Mediterranean Diet, Physical Activity, and Sleep in Endometriosis: An Age-Comparable Case-Control Study with Exploratory Machine Learning Discrimination

Background/Objectives: Diet, physical activity, and sleep have been proposed as modulators of endometriosis, yet most evidence comes from studies in which cases are much older than controls, confounding lifestyle comparisons by age. We compared these profiles against controls of closer reproductive age and, as a secondary aim, explored how far self-reported data discriminate endometriosis. Methods: Cross-sectional case-control study of 177 women: 77 with self-reported, procedure-confirmed endometriosis recruited through a patient association and 100 controls consecutively enrolled from the general adult population. Measures included Mediterranean diet adherence (PREDIMED-14), physical activity (IPAQ), pain scales, menstrual quality of life (CVM-22) and the Epworth Sleepiness Scale. Analyses used age-adjusted logistic regression with Benjamini–Hochberg correction; three machine learning algorithms were evaluated with cross-validation. Results: Mediterranean diet adherence and physical activity did not differ between groups; body mass index was modestly lower in cases, and daytime sleepiness was marginally higher but not after age adjustment. Of the 13 testable dietary items, only sofrito (vegetables slowly cooked in extra-virgin olive oil) survived correction, being reported less often by cases. Menstrual quality of life was markedly worse in cases. Discrimination (best AUC-ROC 0.933) reflected concurrent symptoms rather than nutrition: restricted to antecedent and dietary variables it reached only 0.67–0.73. Conclusions: Once age and multiple testing were accounted for, diet and physical activity did not distinguish women with endometriosis from controls. The lower sofrito intake is a single-item, cross-sectional finding that should be regarded as hypothesis-generating and requires independent validation.