In Reply: In response to Drs Ramaraj and Chellappa, we excluded demented participants at baseline; therefore, all participants were free of dementia when the 24-hour dietary recall was performed. Moreover, at that time we had no specific hypothesis for the potential role of the Mediterranean diet on cognitive decline and dementia onset so that recall should not have been biased with respect to this outcome.
The MMSE was not used as a criterion for dementia but only to ascertain cognitive decline in all participants. In our study, we were interested in change in cognitive performances assessed on the MMSE and on 3 other cognitive tests (Free and Cued Selective Reminding Test, Isaacs Set Test, and Benton Visual Retention Test). In addition, diagnosis of incident dementia was based on a 3-step procedure.1 All participants whose performance had declined on neuropsychological tests (not on the MMSE) compared with a previous examination, or who were suspected of having dementia by the psychologist, were examined by a neurologist. All potential incident cases of dementia were validated by the independent expert committee of neurologists who analyzed in depth the medical history of each participant and ascertained the cause (Alzheimer disease or other causes of dementia). All of the statistical analyses were adjusted for age (as a time scale in Cox proportional hazards models2) and education.