and more practical connection to MD concepts. Field-based learning modules, supported by collaborations with local food producers, restaurants, and cultural heritage actors, can expose students to real-world applications of MD principles. Furthermore, digital tools, virtual environments, and social media engagement may enhance knowledge retention and support interactive, student-driven learning. Encouraging students to document and share their MD-related experiences can also strengthen reflective and peer-based learning.

In the hospitality industry, adopting MD-compliant menus, prioritizing locally sourced and seasonal ingredients, and training staff on the cultural and nutritional significance of the MD can reinforce its visibility and relevance. Collaborative efforts between academic institutions, tourism businesses, and food producers may foster both curriculum innovation and broader industry awareness, facilitating the systemic adoption of MD principles.

By addressing both individual and environmental factors influencing MD adherence, these strategies can help bridge the persistent gap between knowledge and practice. Ensuring that future tourism professionals not only understand but also embody the MD is essential for its long-term sustainability and cultural transmission. These findings contribute not only to the academic understanding of dietary behavior among young professionals but also offer practical, actionable guidance for educators and practitioners striving to align tourism education and development with a health-oriented and culturally grounded tourism offer.