The Role of the Mediterranean Diet in the Prevention of Sarcopenia and Frailty in Older Adults: A Narrative Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This study provides interesting information. However, following points should be addressed before publication.

This review evaluates recent studies on the roles of MD diet in the prevention of sarcopenia and frailty. 
1.    Reference No. of “some research studies” of L72-74 in Introduction is necessary. 
2.    Following 3 articles should be cited as references.

(1) The Mediterranean Diet Slows Down the Progression of Aging and Helps to Prevent the Onset of Frailty: A Narrative Review. Capurso et al. Nutrients. 2019 Dec 21;12(1):35.
(2) The Influence of the Mediterranean Dietary Pattern on Osteoporosis and Sarcopenia. Andreo-López et al. Nutrients. 2023 Jul 20;15(14):3224. 
(3) Associations Between Adherence to the Mediterranean Diet and Incident Sarcopenia in Prospective Cohort Studies. Dominguez et al. Nutrients. 2025 Jan 16;17(2):313. 

Author Response

First of all, we would like to thank the reviewers for taking the time to analyze our article. Their feedback has undoubtedly helped us improve its quality and make it more interesting for readers of Nutrients. Below, we answer point by point all the questions raised by the reviewers.

Comments and Suggestions for Authors

This study provides interesting information. However, the following points should be addressed before publication. This review evaluates recent studies on the roles of MD diet in the prevention of sarcopenia and frailty. 

1.  Reference No. of “some research studies” of L72-74 in Introduction is necessary.As suggested by the reviewers, we have introduced several references (3, 14,15) in that paragraph (lines 88-90).
2.  Following 3 articles should be cited as references.

As suggested by the reviewers, we have introduced the following references (3, 14,15)

13. The Influence of the Mediterranean Dietary Pattern on Osteoporosis and Sarcopenia. Andreo-López et al. Nutrients. 2023 Jul 20;15(14):3224.
14. Associations Between Adherence to the Mediterranean Diet and Incident Sarcopenia in Prospective Cohort Studies. Dominguez et al. Nutrients. 2025 Jan 16;17(2):313. 
15. The Mediterranean Diet Slows Down the Progression of Aging and Helps to Prevent the Onset of Frailty: A Narrative Review. Capurso et al. Nutrients. 2019 Dec 21;12(1):35.

 

Reviewer 2 Report

Comments and Suggestions for Authors

This is an interesting review article with adequate novelty. Some points should be addressed.

• The authors should provide more epidemiological data for older adults concerning malnutrition (Introduction, 2nd paragraph), includng its prevelance, its health consequenses, etc.
• At the end of the Introduction section, the authors should emphasize the literature gap that their articles aims to cover.
• The size of Figure 1 should be increased.
• In line 203, the authors reported that ''...women represented the largest portion of the sample,...''. This is a limitation concerning the comparison between the existing studies that should be discussed at the end of the Discussion section.
• The sentence in lines 227-229 ""They followed the patients for 14 weeks with no significant changes were observed between the two groups concerning body image perception or adherence to the MD. '' is complex and should be revised concerning its syntax.
• For the study of Coelho-Junior et al. (23), more data concerning the risk of sarcopenia should be reported.
• The sentence in line 351 "In the article by Dominguez et al. (39) investigates the relationship...'' should be revised concerning its syntax.
• Recall bias concerning the self-reported completion of the questionnaires assesing Mediterranean diet adherence should be reported in the limitations section.
• Throughout, the critical point of view of authors is missing. The authors should try to include for each study their strengths and their limitations.
• English language editing is highly recommended.
• There are several typos and grammar/syntax errors throughout the manuscript which should be revised.

Comments on the Quality of English Language

• English language editing is highly recommended.
• There are several typos and grammar/syntax errors throughout the manuscript which should be revised.

Author Response

First of all, we would like to thank the reviewers for taking the time to analyze our article. Their feedback has undoubtedly helped us improve its quality and make it more interesting for readers of Nutrients. Below, we answer point by point all the questions raised by the reviewers.

Comments and Suggestions for Authors

This is an interesting review article with adequate novelty. Some points should be addressed.

1.The authors should provide more epidemiological data for older adults concerning malnutrition (Introduction, 2nd paragraph), including its prevalence, its health consequences, etc.

As suggested by the reviewers, we have rewritten and expanded the information on malnutrition in the elderly to include data on prevalence, risk factors and consequences of malnutrition (lines 62-67). The new paragraph is the following; 

“Malnutrition is a common geriatric syndrome that is often overlooked among the elderly, affecting up to 30–50% of older adults in hospitals and long-term care facilities. Age-related physiological changes, chronic diseases and social factors significantly contribute to nutritional decline. It is associated with an impaired immune response, higher rates of hospitalization, and morbidity and mortality (5, 44) and also emerges as a critical factor in the development of sarcopenia and/or frailty (5, 44, 13, 14).

 

2. At the end of the Introduction section, the authors should emphasize the literature gap that their articles aims to cover.

As suggested by the reviewers, we have clarified the literature gap our article tries to cover. We have rewritten the old paragraph. The new paragraph is the following:

“The objective of this review is to analyze the scientific evidence regarding the potential protective role of the Mediterranean diet against the development of sarcopenia and frailty, and its ability to enhance physical function in older people. We also aim to assess whether the positive effects of this dietary pattern can be generalized to all elderly people (non-frail, pre-frail, and frail subjects)”.  (lines 90-95)

3. The size of Figure 1 should be increased.

The size of the figure has increased.

 

4. In line 203, the authors reported that ''...women represented the largest portion of the sample,...''. This is a limitation concerning the comparison between the existing studies that should be discussed at the end of the Discussion section.

We have introduced a new paragraph with the limitations observed in the articles reviewed (lines (491-507). Specifically, limitations related to overrepresentation of women is described in line 496-497.

5. The sentence in lines 227-229 ""They followed the patients for 14 weeks with no significant changes were observed between the two groups concerning body image perception or adherence to the MD. '' is complex and should be revised concerning its syntax.

The whole paragraph was rewritten to improve understanding (lines 251-262). The new paragraph is the following:

 

“A study by Martínez-Rodríguez et al. (46) assessed the effects of water-based resistance training on body composition, body image perception, and adherence to the MD in older women participating in a nutrition education programme for 14 weeks. The study involved 34 participants, who were divided into two groups: one group participated in water-based resistance training combined with a nutritional intervention based on the MD (the interventional group), while the control group received only the nutritional intervention based on the MD. No significant differences were found between the groups regarding body image perception or adherence to the MD. However, the interventional group showed a significant increase in muscle mass (2 ± 5.85 kg, p < 0.001) and a decrease in fat mass (p < 0.001) compared to the control group. This suggests that, although water-based resistance training did not affect body image or adherence to the MD, it led to significant improvements in body composition”.

6. For the study of Coelho-Junior et al. (23), more data concerning the risk of sarcopenia should be reported.

More detailed information is provided about the study of Coelho-Junior et al. (28), The new paragraph is the following:

 

“Finally, another observational study by Coelho-Junior (28) in a sample of 491 Italian subjects over 65 years of age investigated whether adherence to DM and regular aerobic physical activity reduced the risk of sarcopenia. Eighty-eight percent of the subjects had moderate to high adherence to the DM and the incidence of sarcopenia was low (5.3%). There were no significant differences in sarcopenia between the low, moderate and high adherence groups. Although the results were negative, the limitations of the study should be highlighted: it was an observational cross-sectional study, the information collected was not complete, and the MED-LITE scale for measuring adherence to the diet is not optimal.” (lines 323-331).

7. The sentence in line 351 "In the article by Dominguez et al. (39) investigates the relationship...'' should be revised concerning its syntax.

The paragraph was rewritten to clarify its understanding. The new paragraph is the following:

“A meta-analysis published by Domínguez et al (44), including 11 cohort studies with a total of 106,615 people over 60 years of age followed for 1 year, analysed the relationship between adherence to the MD and the incidence of frailty. The diagnosis of frailty was based on Fried's criteria. The authors observed a 45% reduction in the incidence of frailty in patients with high adherence to MD compared with those with low adherence, and suggest that there is an inversely proportional relationship between adherence to MD and the incidence of frailty. According to the authors, the anti-inflammatory effect of several key components of the diet (vegetables, extra virgin olive oil, fruits) could be responsible for this beneficial effect and lend plausibility to the association found” (lines 405-414).

 

8. Recall bias concerning the self-reported completion of the questionnaires assesing Mediterranean diet adherence should be reported in the limitations section.

We have introduced a new paragraph with the limitations observed in the articles reviewed (lines (491-507). Specifically, limitations related to recall bias concerning the self-reported completion of the questionnaires are described in line 500-503

 

9. Throughout, the critical point of view of authors is missing. The authors should try to include for each study their strengths and their limitations.

We have introduced our critical point of view for each study included in the review and also their strengths and limitations in the results and discussion section.

 

10. English language editing is highly recommended.

We have performed an integral revision of the manuscript to improve English language.

11. There are several typos and grammar/syntax errors throughout the manuscript which should be revised. English language editing is highly recommended.

We have revised integrally the manuscript to delete grammar/syntax errors

 

12. Comments on the Quality of English Language

• We have revised integrally the manuscript to improve the quality of English language

 

 

Reviewer 3 Report

Comments and Suggestions for Authors

This study explores the preventive role of the Mediterranean Diet (MD) in age-related conditions, specifically sarcopenia and frailty, among older adults. The research examines the effects of dietary adherence to the MD—characterized by high intake of fruits, vegetables, legumes, whole grains, and olive oil—on physical function, muscle strength, and metabolic health. Through a synthesis of observational studies, clinical trials, and meta-analyses, the review highlights the association between MD adherence and improved outcomes such as enhanced hand grip strength, reduced frailty scores, and better mobility metrics. In addition, the study investigates the synergistic impact of combining MD adherence with physical activity, particularly resistance training, on muscle mass retention and functional independence. It also discusses the role of antioxidant and anti-inflammatory dietary components in mitigating the physiological mechanisms underlying sarcopenia and frailty. The findings underscore the importance of lifestyle-based interventions, positioning the Mediterranean Diet as a promising non-pharmacological approach for promoting healthy aging, delaying functional decline, and reducing the burden of age-related disability in elderly populations.

 

However, I therefore have to point out some comments:

 

Line 3: The phrase “in elderly” is grammatically incorrect. It should be changed to “in the elderly” or “in older adults” to reflect proper academic language.

Lines 26–27: The sentence “From 111 identified articles, 13 met the inclusion criteria…” lacks transparency.

Line 33: The term “especially in pre-frail individuals” is vague. Specify which studies demonstrated this and the statistical significance if available.

Lines 34–36: The final sentences of the abstract largely repeat what is said later in the conclusion. Consider removing or rephrasing.

Line 55: The sentence “seems that a balanced diet…” is grammatically incomplete. It should be “It seems that a balanced diet…”

Line 61: A transitional sentence is needed between the discussion of nutrient intake and the introduction of the Mediterranean Diet (MD) to improve flow.

Line 66: The phrase “which undoubtedly are implicated...” is too strong. Replace “undoubtedly” with “are thought to be” or “are believed to be” for scientific neutrality.

Line 71: “Even, some authors have suggested…” is ungrammatical. Rewrite as “Some authors have even suggested…”

Line 99: The phrase “will be included” should be in the past tense (“were included”), as the selection has already occurred.

Lines 248–249: The conclusion that MD improves “body composition and metabolic health” should include a note on intervention fidelity and study limitations.

Line 67: The phrase “the well-known of the beneficial effects” is incorrect. Correct form: “the well-known beneficial effects.”

Comments on the Quality of English Language

no

Author Response

First of all, we would like to thank the reviewers for taking the time to analyze our article. Their feedback has undoubtedly helped us improve its quality and make it more interesting for readers of Nutrients. Below, we answer point by point all the questions raised by the reviewers.

 

Comments and Suggestions for Authors

This study explores the preventive role of the Mediterranean Diet (MD) in age-related conditions, specifically sarcopenia and frailty, among older adults. The research examines the effects of dietary adherence to the MD—characterized by high intake of fruits, vegetables, legumes, whole grains, and olive oil—on physical function, muscle strength, and metabolic health. Through a synthesis of observational studies, clinical trials, and meta-analyses, the review highlights the association between MD adherence and improved outcomes such as enhanced hand grip strength, reduced frailty scores, and better mobility metrics. In addition, the study investigates the synergistic impact of combining MD adherence with physical activity, particularly resistance training, on muscle mass retention and functional independence. It also discusses the role of antioxidant and anti-inflammatory dietary components in mitigating the physiological mechanisms underlying sarcopenia and frailty. The findings underscore the importance of lifestyle-based interventions, positioning the Mediterranean Diet as a promising non-pharmacological approach for promoting healthy aging, delaying functional decline, and reducing the burden of age-related disability in elderly populations.

 However, I therefore have to point out some comments:

1. Line 3: The phrase “in elderly” is grammatically incorrect. It should be changed to “in the elderly” or “in older adults” to reflect proper academic language.

As suggested by the reviewer we have changed the title of the manuscript to reflect proper academic language. The new title is the following:

“The role of Mediterranean Diet in the prevention of sarcopenia and frailty in older adults: A Narrative review” (lines 2-3)

2. Lines 26–27: The sentence “From 111 identified articles, 13 met the inclusion criteria…” lacks transparency.

The text has been rewritten to offer more detail and transparency of the selection process (lines 26-30). Likewise, in figure 2 this process is detailed (line 120).

3. Line 33: The term “especially in pre-frail individuals” is vague. Specify which studies demonstrated this and the statistical significance if available.

We have introduced and explanation in the abstract as suggested by the reviewer (lines 34-37).

4. Lines 34–36: The final sentences of the abstract largely repeat what is said later in the conclusion. Consider removing or rephrasing.

The last sentence of the abstract has been rewritten (lines 39-41).

5. Line 55: The sentence “seems that a balanced diet…” is grammatically incomplete. It should be “It seems that a balanced diet…”

The sentence has been changed according to reviewer’s comment. (line 68-69).

6. Line 61: A transitional sentence is needed between the discussion of nutrient intake and the introduction of the Mediterranean Diet (MD) to improve flow.

A transitional sentence has been included to improve flow. The new sentence is the following:

“One of the healthiest and most complete dietary patterns is the Mediterranean diet, whose numerous beneficial effects in the prevention of various diseases are well known. However, there is limited information on its potential effect in preventing sarcopenia and frailty in older adults (13, 14, 15)”. (lines 74-77)

7. Line 66: The phrase “which undoubtedly are implicated...” is too strong. Replace “undoubtedly” with “are thought to be” or “are believed to be” for scientific neutrality.

The sentence has been changed. The new sentence is the following:

“Most of these foods are rich in antioxidants and anti-inflammatory molecules, as well as omega-3 fatty acids, which are believed to be responsible for the well-known beneficial effects of the Mediterranean diet (17)”. (lines 81-83)

8. Line 71: “Even, some authors have suggested…” is ungrammatical. Rewrite as “Some authors have even suggested…”

The sentence has been rewritten (lines 87-88)

9. Line 99: The phrase “will be included” should be in the past tense (“were included”), as the selection has already occurred.

The sentence has been rewritten (line 124)

10. Lines 248–249: The conclusion that MD improves “body composition and metabolic health” should include a note on intervention fidelity and study limitations.

The information asked for the reviewers has been included (lines 281-285)

 

11. Line 67: The phrase “the well-known of the beneficial effects” is incorrect. Correct form: “the well-known beneficial effects.”

The sentence has been rewritten (line 83)

 

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

no