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Abstract

Background

Dietary intervention success requires strong participant adherence, but very few studies have examined factors related to both short-term and long-term adherence. A better understanding of predictors of adherence is necessary to improve the design and execution of dietary intervention trials. This study was designed to identify participant characteristics at baseline and study features that predict short-term and long-term adherence with interventions promoting the Mediterranean-type diet (MedDiet) in the PREvención con DIeta MEDiterránea (PREDIMED) randomized trial.

Methods

Analyses included men and women living in Spain aged 55–80 at high risk for cardiovascular disease. Participants were randomized to the MedDiet supplemented with either complementary extra-virgin olive oil (EVOO) or tree nuts. The control group and participants with insufficient information on adherence were excluded. PREDIMED began in 2003 and ended in 2010. Investigators assessed covariates at baseline and dietary information was updated yearly throughout follow-up. Adherence was measured with a validated 14-point Mediterranean-type diet adherence score. Logistic regression was used to examine associations between baseline characteristics and adherence at one and four years of follow-up.

Results

Participants were randomized to the MedDiet supplemented with EVOO (n = 2,543; 1,962 after exclusions) or tree nuts (n = 2,454; 2,236 after exclusions). A higher number of cardiovascular risk factors, larger waist circumference, lower physical activity levels, lower total energy intake, poorer baseline adherence to the 14-point adherence score, and allocation to MedDiet + EVOO each independently predicted poorer adherence. Participants from PREDIMED recruiting centers with a higher total workload (measured as total number of persons-years of follow-up) achieved better adherence. No adverse events or side effects were reported.

Conclusions

To maximize dietary adherence in dietary interventions, additional efforts to promote adherence should be used for participants with lower baseline adherence to the intended diet and poorer health status. The design of multicenter nutrition trials should prioritize few large centers with more participants in each, rather than many small centers.

Trial registration

This study was registered at controlled-trials.com (http://www.controlled-trials. com/ISRCTN35739639). International Standard Randomized Controlled Trial Number (ISRCTN): 35739639. Registration date: 5 October 2005.

Trial design: parallel randomized trial.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-016-0394-6) contains supplementary material, which is available to authorized users.

Background

The global burden of diet-related chronic diseases has skyrocketed over the last few decades. As rates continue to rise [1] and food environments become increasingly obesogenic [2], it is more important than ever to improve understanding of diet-disease relationships and decrease the risk of chronic disease through diet modification. Effective dietary intervention strategies can help accomplish both of these objectives. The Mediterranean-type diet (MedDiet) is associated with decreased risk of all-cause [3, 4] and premature [5, 6] death, cardiovascular disease [7, 8], type 2 diabetes [9, 10], overweight and obesity [11, 12], and several cancers [13, 14]. Experimental interventions and randomized controlled trials (RCTs) have confirmed these findings [7, 8, 14–19]. It is very likely that future intervention trials in nutrition will adopt the paradigm of the Mediterranean food pattern, as the 2015 Dietary Guidelines for Americans have recommended [20]. In this context, information about the predictors of success in interventions using such a food pattern is very much needed.

Permanent dietary modifications are difficult to achieve; long-term dietary interventions often have low adherence [21–26]. Identifying participant characteristics and study design features that predict long-term adherence will substantially help investigators design dietary interventions to maximize adherence, achieve sufficient contrast in nutritional exposures between intervention arms, and reduce diet-related chronic diseases in target populations.

A handful of studies have identified predictors of short-term adherence to dietary interventions [27–35]. Predictors included the female sex [35], older age [27, 29], a non-diabetic [28, 35] and non-depressive status [34, 36], normal weight [29, 30, 34], higher physical activity levels [34, 35], not smoking [35], white ethnicity [29, 32], higher socioeconomic status [27, 29, 33], and being married [35]. Only two studies have investigated predictors of adherence to the MedDiet [35, 37]. PREvención con DIeta MEDiterránea (PREDIMED) researchers investigated the relationship between baseline characteristics and MedDiet adherence, but that study included only a partial sample of the trial and evaluated only short-term adherence [35]. Another study had longer follow-up but lacked a control group [37].

Among the very few studies that have examined long-term dietary adherence, the outcome was often defined as meeting weight-loss goals, which is only a proxy for dietary adherence. Because only sustained, long-term dietary patterns modify chronic disease risk [38–40], a better understanding of long-term adherence to healthy dietary patterns is needed.

The aim of the present study was to identify predictors of short and long-term adherence with a MedDiet intervention. This study uses data from the PREDIMED trial, a RCT of the MedDiet for the primary prevention of cardiovascular disease [41, 42].

Methods

Study population

Details on the PREDIMED design and methods are described in detail elsewhere [18, 23, 43]. Briefly, the PREDIMED trial was a multicenter, randomized, controlled, single-blinded cardiovascular disease prevention trial conducted in Spain [41]. It was designed to assess the effects of the MedDiet on cardiovascular disease in 7,447 participants recruited between 2003 and 2009. Eligible participants were aged 55 to 80 and at high risk for developing cardiovascular disease (CVD). High risk was defined as having type 2 diabetes or at least three of the following major (CVD) risk factors: current smoking, hypertension, elevated low-density lipoprotein cholesterol levels, BMI ≥25 kg/m², or a family history of premature coronary heart disease (CHD). After providing written informed consent, participants were randomized to one of three interventions; a traditional MedDiet supplemented with either complementary extra-virgin olive oil (EVOO) or tree nuts or a control diet (advice to reduce all types of dietary fat). The control group was excluded from the present analyses because the focus of this study was the adherence with the intervention promoting the MedDiet. Inclusion criteria into this study are depicted in the flow diagram figure provided below, along with the CONSORT checklist for randomized trials. The trial ended in 2010, after a median follow-up of 4.8 years, because of the observed benefit of the MedDiet compared to the low-fat control diet in the prevention of CVD. Institutional Review Boards at 11 recruiting centers approved the study protocol [44]. No harm or unintended effects were reported in any arm [41].

When one-year dietary adherence was the outcome of interest, the present study excluded participants missing information on any of the 14-point dietary adherence score items at one year of follow-up (n = 799), leaving 4,198 participants for analysis. When four-year dietary adherence was the outcome of interest, participants recruited after November 2006 (n = 1,495) were excluded because subsequent follow-up was less than four years. Participants who had missing information on any of the 14-point dietary adherence score items at four years of follow-up were further excluded (n = 1,149), leaving 2,353 participants available for analysis.

Outcome assessment

Registered dietitians conducted quarterly group sessions and one-on-one in-person interviews to deliver a comprehensive motivational educational intervention aimed at modifying participant eating habits. Dietitians collected detailed dietary information at baseline and yearly thereafter during follow-up. Individual interviews and group sessions were conducted every three months throughout the trial. A previously validated 14-item Mediterranean Diet Assessment Tool [45] was the primary method for assessing adherence to the intervention (Additional file 1: Figure S1). PREDIMED dietitians assessed participant adherence using this tool during each visit. A value of 0 (non-compliant) or 1 (compliant) was assigned to each item [46]. Higher scores reflected better adherence. High adherence was defined as meeting at least 11 of the 14 items. This cut-point was used because roughly half of participants complied with 11 or more items at each follow-up visit.

Covariate assessment

Dietitians administered a validated 137-item food frequency questionnaire (FFQ) at each yearly visit [47], from which total energy and alcohol intake was computed [48]. Another questionnaire collected information on sociodemographic variables, lifestyle, and family history data. A validated Spanish version of the Minnesota questionnaire [49, 50] was used to assess physical activity. Investigators reviewed medical records at baseline and yearly thereafter to assess medical diagnoses. Nurses measured weight and height using standardized procedures, and blood pressure using a validated [51] semiautomatic oscillometer in triplicate (Omron HEM_705CP). Primary care doctors assessed participants for new diagnoses of hypercholesterolemia, hypertension and type 2 diabetes. Definitions for these diagnoses are described elsewhere [42].

Exposure assessment

Potential baseline predictors of adherence were assessed based on clinical relevance and findings from previously published studies. These included sex (male, female), age (<65 years, ≥65 years), highest educational level attained (less than primary school, primary school, secondary school, university or more), occupation (retired, working, housewife, unemployed or unable to work), marital status (married, other), number of people in household, continuous cardiovascular risk factor score (one point was assigned for each of the following diagnoses or conditions: type 2 diabetes, hypertension, high blood cholesterol, family history of premature CHD, depression, and obesity; scores of 0–1 and 5–6 were collapsed due to low frequency), individual cardiovascular risk factors (each of the six factors included in the cardiovascular risk score were also assessed separately instead of as a continuous score), systolic blood pressure and diastolic blood pressure (SBP and DBP, continuous, per 5 mmHg), waist circumference (continuous, per 5 cm), physical activity (tertiles of MET-min/day), smoking status (never, former, current), total energy intake (quartiles of kcal/day), alcohol other than wine (low: <10 g/day for men, <5 for women; moderate: 10–50 for men, 5–10 for women; high: >50 for men, >10 for women), baseline 14-point dietary adherence score (<11 points, ≥11 points), and MedDiet intervention group (mixed nuts, EVOO). This analysis also evaluated whether the “total workload”, measured in person-years of follow-up and an indicator of how many participants a given center delivers the intervention to throughout follow-up, was associated with dietary adherence.

Statistical methods

Chi-square tests were used to assess differences in distributions of baseline characteristics between those with low adherence (<11 points) and high adherence (≥11 points). In Table 2, crude and multivariate-adjusted logistic regression was used to calculate odds ratios (ORs) of adherence to the MedDiet at one and four years of follow-up according to baseline characteristics. Multivariate models were adjusted for all potential predictors of dietary adherence listed above. To calculate p-values for trend, the median value was assigned to each category and the resulting variable was treated as continuous. Quantiles were not treated as ordinal variables to account for the fact that the differences in median values across quantiles were not equal.

Table 2

Odds of high adherence with the MedDiet intervention at one and four years of follow-up^a

^a ORs < 1 imply poorer adherence. ORs > 1 imply better adherence. A validated MedDiet adherence assessment tool was used. 1 point was added for each item in adherence with the traditional MedDiet. High adherence = adherence with ≥11 items on 14-point dietary adherence score. Low adherence = adherence with <11 items. ^b All models are from logistic regression analysis. Multivariate models are mutually adjusted for all characteristics displayed in this table including total CVD risk score but excluding individual CVD risk factors (type 2 diabetes, hypertension, hypercholesterolaemia, family history of pre-mature CHD, depression, obesity). When an individual CVD risk factors was the exposure of interest, the model was mutually adjusted for other individual CVD risk factors but not total CVD risk score. ^c P-values for trend were calculated by assigning the median value to each category and treating the resulting variable as continuous ^d Total CVD risk score calculated by summing the following CVD risk factors: type 2 diabetes, hypertension, high blood cholesterol, family history of premature CHD, depression, obesity. ^e Tertiles of physical activity (MET-min/d): T1: <108; T2: 108–268; T3: ≥268. ^f Quartiles of energy intake (kcal/d), by sex: Men: Q1: <2051; Q2: 2051- < 2394; Q3:2934- < 2801; Q4: ≥2801. Women: Q1: <1786; Q2: 1786- < 2109; Q3: 2109- < 2465; Q4: ≥2465. ^g Measured in quartiles of person years at center. After 1 Year: Q1: 133- < 352; Q2: 352- < 537; Q3: 537- < 650; Q4: ≥650. After 4 years: Q1: 893- < 1220; Q2: 1220- < 2175; Q3: 2175- < 2384; Q4: ≥2384

Several sensitivity analyses were conducted using multivariate logistic regression. Analyses looked at associations between potential baseline predictors and adherence at two and three years of follow-up (instead of one and four years), and with ≥10 and ≥12 as alternative cut-points for dietary adherence (instead of ≥11).

All p-values are two-tailed. Values of ≤0.05 are considered statistically significant. All statistical analyses were performed using Stata software (version 12.0, StataCorp 2011, College Station, TX, USA).

Results

Table 1 shows the mean (±SD) or percentage of participants with high adherence and low adherence (≥11 and <11 points on 14-point score) after 1-y and 4-y follow-up across levels of baseline characteristics. 54 % of participants complied at one-year follow-up, and 58 % at 4-y follow-up. The mean (±SD) age at baseline was 66.9 (±6.1) years, and 56.4 % of participants were female. The following baseline characteristics were associated with lower adherence at both time points: female sex, a greater number of cardiovascular risk factors, larger waist circumference, less physical activity, less total energy intake, and lower baseline 14-point dietary adherence score. When individual risk factors were assessed, type 2 diabetes diagnosis and obesity were associated with poorer adherence at both time points. Randomization to the MedDiet supplemented with MedDiet + EVOO and inclusion at a center following a lower intervention workload were also correlated with lower adherence at one and four years. Additional file 2: Table S5 shows that distributions of baseline characteristics did not differ depending on time period of enrollment, with the exception of number of total workload per center. Centers that began recruitment after November, 2006 were the only centers with less than 300 participants. November, 2006 was selected as the cut-point because participants recruited after this date were followed for less than four years, and thus were excluded from analyses where dietary adherence at four years is the outcome of interest.

Table 1

Baseline characteristics according to a 14-point dietary adherence score after 1, 4 years of follow-up^a

^a Those randomized after November 2006 did not have the opportunity to provide information on 4-year adherence. ^b A validated MedDiet adherence assessment tool was used. 1 point was added for each item in adherence with the traditional MedDiet. High adherence = adherence with ≥11 items on 14-point dietary adherence score. Low adherence = adherence with <11 items. ^c Total CVD risk score was calculated by summing the following CVD risk factors: type 2 diabetes, hypertension, high blood cholesterol, family history of premature CHD, depression, obesity. ^d Tertiles of physical activity (MET-min/d): T1: <108; T2: 108–268; T3: ≥268. ^e Quartiles of energy intake (kcal/d), by sex: Men: Q1: <2051; Q2: 2051- < 2394; Q3:2934- < 2801; Q4: ≥2801. Women: Q1: <1786; Q2: 1786- < 2109; Q3: 2109- < 2465; Q4: ≥2465. ^f Measured in quartiles of person years at center. After 1 Year: Q1: 133- < 352; Q2: 352- < 537; Q3: 537- < 650; Q4: ≥650. After 4 years: Q1: 893- < 1220; Q2: 1220- < 2175; Q3: 2175- < 2384; Q4: ≥2384

Figure 1 provides a summary diagram comparing multivariate logistic regression results across all primary and sensitivity analyses.

Summary of primary and sensitivity analysis results from multivariate logistic regression models investigating predictors of dietary adherence with the 14-point MedDiet score

Short term dietary adherence (one year of follow-up)

Table 2 shows primary results for the association between potential baseline characteristics and dietary adherence after one and and four years of follow-up. The following baseline characteristics were associated with lower dietary adherence at one year of follow-up in multivariate logistic regression models: the female sex, working (vs. retired), type 2 diabetes diagnosis, obesity, larger waist circumference, lower physical activity, lower total energy intake, and lower 14-point baseline adherence score. Both study design features, randomization to the MedDiet + EVOO intervention arm, and belonging to a PREDIMED center that had a lower workload (fewer person years), were also associated with lower one-year adherence. In Additional file 2: Table S2, the dietary adherence score cut-off point is changed from ≥11 to the alternative cut-off points of ≥10 and ≥12. The majority of predictors of low one-year adherence observed in Table 2, when ≥11 items was the cut-off point, remained after changing the cut-off point. Exceptions include obesity (no longer a predictor when either alternate cut-off point was used) and lower energy intake (no longer a predictor when ≥10 items was the cut-off point). Additional file 2: Table S4 investigates adherence at one year of follow-up after excluding those recruited after November 2006 in order to restrict to the group that could be analyzed at both time points. A handful of associations did not hold, likely due to reduced power as a result of smaller sample size. Associations with lower one-year adherence that did not hold included the female gender, working (vs. retired), obesity, lower physical activity, and lower total energy intake. Baseline predictors of lower one-year adherence that remained significant throughout all sensitivity analyses include type 2 diabetes, larger waist circumference, and lower 14-point baseline adherence score. Both study design features (randomization to the MedDiet + EVOO intervention arm and belonging to a PREDIMED center with a lower workload) were also associated with lower one-year adherence throughout all sensitivity analyses.

Long term dietary adherence (after four years of follow-up)

Based on the primary analysis in Table 2, the following baseline characteristics were associated with lower dietary adherence after four years in multivariate logistic regression models: higher total number of cardiovascular risk factors, specifically type 2 diabetes diagnosis, hypertension, and family history of premature CHD, higher SBP, lower physical activity levels, lower total energy intake, and lower baseline14-point adherence score. Study design features predicting lower adherence after four years of follow-up included being in the MedDiet + EVOO intervention arm and belonging to a PREDIMED center with a lower workload over follow-up. Table 3 defines four-year adherence as consistently meeting the criteria for high dietary adherence (≥11 points on 14-point score) every year throughout the first four years of follow-up. Results were similar to four-year results in Table 2. However, with this more stringent definition, hypertension, higher SBP, and lower energy intake were no longer associated with poorer four-year adherence. After changing the dietary adherence cut-off points to ≥10 and ≥12 items (Additional file 2: Table S2), all associations between potential predictors and lower four-year adherence remained except for total number of cardiovascular risk factors (no longer a predictor when cut-off point was ≥10 items), type 2 diabetes diagnosis (no longer a predictor when cut-point was ≥10 items), higher SBP (no longer a predictor for either alternative cut-point), and lower total energy intake (no longer a predictor using either alternative cut-off point). Baseline predictors of lower four-year adherence that remained significant throughout all sensitivity analyses included family history of CHD, lower physical activity, lower baseline 14-point adherence score, randomization to the MedDiet + EVOO arm, and belonging to a PREDIMED center with a lower workload.

Table 3

Odds of high adherence with the MedDiet intervention every year throughout four years of follow-up. ^a

^a ORs < 1 imply poorer adherence. ORs > 1 imply better adherence. A validated MedDiet adherence assessment tool was used. 1 point was added for each item in adherence with the traditional MedDiet. High adherence = adherence with ≥11 items on 14-point dietary adherence score. Low adherence = adherence with <11 items. ^b All models are from logistic regression analysis. Multivariate models are mutually adjusted for all characteristics displayed in this table including total CVD risk score but excluding individual CVD risk factors (type 2 diabetes, hypertension, hypercholesterolaemia, family history of pre-mature CHD, depression, obesity). When an individual CVD risk factors was the exposure of interest, the model was mutually adjusted for other individual CVD risk factors but not total CVD risk score. ^c P-values for trend were calculated by assigning the median value to each category and treating the resulting variable as continuous. ^d Risk score calculated by summing the following CVD risk factors: type 2 diabetes, hypertension, high blood cholesterol, family history of premature CHD, depression, obesity. ^e Tertiles of physical activity (MET-min/d): T1: <108; T2: 108–268; T3: ≥268. ^f Quartiles of energy intake (kcal/d), by sex: Men: Q1: <2051; Q2: 2051- < 2394; Q3:2934- < 2801; Q4: ≥2801. Women: Q1: <1786; Q2: 1786- < 2109; Q3: 2109- < 2465; Q4: ≥2465. ^g Measured in quartiles of person years at center. After 4 years: Q1: 893- < 1220; Q2: 1220- < 2175; Q3: 2175- < 2384; Q4: ≥2384

Medium-term adherence (two and three years of follow-up)

Additional file 2: Table S1 shows results for the association between potential predictors and adherence at the alternate time points of two and three years of follow-up. All characteristics that predicted lower adherence at both one and four years in the primary analysis multivariate logistic regression models (type 2 diabetes diagnosis, lower physical activity, lower total energy intake, lower 14-point adherence score, randomization to the MedDiet + EVOO arm, and belonging to a PREDIMED center with a lower workload) also predicted low adherence at both two and three years.

Additional file 2: Table S3 presents results from logistic regression analyses of the association between MedDiet intervention (nuts or EVOO) and dietary adherence to nut and olive oil items on the 14-point dietary adherence score (≥4 tbsp olive oil per day; olive oil as main culinary fat; ≥3 servings of nuts per week). Those in the MedDiet + EVOO intervention arm had significantly higher odds of complying with either of the two olive oil items (5 to 10 times the odds) at both one and four years of follow-up. In contrast, those in the nut intervention group had about 20 times the odds of complying with the nut item.

Discussion

In the PREDIMED trial, baseline characteristics showing the strongest associations with both low short-term and low long-term dietary adherence with a MedDiet intervention included a higher number of cardiovascular risk factors (including specifically type 2 diabetes diagnosis), larger waist circumference, lower levels of physical activity, lower baseline dietary adherence, randomization to the MedDiet + EVOO intervention arm and belonging to a PREDIMED center with a lower workload, measured by total person years of follow-up.

Study design

It is not surprising that the total workload (measured in person years) at a PREDIMED center was associated with both short-term and long-term adherence; the workload likely represents the level of experience the research team had with intervention delivery. Similar findings have been observed in hospitals, where quality of care is often related to number of administered procedures [52]. This finding suggests that multicenter interventions should recruit participants to fewer centers with more participants in each, instead of more centers with fewer participants in each, to maximize effectiveness and adherence. Streamlining intervention delivery would have an added benefit of reducing costs. While this would not explain the difference in adherence, this would free up resources for increased support for participants at risk of poor or suboptimal adherence.

Participants randomized to the MedDiet + EVOO (compared to tree nuts) had lower dietary adherence. This is probably because olive oil is a staple ingredient in the Spanish diet; participants consume olive oil regardless of supplementation from PREDIMED. Nut consumption is not as commonplace. As a result, it is easier for the nut group to adhere to the olive oil criteria compared to the olive oil group’s ability to adhere to the nut criteria. Additional file 2: Table S3 shows that intervention group is a much stronger predictor of complying with the nut adherence item compared to the olive oil adherence items. This suggests that, for dietary interventions providing participants with complementary food items, it may be most effective to provide them with foods that are less commonplace.

Baseline health and lifestyle characteristics

In the present study, many predictors of low adherence with the MedDiet are indicators of poorer baseline health, including various cardiovascular risk factors, less physical activity, and poorer baseline diet. These results are consistent with previous findings investigating predictors of adherence with dietary interventions for reducing fat [29] and carbohydrates [28], family-level interventions [34], and MedDiet interventions [35, 37]. Baseline health status may indicate how much a person values his or her health, which may moderate one’s motivation to comply with the intervention. Alternatively, some research suggests that individuals may be more willing or motivated to make dietary and lifestyle improvements following a medical diagnosis [53]. These findings do not necessarily contradict this notion, as many of these indicators of baseline health are likely long-standing conditions and/or habits; the time during which one is more motivated to make improvements may have passed. Regardless, unhealthy individuals have a greater need for dietary improvement. Thus, they are often the most important targets of dietary interventions. Personalized, higher-intensity intervention approaches may be needed to achieve optimal adherence among less healthy individuals.

Demographic characteristics

Like this study, most previous studies [35, 37] found that women have lower adherence than men. The only exception was a family intervention study [34]. It is possible that because mothers traditionally plan family meals, they were motivated to set a positive example through intervention adherence [34]. However, in this study population, it is possible that spouses and children influence meal preparation, leading to these disparate findings. Different strategies likely have different levels of effectiveness based on sex [54]. However, in the present study the female sex only predicted lower adherence at one year of follow-up, and not four years.

There have been conflicting findings about the relationship between age and dietary adherence [27, 29, 37]. The age range in the present study was restricted to 55–80 years; hence little age variability likely limited the ability to detect an association.

There was little evidence for an association between educational attainment and intervention adherence. While participants with less than a primary school education had lower long-term adherence than those with university level or higher, this did not hold in several sensitivity analyses. Previous studies have found that higher socioeconomic status predicted better dietary adherence, but findings did not hold for long-term adherence [27, 29] and were limited to low-fat dietary interventions [33]. This suggests that dietary interventions may be able to overcome the socioeconomic disparities that often exist in nutrition [55].

Further discussion

The present study has several strengths. First, the sample size was large and it was conducted in an established, long-term, and successful randomized trial. Second, because all study participants were at high risk for CVD, it was possible to assess adherence among participants who were less healthy compared to the general population. Because they also were likely to have poorer baseline diets, adherence was probably especially challenging for these individuals. Thus, significant predictors of adherence may be even more meaningful in this setting. Third, this is one of the few studies that has been able to assess long-term dietary adherence. This is critical, as long-term, high-quality dietary pattern is the relevant dietary exposure for the prevention of chronic disease. Fourth, mutually adjusting for a wide array of baseline characteristics minimized residual confounding. Lastly, significant measurement error is unlikely because only 0.3 % of covariate values were missing, a validated measure for assessing dietary adherence was used [46], and previous analyses show that self-reported dietary intake is highly correlated with biomarkers in this population [18, 23].

It is important to note that because the high adherence is not rare, the ORs do not approximate risk ratios (RRs) and thus should not be incorrectly interpreted as RRs. However, provided appropriate interpretation, ORs still provide valid estimates, and it is more appropriate to apply OR estimates to all individuals within a population. Furthermore, because an OR incorporates both success and failure symmetrically, it is less arbitrary than a RR and thus a more robust estimate [56].

There are also limitations in this study. The potential for measurement error always exists. To include as many people as possible in the present analyses, missing covariate values were imputed for 0.3 % of values. Recall bias, social desirability bias and differential misreporting are always possible when diet is self-reported. Finally, it is always possible that failure to control for unmeasured confounders may have distorted results for predictors of dietary adherence. However, analyses were adjusted for a wide array of important baseline characteristics, and a strong confounder unrelated to these characteristics is unlikely. This unique population of older Spanish participants at high risk for cardiovascular disease may have low generalizability to the general public at lower risk of CVD.

The relative success of a dietary intervention to induce changes in the overall food pattern has been more frequently ascribed to strategies related to negotiation, goal setting, self monitoring, and skill building [57–59]. Other strategies such as the training of dietitians, length and intensity of intervention, frequency of contacts, multiplicity of channels used for the delivery of the intervention, the initial motivation of participants for adherence, and the provision of appropriate means for feedback should not be forgotten.

It is clear that certain participants have greater difficulty complying with dietary interventions. Our results identify specific baseline characteristics that predict better adherence, which is an instrumental first step for designing personalized intervention delivery strategies. However, further research is needed to also identify barriers to dietary adherence. Identifying both individual and universal barriers will have important implications for exactly how to promote adherence, and allow for an even more targeted and personalized intervention approach.

Conclusion

Investigators should design dietary interventions for maximum dietary adherence. Long-term adherence is especially important. With a growing worldwide interest in interventions promoting the MedDiet, these results suggest the need for an early identification of participants with lower baseline adherence to a healthy diet and poorer health status. Additional efforts to promote adherence might be required among this group. Further research is needed to identify the most effective approach for overcoming the inherent difficulties in achieving optimal adherence, including identifying barriers to dietary change and adherence at an individual level. For multi-centered studies, it may be more effective to streamline intervention delivery by allocating participants to few large centers rather to many small centers; a higher volume of participants per dietitian in these large center will be more effective to obtain adherence. Dietary intervention studies designed to maximize adherence will contribute higher quality public health research and generate more effective and permanent dietary improvements among participants. This will ultimately decrease the burden of diet-related non-communicable diseases.

Abbreviations

CHD, coronary heart disease; CVD, cardiovascular disease; DBP, diastolic blood pressure; EVOO, extra virgin olive oil; FFQ, food frequency questionnaire; MedDiet, Mediterranean-type diet; MET, metabolic equivalent of task; OR, odds ratio; PREDIMED, PREvención con DIeta MEDiterránea; RCTs, randomized controlled trials; RR, risk ratio; SBP, systolic blood pressure; SD, standard deviation

Acknowledgements

N/A-everyone included in author list and funding section.

Funding

This study was funded by the Spanish Ministry of Health (ISCIII), PI1001407, Thematic Network G03/140, RD06/0045, FEDER (Fondo Europeo de Desarrollo Regional), and the Centre Català de la Nutrició de l’Institut d’Estudis Catalans. The Fundación Patrimonio Comunal Olivarero and Hojiblanca SA (Málaga, Spain), California Walnut Commission (Sacramento, CA), Borges SA (Reus, Spain), and Morella Nuts SA (Reus, Spain) donated the olive oil, walnuts, almonds and hazelnuts, respectively, used in the study. CIBEROBN is an initiative of ISCIII, Spain.

Availability of data and materials

If you do not wish to share your data, please state that data will not be shared, and state the reason. Due to PREDIMED confidentiality policies, data will not be shared.

Authors’ contributions

MKD, AG, MAMG designed the research. MKD conducted the research. MKD, AG, MAMG analyzed the data. MKD wrote the paper, with guidance and editing from AG, MAMG, MJ. AST was a primary PREDIMED dietitian. MAMG, DC, JSS, ER, RE, MF, EG-G, FA, ML, FJG, LSM, XP, JB, JVS, EV, SLM, XP, JB, EV were coordinators of subject recruitment. IZ assisted with administrative logistics. MKD, AG, MAMG had full access to all the data and the study and take responsibility for the integrity of the analysis. All authors revised the manuscript. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests. None of the funding sources played a role in the design, collection, analysis or interpretation of the data or in the decision to submit the manuscript for publication.

Ethics approval and consent to participate

During enrollment, investigators conducted face-to-face interviews with potential participants, during which the purpose and characteristics of the study were explained and informed consent was obtained from willing participants. The International Review Board (IRB) of Hospital Clinic in Barcelona, Spain, approved the study protocol in July 2002. Following this, IRBs of all other centers approved. Participants were randomized to one of three interventions after providing written consent. No harm or unintended effects were reported in any arm [40].

Additional files

Additional file 1:^{(615K, doc)}

Table S1. Odds of high adherence with the MedDiet intervention at two and three years of follow-up. Table S2. Odds of high adherence with the MedDiet intervention using alternate adherence score cut-points. Table S3. Odds of adherence with olive oil and nut consumption after 1 and 4 years of follow-up. Table S4. Odds of high adherence with the MedDiet intervention at one year^a, restricting the analyses to those participants recruited before 2006. Table S5. Adherence at one year of follow-up according to a 14-point dietary adherence score and year of recruitment into PREDIMED. Table S6. Odds of high adherence with the MedDiet intervention at one and four years of follow-up^a, with alternate representation of “total workload”. (DOC 615 kb)

Figure S1. Validated 14-item questionnaire of mediterranean diet adherence (DOCX 205 kb)

Consort 2010 Checklist. (DOC 219 kb)

References

The 2018 FIFA World Cup was the 21st FIFA World Cup, an international football tournament contested by the men's national teams of the member associations of FIFA once every four years. It took place in Russia from 14 June to 15 July 2018.^[1] It was the first World Cup to be held in Eastern Europe,^[2] and the 11th time that it had been held in Europe. At an estimated cost of over $14.2 billion, it was the most expensive World Cup.^[3] It was also the first World Cup to use the video assistant referee (VAR) system.^[4][5]

The finals involved 32 teams, of which 31 came through qualifying competitions, while the host nation qualified automatically. Of the 32 teams, 20 had also appeared in the previous tournament in 2014, while both Iceland and Panama made their first appearances at a FIFA World Cup. A total of 64 matches were played in 12 venues across 11 cities.^[6]

Germany were the defending champions, but were eliminated in the group stage.

The final took place on 15 July at the Luzhniki Stadium in Moscow, between France and Croatia. France won the match 4–2 to claim their second World Cup title, marking the fourth consecutive title won by a European team.

• 1Host selection
• 2Teams
• 3Officiating
• 4Venues
• 5Preparation and costs
• 8Group stage
• 9Knockout stage
• 10Statistics
  • 10.3Awards
• 11Marketing
• 12Controversies

Host selection

The bidding procedure to host the 2018 and 2022 FIFA World Cup tournaments began in January 2009, and national associations had until 2 February 2009 to register their interest.^[7] Initially, nine countries placed bids for the 2018 FIFA World Cup, but Mexico later withdrew from proceedings,^[8] and Indonesia's bid was rejected by FIFA in February 2010 after the Indonesian government failed to submit a letter to support the bid.^[9] During the bidding process, the three remaining non-UEFA nations (Australia, Japan, and the United States) gradually withdrew from the 2018 bids, and the UEFA nations were thus ruled out of the 2022 bid. As such, there were eventually four bids for the 2018 FIFA World Cup, two of which were joint bids: England, Russia, Netherlands/Belgium, and Portugal/Spain.

The 22-member FIFA Executive Committee convened in Zürich on 2 December 2010 to vote to select the hosts of both tournaments.^[10] Russia won the right to be the 2018 host in the second round of voting. The Portugal/Spain bid came second, and that from Belgium/Netherlands third. England, which was bidding to host its second tournament, was eliminated in the first round.^[11]

The voting results were as follows:^[12]

Criticism

The English Football Association and others raised concerns of bribery on the part of the Russian team and corruption from FIFA members. They claimed that four members of the executive committee had requested bribes to vote for England, and Sepp Blatter had said that it had already been arranged before the vote that Russia would win.^[13] The 2014 Garcia Report, an internal investigation led by Michael J. Garcia, was withheld from public release by Hans-Joachim Eckert, FIFA's head of adjudication on ethical matters. Eckert instead released a shorter revised summary, and his (and therefore FIFA's) reluctance to publish the full report caused Garcia to resign in protest.^[14] Because of the controversy, the FA refused to accept Eckert's absolving of Russia from blame, with Greg Dyke calling for a re-examination of the affair and David Bernstein calling for a boycott of the World Cup.^[15][16]

Teams

Qualification

For the first time in the history of the FIFA World Cup, all eligible nations – the 209 FIFA member associations minus automatically qualified hosts Russia – applied to enter the qualifying process.^[17]Zimbabwe and Indonesia were later disqualified before playing their first matches,^[18][19] while Gibraltar and Kosovo, who joined FIFA on 13 May 2016 after the qualifying draw but before European qualifying had begun, also entered the competition.^[20] Places in the tournament were allocated to continental confederations, with the allocation unchanged from the 2014 World Cup.^[21][22] The first qualification game, between Timor-Leste and Mongolia, began in Dili on 12 March 2015 as part of the AFC's qualification,^[23] and the main qualifying draw took place at the Konstantinovsky Palace in Strelna, Saint Petersburg, on 25 July 2015.^{[24][25][26][1]}

Of the 32 nations qualified to play at the 2018 FIFA World Cup, 20 countries competed at the previous tournament in 2014. Both Iceland and Panama qualified for the first time, with the former becoming the smallest country in terms of population to reach the World Cup.^[27] Other teams returning after absences of at least three tournaments include: Egypt, returning to the finals after their last appearance in 1990; Morocco, who last competed in 1998; Peru, returning after 1982; and Senegal, competing for the second time after reaching the quarter-finals in 2002. It is the first time three Nordic countries (Denmark, Iceland and Sweden) and four Arab nations (Egypt, Morocco, Saudi Arabia and Tunisia) have qualified for the World Cup.^[28]

Notable countries that failed to qualify include four-time champions Italy (for the first time since 1958), three-time runners-up and third placed in 2014 the Netherlands (for the first time since 2002), and four reigning continental champions: 2017 Africa Cup of Nations winners Cameroon, two-time Copa América champions and 2017 Confederations Cup runners-up Chile, 2016 OFC Nations Cup winners New Zealand, and 2017 CONCACAF Gold Cup champions United States (for the first time since 1986). The other notable qualifying streaks broken were for Ghana and Ivory Coast, who had both made the previous three tournaments.^[29]

Note: Numbers in parentheses indicate positions in the FIFA World Rankings at the time of the tournament.^[30]

Draw

The draw was held on 1 December 2017 at 18:00 MSK at the State Kremlin Palace in Moscow.^[31][32] The 32 teams were drawn into 8 groups of 4, by selecting one team from each of the 4 ranked pots.

For the draw, the teams were allocated to four pots based on the FIFA World Rankings of October 2017. Pot 1 contained the hosts Russia (who were automatically assigned to position A1) and the best seven teams, pot 2 contained the next best eight teams, and so on for pots 3 and 4.^[33] This was different from previous draws, when only pot 1 was based on FIFA rankings while the remaining pots were based on geographical considerations. However, teams from the same confederation still were not drawn against each other for the group stage, except that two UEFA teams could be in each group.

Squads

Initially, each team had to name a preliminary squad of 30 players but, in February 2018, this was increased to 35.^[34] From the preliminary squad, the team had to name a final squad of 23 players (three of whom must be goalkeepers) by 4 June. Players in the final squad may be replaced for serious injury up to 24 hours prior to kickoff of the team's first match and such replacements do not need to have been named in the preliminary squad.^[35]

For players named in the 35-player preliminary squad, there was a mandatory rest period between 21 and 27 May 2018, except for those involved in the 2018 UEFA Champions League Final played on 26 May.^[36]

Officiating

On 29 March 2018, FIFA released the list of 36 referees and 63 assistant referees selected to oversee matches.^[37] On 30 April 2018, FIFA released the list of 13 video assistant referees, who solely acted in this capacity in the tournament.^[38]

Referee Fahad Al-Mirdasi of Saudi Arabia was removed in 30 May 2018 over a match-fixing attempt,^[39] along with his two assistant referees, compatriots Mohammed Al-Abakry and Abdulah Al-Shalwai. A new referee was not appointed, but two assistant referees, Hasan Al Mahri of the United Arab Emirates and Hiroshi Yamauchi of Japan, were added to the list.^[40][41] Assistant referee Marwa Range of Kenya also withdrew after the BBC released an investigation conducted by a Ghanaian journalist which implicated Marwa in a bribery scandal.^[42]

Video assistant referees

Shortly after the International Football Association Board's decision to incorporate video assistant referees (VARs) into the Laws of the Game, on 16 March 2018, the FIFA Council took the much-anticipated step of approving the use of VAR for the first time in a FIFA World Cup tournament.^[43][44]

VAR operations for all games are operating from a single headquarters in Moscow, which receives live video of the games and are in radio contact with the on-field referees.^[45] Systems are in place for communicating VAR-related information to broadcasters and visuals on stadiums' large screens are used for the fans in attendance.^[45]

VAR had a significant impact in several games.^[46] On 15 June 2018, Diego Costa's goal against Portugal became the first World Cup goal based on a VAR decision;^[47] the first penalty as a result of a VAR decision was awarded to France in their match against Australia on 16 June and resulted in a goal by Antoine Griezmann.^[48] A record number of penalties were awarded in the tournament, with this phenomenon being partially attributed to VAR.^[49] Overall, the new technology has been both praised and criticised by commentators.^[50] FIFA declared the implementation of VAR a success after the first week of competition.^[51]

Venues

Russia proposed the following host cities: Kaliningrad, Kazan, Krasnodar, Moscow, Nizhny Novgorod, Rostov-on-Don, Saint Petersburg, Samara, Saransk, Sochi, Volgograd, Yaroslavl, and Yekaterinburg.^[52] Most cities are in European Russia, while Yekaterinburg^[53] is very close to the Europe-Asia border, to reduce travel time for the teams in the huge country. The bid evaluation report stated: 'The Russian bid proposes 13 host cities and 16 stadiums, thus exceeding FIFA's minimum requirement. Three of the 16 stadiums would be renovated, and 13 would be newly constructed.'^[54]

In October 2011, Russia decreased the number of stadiums from 16 to 14. Construction of the proposed Podolsk stadium in the Moscow region was cancelled by the regional government, and also in the capital, Otkrytiye Arena was competing with Dynamo Stadium over which would be constructed first.^[55]

The final choice of host cities was announced on 29 September 2012. The number of cities was further reduced to 11 and number of stadiums to 12 as Krasnodar and Yaroslavl were dropped from the final list. Of the 12 stadiums used for the tournament, 3 (Luzhniki, Yekaterinburg and Sochi) have been extensively renovated and the other 9 stadiums to be used are brand new; $11.8 billion has been spent on hosting the tournament.^[56]

Sepp Blatter stated in July 2014 that, given the concerns over the completion of venues in Russia, the number of venues for the tournament may be reduced from 12 to 10. He also said, 'We are not going to be in a situation, as is the case of one, two or even three stadiums in South Africa, where it is a problem of what you do with these stadiums'.^[57]

In October 2014, on their first official visit to Russia, FIFA's inspection committee and its head Chris Unger visited St Petersburg, Sochi, Kazan and both Moscow venues. They were satisfied with the progress.^[58]Free troy bilt service manuals.

On 8 October 2015, FIFA and the Local Organising Committee agreed on the official names of the stadiums used during the tournament.^[59]

Of the twelve venues used, the Luzhniki Stadium in Moscow and the Saint Petersburg Stadium – the two largest stadiums in Russia – were used most, both hosting seven matches. Sochi, Kazan, Nizhny Novgorod and Samara all hosted six matches, including one quarter-final match each, while the Otkrytiye Stadium in Moscow and Rostov-on-Don hosted five matches, including one round-of-16 match each. Volgograd, Kaliningrad, Yekaterinburg and Saransk all hosted four matches, but did not host any knockout stage games.

Stadiums

Twelve stadiums in eleven Russian cities were built and renovated for the FIFA World Cup.^[60]

• Kaliningrad: Kaliningrad Stadium. The first piles were driven into the ground in September 2015. On 11 April 2018 the new stadium hosted its first match.
• Kazan: Kazan Arena. The stadium was built for the 2013 Summer Universiade. It has since hosted the 2015 World Aquatics Championship and the 2017 FIFA Confederations Cup. The stadium serves as a home arena to FC Rubin Kazan.
• Moscow: Luzhniki Stadium. The largest stadium in the country was closed for renovation in 2013. The stadium was commissioned in November 2017.
• Moscow: Spartak Stadium. The stadium is a home arena to its namesake FC Spartak Moscow. In accordance with the FIFA requirements, during the 2018 World Cup it is called Spartak Stadium instead of its usual name Otkritie Arena. The stadium hosted its first match on 5 September 2014.
• Nizhny Novgorod: Nizhny Novgorod Stadium. The construction of the Nizhny Novgorod Stadium commenced in 2015. The project was completed in December 2017.^[61]
• Rostov-on-Don: Rostov Arena. The stadium is located on the left bank of the Don River. The stadium construction was completed on 22 December 2017.
• Saint Petersburg: Saint Petersburg Stadium. The construction of the stadium commenced in 2007. The project was officially completed on 29 December 2016.^[62] The stadium has hosted games of the 2017 FIFA Confederations Cup and will serve as a venue for UEFA Euro 2020.
• Samara: Samara Arena. The construction officially started on 21 July 2014. The project was completed on 21 April 2018.
• Saransk: Mordovia Arena. The stadium in Saransk was scheduled to be commissioned in 2012 in time for the opening of the all-Russian Spartakiad, but the plan was revised. The opening was rescheduled to 2017. The arena hosted its first match on 21 April 2018.
• Sochi: Fisht Stadium. The stadium hosted the opening and closing ceremonies of the 2014 Winter Olympics. Afterwards, it was renovated in preparation for the 2017 FIFA Confederations Cup and 2018 World Cup.
• Volgograd: Volgograd Arena. The main arena of Volgograd was built on the demolished Central Stadium site, at the foot of the Mamayev Kurgan memorial complex. The stadium was commissioned on 3 April 2018.^[63]
• Yekaterinburg: Ekaterinburg Arena. The Central Stadium of Yekaterinburg has been renovated for the FIFA World Cup. The arena's stands have a capacity of 35,000 spectators. The renovation project was completed in December 2017.

Team base camps

Base camps were used by the 32 national squads to stay and train before and during the World Cup tournament. On 9 February 2018, FIFA announced the base camps for each participating team.^[76]

• Argentina: Bronnitsy, Moscow Oblast
• Australia: Kazan, Tatarstan
• Belgium: Krasnogorsky, Moscow Oblast
• Brazil: Sochi, Krasnodar Krai
• Colombia: Verkhneuslonsky, Tatarstan
• Costa Rica: Saint Petersburg
• Croatia: Roshchino, Leningrad Oblast^[77]
• Denmark: Anapa, Krasnodar Krai
• Egypt: Grozny, Chechnya
• England: Repino, Saint Petersburg^[78]
• France: Istra, Moscow Oblast
• Germany: Vatutinki, Moscow^[79]
• Iceland: Gelendzhik, Krasnodar Krai
• Iran: Bakovka, Moscow Oblast
• Japan: Kazan, Tatarstan
• Mexico: Khimki, Moscow Oblast
• Morocco: Voronezh, Voronezh Oblast
• Nigeria: Yessentuki, Stavropol Krai
• Panama: Saransk, Mordovia
• Peru: Moscow
• Poland: Sochi, Krasnodar Krai
• Portugal: Ramenskoye, Moscow Oblast
• Russia: Khimki, Moscow Oblast
• Saudi Arabia: Saint Petersburg
• Senegal: Kaluga, Kaluga Oblast
• Serbia: Svetlogorsk, Kaliningrad Oblast
• South Korea: Saint Petersburg
• Spain: Krasnodar, Krasnodar Krai
• Sweden: Gelendzhik, Krasnodar Krai
• Switzerland: Togliatti, Samara Oblast
• Tunisia: Pervomayskoye, Moscow Oblast
• Uruguay: Bor, Nizhny Novgorod Oblast

Preparation and costs

Budget

At an estimated cost of over $14.2 billion as of June 2018,^[3] it is the most expensive World Cup in history, surpassing the cost of the 2014 FIFA World Cup in Brazil.^[80]

The Russian government had originally earmarked a budget of around $20 billion^[81] which was later slashed to $10 billion for the preparations of the World Cup, of which half is spent on transport infrastructure.^[82] As part of the program for preparation to the 2018 FIFA World Cup, a federal sub-program 'Construction and Renovation of Transport Infrastructure' was implemented with a total budget of 352.5 billion rubles, with 170.3 billion coming from the federal budget, 35.1 billion from regional budgets, and 147.1 billion from investors.^[83] The biggest item of federal spending was the aviation infrastructure (117.8 billion rubles).^[84] Construction of new hotels was a crucial area of infrastructure development in the World Cup host cities. Costs continued to balloon as preparations were underway.^[80]

Infrastructure spending

Platov International Airport in Rostov-on-Don was upgraded with automated air traffic control systems, modern surveillance, navigation, communication, control, and meteorological support systems.^[85]Koltsovo Airport in Yekaterinburg was upgraded with radio-engineering tools for flight operation and received its second runway strip. Saransk Airport received a new navigation system; the city also got two new hotels, Mercure Saransk Centre (Accor Hotels) and Four Points by Sheraton Saransk (Starwood Hotels) as well as few other smaller accommodation facilities.^[86] In Samara, new tram lines were laid.^[87]Khrabrovo Airport in Kaliningrad was upgraded with radio navigation and weather equipment.^[88] Renovation and upgrade of radio-engineering tools for flight operation was completed in the airports of Moscow, Saint Petersburg, Volgograd, Samara, Yekaterinburg, Kazan and Sochi.^[85] On 27 March, the Ministry of Construction Industry, Housing and Utilities Sector of Russia reported that all communications within its area of responsibility have been commissioned. The last facility commissioned was a waste treatment station in Volgograd. In Yekaterinburg, where four matches are hosted, hosting costs increased to over 7.4 billion rubles, over-running the 5.6 billion rubles originally allocated from the state and regional budget.^[89]

Volunteers

Volunteer applications to the Russia 2018 Local Organising Committee opened on 1 June 2016. The 2018 FIFA World Cup Russia Volunteer Program received about 177,000 applications,^[90] and engaged a total of 35,000 volunteers.^[91] They received training at 15 Volunteer Centres of the Local Organising Committee based in 15 universities, and in Volunteer Centres in the host cities. Preference, especially in the key areas, was given to those with knowledge of foreign languages and volunteering experience, but not necessarily to Russian nationals.^[92]

Transport

Free public transport services were offered for ticketholders during the World Cup, including additional trains linking between host cities, as well as services such as bus service within them.^[93][94][95]

Schedule

The full schedule was announced by FIFA on 24 July 2015 (without kick-off times, which were confirmed later).^[96][97] On 1 December 2017, following the final draw, six kick-off times were adjusted by FIFA.^[98]

Russia was placed in position A1 in the group stage and played in the opening match at the Luzhniki Stadium in Moscow on 14 June against Saudi Arabia, the two lowest-ranked teams of the tournament at the time of the final draw.^[99] The Luzhniki Stadium also hosted the second semi-final on 11 July and the final on 15 July. The Krestovsky Stadium in Saint Petersburg hosted the first semi-final on 10 July and the third place play-off on 14 July.^[100][21]

Opening ceremony

The opening ceremony took place on Thursday, 14 June 2018, at the Luzhniki Stadium in Moscow, preceding the opening match of the tournament between hosts Russia and Saudi Arabia.^[101][102]

At the start of the ceremony, Russian president Vladimir Putin gave a speech, welcoming the countries of the world to Russia and calling football a uniting force.^[103] Brazilian World Cup-winning striker Ronaldo entered the stadium with a child in a Russia shirt.^[103] Pop singer Robbie Williams then sang two of his songs solo before he and Russian soprano Aida Garifullina performed a duet.^[103] Dancers dressed in the flags of the 32 competing teams appeared carrying a sign with the name of each nation.^[103] At the end of the ceremony Ronaldo reappeared with the official match ball which had returned from the International Space Station in early June.^[103]

Group stage

Competing countries were divided into eight groups of four teams (groups A to H). Teams in each group played one another in a round-robin basis, with the top two teams of each group advancing to the knockout stage. Ten European teams and four South American teams progressed to the knockout stage, together with Japan and Mexico.

For the first time since 1938, Germany (reigning champions) did not advance past the first round. For the first time since 1982, no African team progressed to the second round. For the first time, the fair play criteria came into use, when Japan qualified over Senegal due to having received fewer yellow cards. Only one match, France v Denmark, was goalless. Until then there were a record 36 straight games in which at least one goal was scored.^[104]

All times listed below are local time.^[98]

Tiebreakers

The ranking of teams in the group stage was determined as follows:^[35][105]

1. Points obtained in all group matches;
2. Goal difference in all group matches;
3. Number of goals scored in all group matches;
4. Points obtained in the matches played between the teams in question;
5. Goal difference in the matches played between the teams in question;
6. Number of goals scored in the matches played between the teams in question;
7. Fair play points in all group matches (only one deduction could be applied to a player in a single match):
   • Yellow card: –1 points;
   • Indirect red card (second yellow card): –3 points;
   • Direct red card: –4 points;
   • Yellow card and direct red card: –5 points;
8. Drawing of lots.

Group A

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Group B

Group C

Group D

Group E

Group F

Group G

Group H

Knockout stage

In the knockout stages, if a match is level at the end of normal playing time, extra time is played (two periods of 15 minutes each) and followed, if necessary, by a penalty shoot-out to determine the winners.^[35]

If a match went into extra time, each team was allowed to make a fourth substitution, the first time this had been allowed in a FIFA World Cup tournament.^[43]

Bracket

Round of 16

Quarter-finals

Semi-finals

Third place play-off

Final

Statistics

Goalscorers

There were 169 goals scored in 64 matches, for an average of 2.64 goals per match.

Twelve own goals were scored during the tournament, doubling the record of six set in 1998.^[170]

6 goals

• Harry Kane

4 goals

• Romelu Lukaku
• Antoine Griezmann
• Kylian Mbappé
• Cristiano Ronaldo
• Denis Cheryshev

3 goals

• Eden Hazard
• Yerry Mina
• Mario Mandžukić
• Ivan Perišić
• Artem Dzyuba
• Diego Costa
• Edinson Cavani

2 goals

• Sergio Agüero
• Mile Jedinak
• Philippe Coutinho
• Neymar
• Luka Modrić
• Mohamed Salah
• John Stones
• Takashi Inui
• Ahmed Musa
• Son Heung-min
• Andreas Granqvist
• Wahbi Khazri
• Luis Suárez

1 goal

• Ángel Di María
• Gabriel Mercado
• Lionel Messi
• Marcos Rojo
• Michy Batshuayi
• Nacer Chadli
• Kevin De Bruyne
• Marouane Fellaini
• Adnan Januzaj
• Dries Mertens
• Thomas Meunier
• Jan Vertonghen
• Roberto Firmino
• Paulinho
• Renato Augusto
• Thiago Silva
• Juan Cuadrado
• Radamel Falcao
• Juan Fernando Quintero
• Kendall Waston
• Milan Badelj
• Andrej Kramarić
• Ivan Rakitić
• Ante Rebić
• Domagoj Vida
• Christian Eriksen
• Mathias Jørgensen
• Yussuf Poulsen
• Dele Alli
• Jesse Lingard
• Harry Maguire
• Kieran Trippier
• Benjamin Pavard
• Paul Pogba
• Samuel Umtiti
• Raphaël Varane
• Toni Kroos
• Marco Reus
• Alfreð Finnbogason
• Gylfi Sigurðsson
• Karim Ansarifard
• Genki Haraguchi
• Keisuke Honda
• Shinji Kagawa
• Yuya Osako
• Javier Hernández
• Hirving Lozano
• Carlos Vela
• Khalid Boutaïb
• Youssef En-Nesyri
• Victor Moses
• Felipe Baloy
• André Carrillo
• Paolo Guerrero
• Jan Bednarek
• Grzegorz Krychowiak
• Pepe
• Ricardo Quaresma
• Mário Fernandes
• Yury Gazinsky
• Aleksandr Golovin
• Salem Al-Dawsari
• Salman Al-Faraj
• Sadio Mané
• M'Baye Niang
• Moussa Wagué
• Aleksandar Kolarov
• Aleksandar Mitrović
• Kim Young-gwon
• Iago Aspas
• Isco
• Nacho
• Ludwig Augustinsson
• Emil Forsberg
• Ola Toivonen
• Josip Drmić
• Blerim Džemaili
• Xherdan Shaqiri
• Granit Xhaka
• Steven Zuber
• Dylan Bronn
• Ferjani Sassi
• Fakhreddine Ben Youssef
• José Giménez

1 own goal

• Aziz Behich (against France)
• Fernandinho (against Belgium)
• Mario Mandžukić (against France)
• Ahmed Fathy (against Russia)
• Edson Álvarez (against Sweden)
• Aziz Bouhaddouz (against Iran)
• Peter Etebo (against Croatia)
• Thiago Cionek (against Senegal)
• Denis Cheryshev (against Uruguay)
• Sergei Ignashevich (against Spain)
• Yann Sommer (against Costa Rica)
• Yassine Meriah (against Panama)

Source: FIFA^[171]

Discipline

In total, only four players were sent off in the entire tournament, the fewest since 1978.^[172]International Football Association Board technical director David Elleray stated a belief that this was due to the introduction of VAR, since players would know that they would not be able to get away with anything under the new system.^[173]

A player is automatically suspended for the next match for the following offences:^[35]

• Receiving a red card (red card suspensions may be extended for serious offences)
• Receiving two yellow cards in two matches; yellow cards expire after the completion of the quarter-finals (yellow card suspensions are not carried forward to any other future international matches)

The following suspensions were served during the tournament:

Awards

The following awards were given at the conclusion of the tournament. The Golden Boot (top scorer), Golden Ball (best overall player) and Golden Glove (best goalkeeper) awards were all sponsored by Adidas.^[174]

Additionally, FIFA.com shortlisted 18 goals for users to vote on as the tournaments' best.^[175] The poll closed on 23 July. The award was sponsored by Hyundai.^[176]

Dream Team

As was the case during the 2010 and 2014 editions, FIFA did not release an official All-Star Team, but instead invited users of FIFA.com to elect their Fan Dream Team.^[177][178]

FIFA also published an alternate team of the tournament based on player performances evaluated through statistical data.^[179]

Prize money

Prize money amounts were announced in October 2017.^[180]

Marketing

Branding

The tournament logo was unveiled on 28 October 2014 by cosmonauts at the International Space Station and then projected onto Moscow's Bolshoi Theatre during an evening television programme. Russian Sports Minister Vitaly Mutko said that the logo was inspired by 'Russia's rich artistic tradition and its history of bold achievement and innovation', and FIFA President Sepp Blatter stated that it reflected the 'heart and soul' of the country.^[181] For the branding, Portuguese design agency Brandia Central created materials in 2014, with a typeface called Dusha (from душа, Russian for soul) designed by Brandia Central and edited by Adotbelow of DSType Foundry in Portugal.^[182]

Mascot

The official mascot for the tournament was unveiled 21 October 2016, and selected through a design competition among university students. A public vote was used to select from three finalists—a cat, a tiger, and a wolf. The winner, with 53% of approximately 1 million votes, was Zabivaka—an anthropomorphic wolf dressed in the colours of the Russian national team. Zabivaka's name is a portmanteau of the Russian words забияка ('hothead') and забивать ('to score'), and his official backstory states that he is an aspiring football player who is 'charming, confident and social'.^[183]

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Ticketing

The first phase of ticket sales started on 14 September 2017, 12:00 Moscow Time, and lasted until 12 October 2017.^[184]

The general visa policy of Russia did not apply to participants and spectators, who were able to visit Russia without a visa right before and during the competition regardless of their citizenship.^[185] Spectators were nonetheless required to register for a 'Fan-ID', a special photo identification pass. A Fan-ID was required to enter the country visa-free, while a ticket, Fan-ID and a valid passport were required to enter stadiums for matches. Fan-IDs also granted World Cup attendees free access to public transport services, including buses, and train service between host cities. Fan-ID was administered by the Ministry of Digital Development, Communications and Mass Media, who could revoke these accreditations at any time to 'ensure the defence capability or security of the state or public order'.^[93][94][95]

Match ball

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The official match ball, the 'Telstar 18', was unveiled 9 November 2017. It is based on the name and design of the first Adidas World Cup ball from 1970.^[186] A special red-coloured variation, 'Telstar Mechta', was used for the knockout stage of the tournament. The word mechta (Russian: мечта) means dream or ambition.^[187]

Goalkeepers noted that the ball was slippery and prone to having unpredictable trajectory.^[188][189] In addition, two Telstar 18 balls popped in the midst of a first-round match between France and Australia, leading to further discussions over the ball's performance.^[190][191]

Merchandise

On 29 May 2018, Electronic Arts released a free update to FIFA 18 that added content related to the 2018 FIFA World Cup. The expansion included a World Cup tournament mode with all teams and stadiums from the event, official television presentation elements, and World Cup-related content for the Ultimate Team mode.^[192][193]

Panini continued their partnership with FIFA by producing stickers for their World Cup sticker album.^[194] Panini also developed an app for the 2018 World Cup where fans could collect and swap virtual stickers, with five million fans gathering digital stickers for the tournament.^[195][196]

Official song

The official song of the tournament was 'Live It Up', with vocals from Will Smith, Nicky Jam and Era Istrefi, released on 25 May 2018. Its music video was released on 8 June 2018.^[197]

Controversies

Thirty-three footballers who are alleged to be part of the steroid program are listed in the McLaren Report.^[198] On 22 December 2017, it was reported that FIFA fired a doctor who had been investigating doping in Russian football.^[199] On 22 May 2018 FIFA confirmed that the investigations concerning all Russian players named for the provisional squad of the FIFA World Cup in Russia had been completed, with the result that insufficient evidence was found to assert an anti-doping rule violation.^[200] FIFA's medical committee also decided that Russian personnel would not be involved in performing drug testing procedures at the tournament; the action was taken to reassure teams that the samples would remain untampered.^[201]

Host selection

The choice of Russia as host has been challenged. Controversial issues have included the level of racism in Russian football,^{[202][203][204]} and discrimination against LGBT people in wider Russian society.^[205][206] Russia's involvement in the ongoing conflict in Ukraine has also caused calls for the tournament to be moved, particularly following the annexation of Crimea.^[207][208] In 2014, FIFA President Sepp Blatter stated that 'the World Cup has been given and voted to Russia and we are going forward with our work'.^[209]

Allegations of corruption in the bidding processes for the 2018 and 2022 World Cups caused threats from England's FA to boycott the tournament.^[210] FIFA appointed Michael J. Garcia, a US attorney, to investigate and produce a report on the corruption allegations. Although the report was never published, FIFA released a 42-page summary of its findings as determined by German judge Hans-Joachim Eckert. Eckert's summary cleared Russia and Qatar of any wrongdoing, but was denounced by critics as a whitewash.^[211] Garcia criticised the summary as being 'materially incomplete' with 'erroneous representations of the facts and conclusions', and appealed to FIFA's Appeal Committee.^[212][213] The committee declined to hear his appeal, so Garcia resigned in protest of FIFA's conduct, citing a 'lack of leadership' and lack of confidence in the independence of Eckert.^[214]

On 3 June 2015, the FBI confirmed that the federal authorities were investigating the bidding and awarding processes for the 2018 and 2022 World Cups.^[215][216] In an interview published on 7 June 2015, Domenico Scala, the head of FIFA's Audit And Compliance Committee, stated that 'should there be evidence that the awards to Qatar and Russia came only because of bought votes, then the awards could be cancelled'.^[217][218]Prince William, Duke of Cambridge and former British Prime Minister David Cameron attended a meeting with FIFA vice-president Chung Mong-joon in which a vote-trading deal for the right to host the 2018 World Cup in England was discussed.^[219][220]

Response to Skripal poisoning

In response to the March 2018 poisoning of Sergei and Yulia Skripal, British Prime Minister Theresa May announced that no British ministers or members of the royal family would attend the World Cup, and issued a warning to any travelling England fans.^[221] Iceland diplomatically boycotted the World Cup.^[222] Russia responded to the comments from the UK Parliament claiming that 'the west are trying to deny Russia the World Cup'.^[223] The Russian Foreign Ministry denounced Boris Johnson's statements that compared the event to the 1936 Olympics held in Nazi Germany as 'poisoned with venom of hate, unprofessionalism and boorishness' and 'unacceptable and unworthy' parallel towards Russia, a 'nation that lost millions of lives in fighting Nazism'.^[224]

The British Foreign Office and MPs had repeatedly warned English football fans and 'people of Asian or Afro-Caribbean descent' travelling to Russia of 'racist or homophobic intimidation, hooligan violence and anti-British hostility'.^[225][226] English football fans who have travelled have said they have received a warm welcome from ordinary citizens after arriving in Russia.^[227][228]

Critical reception

At the close of the World Cup Russia was widely praised for its success in hosting the tournament, with Steve Rosenberg of the BBC deeming it 'a resounding public relations success' for Putin, adding, 'The stunning new stadiums, free train travel to venues and the absence of crowd violence has impressed visiting supporters. Russia has come across as friendly and hospitable: a stark contrast with the country's authoritarian image. All the foreign fans I have spoken to are pleasantly surprised.'^[229]

FIFA President Gianni Infantino stated, 'Everyone discovered a beautiful country, a welcoming country, that is keen to show the world that everything that has been said before might not be true. A lot of preconceived ideas have been changed because people have seen the true nature of Russia.'^[230] Infantino has proclaimed Russia 2018 to be 'the best World Cup ever', as 98% of the stadiums were sold out, there were three billion viewers on TV all around the world and 7 million fans visited the fan fests.^[231]

Broadcasting rights

FIFA, through several companies, sold the broadcasting rights for the 2018 FIFA World Cup to various local broadcasters. After having tested the technology at limited matches of the 2013 FIFA Confederations Cup,^[232] and the 2014 FIFA World Cup (via private tests and public viewings in the host city of Rio de Janeiro),^[233] the 2018 World Cup was the first World Cup in which all matches were produced in 4Kultra high definition. Host Broadcasting Services stated that at least 75% of the broadcast cut on each match would come from 4K cameras (covering the majority of main angles), with instant replays and some camera angles being upconverted from 1080p high definition sources with limited degradation in quality. These broadcasts were made available from selected rightsholders and television providers.^{[234][235][236]}

In February 2018, Ukrainian rightsholder UA:PBC stated that it would not broadcast the World Cup. This came in the wake of growing boycotts of the tournament among the Football Federation of Ukraine and sports minister Ihor Zhdanov.^[237][238] Additionally, the Football Federation of Ukraine refused to accredit journalists for the World Cup and waived their quota of tickets.^[239] However, the Ukrainian state TV still broadcast the World Cup, and more than 4 million Ukrainians watched the opening match.^[240]

Broadcast rights to the tournament in the Middle East were hampered by an ongoing diplomatic crisis in Qatar, which saw Bahrain, Egypt, Saudi Arabia, and the United Arab Emirates cut diplomatic ties with Qatar—the home country of FIFA's Middle East and Africa rightsholder beIN Sports—in June 2017, over its alleged state support of terrorist groups. On 2 June 2018, beIN pulled its channels from Du and Etisalat, but with service to the latter restored later that day. Etisalat subsequently announced that it would air the World Cup in the UAE, and continue to offer beIN normally and without interruptions.^{[241][242][243]} In Saudi Arabia, beIN was banned from doing business; as a result, its channels and other content have been widely and illegally repackaged by a broadcaster identifying itself as 'beoutQ'. While FIFA attempted to indirectly negotiate the sale of a package consisting of Saudi matches and the final, they were unable to do so. On 12 July 2018, FIFA stated that it had 'engaged counsel to take legal action in Saudi Arabia and is working alongside other sports rights owners that have also been affected to protect its interests.'^[244][245]

In the United States, the 2018 World Cup was the first men's World Cup whose English rights were held by Fox Sports, and Spanish rights held by Telemundo. The elimination of the United States in qualifying led to concerns that US interest and viewership of this World Cup would be reduced, noting that 'casual' viewers of U.S. matches caused them to peak at 16.5 million viewers in 2014, and how much Fox paid for the rights. During a launch event prior to the elimination, Fox stated that it had planned to place a secondary focus on the Mexican team in its coverage to take advantage of their popularity among Hispanic and Latino Americans. Fox stated that it was still committed to broadcasting a significant amount of coverage for the tournament.^{[246][247][248]} Viewership was down overall over 2014, additionally citing match scheduling that was not as favourable to viewers in the Americas than 2014 (with many matches airing in the morning hours, although Telemundo's broadcast of the Mexico-Sweden Group F match was announced as being its most-watched weekday daytime program in network history).^[249][250]

Sponsorship

See also

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