Mediterranean diet

This article is about the dietary recommendation that became popular in the 1990s. For food of the areas around the Mediterranean Sea, see Cuisine of the Mediterranean.

The Mediterranean diet is a modern nutritional recommendation inspired by the traditional dietary patterns of southern Italy, Crete and much of the rest of Greece in the 1960s.^[1]

On November 17, 2010, UNESCO recognized this diet pattern as an Intangible Cultural Heritage of Italy, Greece, Spain and Morocco, thus reinforcing it not only as a fundamental part of their history and background, but also as a great contribution to the world.^[2]Despite its name, this diet is not typical of all Mediterranean cuisine. In Northern Italy, for instance, lard and butter are commonly used in cooking, and olive oil is reserved for dressing salads and cooked vegetables.^[3] In North Africa, wine is traditionally avoided by Muslims. In both North Africa and the Levant, along with olive oil, sheep's tail fat and rendered butter (samna) are traditional staple fats.^[4]

The most commonly understood version of the Mediterranean diet was presented, amongst others, by Dr Walter Willett of Harvard University's School of Public Health from the mid-1990s on,^{[5][6][7][8][9]} including a book for the general public.^[10] Based on "food patterns typical of Crete, much of the rest of Greece, and southern Italy in the early 1960s", this diet, in addition to "regular physical activity," emphasizes "abundant plant foods, fresh fruit as the typical daily dessert, olive oil as the principal source of fat, dairy products (principally cheese and yogurt), and fish and poultry consumed in low to moderate amounts, zero to four eggs consumed weekly, red meat consumed in low amounts, and wine consumed in low to moderate amounts". Total fat in this diet is 25% to 35% of calories, with saturated fat at 8% or less of calories.^[11]

The principal aspects of this diet include high olive oil consumption, high consumption of legumes, high consumption of unrefined cereals, high consumption of fruits, high consumption of vegetables, moderate consumption of dairy products (mostly as cheese and yogurt), moderate to high consumption of fish, low consumption of meat and meat products, and moderate wine consumption.^[12]

Olive oil is particularly characteristic of the Mediterranean diet. It contains a very high level of monounsaturated fats, most notably oleic acid, which epidemiological studies suggest may be linked to a reduction in coronary heart disease risk.^[13] There is also evidence that the antioxidants in olive oil improve cholesterol regulation and LDL cholesterol reduction, and that it has other anti-inflammatory and anti-hypertensive effects.^[14]

History

Although it was first publicized in 1945 by the American doctor Ancel Keys stationed in Salerno, Italy, the Mediterranean diet failed to gain widespread recognition until the 1990s. Objective data showing that Mediterranean diet is healthy first originated from the Seven Countries Study.

Mediterranean diet is based on what from the point of view of mainstream nutrition is considered a paradox: that although the people living in Mediterranean countries tend to consume relatively high amounts of fat, they have far lower rates of cardiovascular disease than in countries like the United States, where similar levels of fat consumption are found. A parallel phenomenon is known as the French Paradox.^[15]

A diet rich in salads was promoted in England during the early Renaissance period by Giacomo Castelvetro in A Brief Account of the Fruits, Herbs and Vegetables of Italy.^[16] He attempted, without success, to convince the English to eat more fruits and vegetables.

Health effects

A number of diets have received attention, but the strongest evidence for a beneficial health effect and decreased mortality after switching to a largely plant based diet comes from studies of Mediterranean diet, e.g. from the NIH-AARP Diet and Health Study.^[17]

The Mediterranean diet is often cited as beneficial for being low in saturated fat and high in monounsaturated fat and dietary fiber. One of the main explanations is thought to be the health effects of olive oil included in the Mediterranean diet.

The Mediterranean diet is high in salt content.^[18] Foods such as olives, salt-cured cheeses, anchovies, capers, salted fish roe, and salads dressed with olive oil all contain high levels of salt.

The inclusion of red wine is considered a factor contributing to health as it contains flavonoids with powerful antioxidant properties.^[19]

Mireille Guiliano credits the health effects of the Mediterranean diet to factors such as small portions, daily exercise, and the emphasis on freshness, balance, and pleasure in food.^[20]

Dietary factors are only part of the reason for the health benefits enjoyed by certain Mediterranean cultures. A healthy lifestyle (notably a physically active lifestyle or labour) is also beneficial.^[21][22] Environment may also be involved. However, on the population level, i.e. for the population of a whole country or a region, the influence of genetics is rather minimal, because it was shown that the slowly changing habits of Mediterranean populations, from a healthy active lifestyle and Mediterranean diet to a not so healthy, less physically active lifestyle and a diet influenced by the Western pattern diet, significantly increases risk of heart disease.^[23][24][25] There is an inverse association between adherence to the Mediterranean diet and the incidence of fatal and non fatal heart disease in initially healthy middle aged adults in the Mediterranean region.^[26]

A 10-year study published in the Journal of American Medical Association (JAMA) found that adherence to a Mediterranean diet and healthful lifestyle was associated with more than a 50% lowering of early death rates.^[27]

The putative benefits of the Mediterranean diet for cardiovascular health are primarily correlative in nature; while they reflect a very real disparity in the geographic incidence of heart disease, identifying the causal determinant of this disparity has proven difficult. The most popular dietary candidate, olive oil, has been undermined by a body of experimental evidence that diets enriched in monounsaturated fats such as olive oil are not atheroprotective when compared to diets enriched in either polyunsaturated or even saturated fats.^[28][29] A recently emerging alternative hypothesis to the Mediterranean diet is that differential exposure to solar ultraviolet radiation accounts for the disparity in cardiovascular health between residents of Mediterranean and more northerly countries. The proposed mechanism is solar UVB-induced synthesis of Vitamin D in the oils of the skin, which has been observed to reduce the incidence of coronary heart disease, and which rapidly diminishes with increasing latitude.^[30] Interestingly, residents of the Mediterranean are also observed to have very low rates of skin cancer (which is widely believed to be caused by over-exposure to solar UV radiation); incidence of melanomas in the Mediterranean countries is lower than in Northern Europe and significantly lower than in other hot countries such as Australia and New Zealand. Its been hypothesized that some components of the Mediterranean diet may provide protection against skin cancer.

A study published in the Archives of General Psychiatry shows that people who followed the Mediterranean diet were less likely to develop depression.^[31]

Medical research

The Seven Countries Study^[32] found that Cretan men had exceptionally low death rates from heart disease, despite moderate to high intake of fat. The Cretan diet is similar to other traditional Mediterranean diets, consisting mostly of olive oil, bread, abundant fruit and vegetables, fish, and a moderate amount of dairy foods and wine.

The Lyon Diet Heart Study^[33] set out to mimic the Cretan diet, but adopted a pragmatic approach. Realizing that some of the people in the study (all of whom had survived a first heart attack) would be reluctant to move from butter to olive oil, they used a margarine based on rapeseed (canola) oil. The dietary change also included 20% increases in vitamin C-rich fruit and bread and decreases in processed and red meat. On this diet, mortality from all causes was reduced by 70%. This study was so successful that the ethics committee decided to stop the study prematurely so that the results of the study could be made available to the public immediately.^[34]

According to a 2008 study published in the British Medical Journal, the traditional Mediterranean diet provides substantial protection against type 2 diabetes.^[35] The study involved over 13 000 graduates from the University of Navarra in Spain with no history of diabetes, who were recruited between December 1999 and November 2007, and whose dietary habits and health were subsequently tracked. Participants initially completed a 136-item food frequency questionnaire designed to measure the entire diet. The questionnaire also included questions on the use of fats and oils, cooking methods and dietary supplements. Every two years participants were sent follow-up questionnaires on diet, lifestyle, risk factors, and medical conditions. New cases of diabetes were confirmed through medical reports. During the follow-up period (median 4.4 years) the researchers from the University of Navarra found that participants who stuck closely to the diet had a lower risk of diabetes. A high adherence to the diet was associated with an 83% relative reduction in the risk of developing diabetes.^[36]

A 2008 study published in The New England Journal of Medicine examined the effects of three diets: low-carb, low-fat, and Mediterranean. The study involved 322 participants and lasted for two years. The low-carb and Mediterranean diet resulted in the greatest weight loss, 12 lbs and 10 lbs, respectively. The low-fat diet resulted in a loss of 7 lbs. One caveat of the study is that 86% of the study participants were men. The low-carb and Mediterranean diets produced similar amounts of weight loss in the overall study results and in the men. In the remaining participants who were women, the Mediterranean diet produced 3.8 kg (8.4 lbs) more weight loss on average than the low-carb diet.^[37]

A meta-analysis published in the British Medical Journal in 2008 showed that following strictly the Mediterranean diet reduced the risk of dying from cancer and cardiovascular disease as well as the risk of developing Parkinson's and Alzheimer's disease. The results report 9%, 9%, and 6% reduction in overall, cardiovascular, and cancer mortality respectively. Additionally a 13% reduction in incidence of Parkinson's and Alzheimer's diseases is to be expected provided strict adherence to the diet is observed.^[38] As well, a 2007 study found that adherence to the Mediterranean diet (MeDi) may affect not only risk for Alzheimer disease (AD) but also subsequent disease course: Higher adherence to the MeDi is associated with lower mortality in AD. The gradual reduction in mortality risk for higher MeDi adherence tertiles suggests a possible dose-response effect.^[39]

A study published in the British Medical Journal in 2009 showed some components of the Mediterranean diet, such as high vegetable consumption and low meat and meat product consumption, are more significantly associated with low risk of mortality than other components, such as cereal consumption and fish consumption. As part of the European Prospective Investigation into Cancer and Nutrition study, researchers followed more than 23,000 Greek men and women for 8.5 years to see how various aspects of a Mediterranean diet affect mortality. Moderate alcohol consumption, high fruit and nut consumption, and high legume consumption were also associated with lower risk of mortality.^[40] Mediterranean Diet, articulated into extensive lifestyles interventions in a clinical follow-up study, improves renal artery circulation, decreasing renal resistive index, even without significant modifications of Insulin Resistance. This is a beneficial effect and modifies the pathophysiology of essential hypertension.^[41] Another study (reported on in the news in February 2010) found that the diet may help keep the brain healthy by reducing the frequency of the mini-strokes that can contribute to mental decline.^[42] Mediterranean Diet is becoming a comprehensive popular and successful translational paradigm for the promotion of healthier lifestyles .^[41]

A 2011 meta-analysis published in the Journal of the American College of Cardiology analyzed the results of 50 studies (35 clinical trials, 2 prospective and 13 cross-sectional) covering about 535,000 people to examine the effect of a Mediterranean diet on metabolic syndrome. The researchers reported that a Mediterranean diet is associated with lower blood pressure, blood sugar, and triglycerides.^[43]

Researcher Antonia Trichopoulou and her team made use of data gathered in the Greek portion of a large-scale European study known as EPIC (European Prospective Investigation into Cancer and Nutrition). For their study, they focused on nearly 15,000 Greek women who joined the study when they were between the ages of 20 and 86. Each woman answered a detailed food-frequency questionnaire that addressed their usual style of eating within the previous year. They also responded to questions about their lifestyle, including smoking status and amount of physical activity, and their reproductive history. Their Body Mass Index was calculated and recorded, and those with a history of cancer were excluded from the study.

Using the food-frequency questionnaire, the researchers were able to calculate each woman's adherence to the Mediterranean Diet by assigning a score ranging from 0 to 9. For those components of the diet that are frequently eaten, such as vegetables, legumes or fish, the women received a score of 1 if their intake was above average, and a 0 if their consumption was below average. Similarly, for those components that are less frequently eaten, such as dairy or red meat, those women who ate less than the average amount also received a 1, while those who ate more than the average received a 0. (This scoring system is a standard one used often in studies of The Mediterranean Diet.)

After a follow-up of 10 years, the researchers compared the incidence of breast cancer with each woman's Mediterranean Diet score. After controlling for such variables as age, smoking status, physical activity, Body Mass Index and use of hormone replacement therapy, the researchers found that overall, there was no statistically significant link between higher Mediterranean Diet adherence and the risk of breast cancer. They then grouped the women in pre- and post-menopausal status at the start of the study and compared their Mediterranean Diet scores with their risk of breast cancer. And they found that for postmenopausal women, those who had high scores on the Mediterranean Diet adherence scale - that of a 6 to 9 - were 41% less likely to develop breast cancer than those whose scores were low - 0 to 3. In fact, an increase of just 2 points on the Mediterranean Diet scale decreased a postmenopausal woman's risk of breast cancer by 22%.^[44][45]

Epidemiology

A lesser known but highly skilled scientist named Dr. Leland Allbaugh was appointed Field Director by the Rockefeller Foundation in the early 1950s to investigate the causes of the high rates of death on the Greek island of Crete and to report to the Greek government on a model which could provide sustainable change. It was envisioned that any results could be adopted into model that could then be taken to other countries suffering with similar rates of high mortality and deprivation.

After systematically reviewing every aspect of life on Crete and comparing it to life in mainland Greece and America, Dr. Allbaugh’s work provided some insightful data on heart disease and mortality rates.

Dr. Allbaugh documented that the rates of death in Crete were high, but the primary problem was poor public health infrastructure, poor access to good quality medical care and the availability of drugs to combat infectious diseases such as malaria, typhoid and dysentery.

Dr. Allbaugh’s data had also inadvertently highlighted that the adults of Crete had substantially better rates of heart disease than in America with a third fewer deaths related to cardiovascular disease and just under a third fewer deaths from cancer.

Although no link was made at the time between diet and heart disease, the research found that the number of daily calories eaten by a typical family in Crete was relatively high and was composed of similar components as found in an American diet, but in substantially different food groups and nutrient sources for the main calories:

^[46]

Sources of calories consumed, by percentage.  Crete, Greece and United States, 1948
Food Group	Crete  Fall 1948	Greece  1948-1949	USA  1948-1949
Cereals	39	61	25
Potatoes	4	2	3
Sugar and honey	2	4	15
Pulses and nuts	7	6	3
Vegetables and fruits	11	5	6
Meat, fish and eggs	4	3	19
Dairy products	3	4	14
Oils and fats	29	15	15
Wine, beer & spirits	1	not given	not given
Total calories per person per day	2,547	2,477	3,129
Sources of protein in the diet, by percentage
Animal protein	24	19	66
Vegetable protein	76	81	34

See also

• Mediterranean Diet Foundation
• Cretan diet
• French Paradox
• Wine and health
• Cuisine of the Mediterranean
• Israeli cuisine

References

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44. ^ Copyright © 2011 by the American Society for Nutrition
45. ^ © 2011 Harlan Bros. Productions, LLC. All rights reserved
46. ^ © 2011 Francesca Sales

• Martin Bruegel, "Alimentary identities, nutritional advice, and the uses of history"
• Simopoulos, Artemis P. (2005). "What is so special about the diet of Greece? The scientific evidence.". In Simopoulos, Artemis P.. Nutrition and Fitness: Mental Health, Aging, and the Implementation of a Healthy Diet and Physical Activity Lifestyle. Karger Publishers. pp. 80–91. ISBN 3805579454. http://books.google.com/?id=LVju5b1gdf0C&printsec=frontcover. 

External links

• Secrets of the Mediterranean Diet, European Food Information Council
• American Heart Association recommendations for the Mediterranean diet
• An Italian Project for the promotion and dissemination of Mediterranean Diet (Federsanità-ANCI – 2010-2012 - Italy).
• Trichopoulou A, Orfanos P, Norat T, et al. (April 2005). "Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study". BMJ 330 (7498): 991. doi:10.1136/bmj.38415.644155.8F. PMC 557144. PMID 15820966. http://bmj.bmjjournals.com/cgi/content/full/330/7498/991. 
• The Mediterranean Diet Pyramid, Oldways