What is the Mediterranean diet?
The concept of the Mediterranean diet was first developed by Ancel Keys in the 1960s when he observed a dietary pattern low in saturated fat and high in vegetable oils among the populations of Greece, Southern Italy, and other countries around the Mediterranean Sea.
Today, the Mediterranean diet is described by its main components, which include a high intake of extra virgin olive oil, leafy green vegetables, fruits, whole grains, nuts, and legumes; a moderate intake of fish and other lean meat, dairy products, and red wine; and a low intake of saturated fat, eggs, sweets, and red meat.[1] The diet is generally considered to be a “plant-based diet” and contains high levels of several nutrients including polyphenols, fiber, and mono- and polyunsaturated fatty acids.
The Mediterranean diet
What are the Mediterranean diet’s main benefits?
The most robust benefits of the Mediterranean diet have been observed for cardiovascular health. In particular, the Mediterranean diet reduces blood pressure[2][3] and improves endothelial function;[4][5] high adherence to the diet is associated with a lower risk for cardiovascular disease morbidity and mortality and longer telomere length (a recognized biomarker of aging).[6]
Evidence from randomized controlled clinical studies and observational studies also supports the benefits of the Mediterranean diet for glycemic control and diabetes risk, cancer incidence, cognitive decline, and overall lifespan/longevity.[7][8][9] Importantly, while these effects are stronger and more consistent among Mediterranean populations, benefits of the Mediterranean diet have been observed in non-Mediterranean countries as well.[10]
What are the Mediterranean diet’s main drawbacks?
One of the biggest problems with the Mediterranean diet is that it’s inconsistently defined. The modern Mediterranean diet has deviated from the traditional foods and culinary traditions that are native to the Mediterranean region, and several misconceptions have emerged about the diet due to its adoption in Western countries. This has led to the false labeling of certain foods and practices as “compatible with the Mediterranean diet.”[11]
First, the Mediterranean diet is not a purely vegetarian diet — it allows for the consumption of meat and fish. Second, certain foods — American-style pizza, for example — are sometimes mistaken as being part of a Mediterranean diet, but they’re actually substantial sources of calories, sodium, and fat. Third, the Mediterranean diet emphasizes moderate alcohol (wine) intake with meals, but the patterns of alcohol consumption in Western countries have strayed far from the concept of drinking red wine only during meals and spread out over the week. Finally, several foods are sometimes erroneously believed to be Mediterranean diet foods, including avocado, certain desserts, quinoa, margarine, potatoes, and tofu. Ultimately, there’s some confusion about what the Mediterranean diet is, making it difficult for individuals to apply this dietary approach to their lives and limiting the transferability of the Mediterranean diet to non-Mediterranean countries.
How does the Mediterranean diet work?
While all foods and nutrients comprising the Mediterranean diet likely interact to exert synergistic effects on health, some benefits may be attributed to specific dietary components.
Bioactive plant compounds like polyphenols and antioxidants are found in many common staples of the Mediterranean diet, including red wine, olive oil, coffee, tea, nuts, fruits, vegetables, herbs, and spices. Polyphenols upregulate the body’s natural antioxidant systems, reduce the production of pro-inflammatory cytokines, lower blood pressure via enhanced nitric oxide production, and decrease levels of systemic oxidative stress — all of which ameliorate recognized cardiovascular disease risk factors.[12] In support of this, a greater estimated intake of dietary polyphenols in participants consuming a Mediterranean diet has been associated with better cardiovascular outcomes, lower blood pressure, less inflammation, and a decreased risk for new-onset type 2 diabetes.[13] The high intake of “healthy” unsaturated fatty acids in the Mediterranean diet may also exert health-protective effects, as may the social and lifestyle practices associated with this diet.
Frequently asked questions
The concept of the Mediterranean diet was first developed by Ancel Keys in the 1960s when he observed a dietary pattern low in saturated fat and high in vegetable oils among the populations of Greece, Southern Italy, and other countries around the Mediterranean Sea.
Today, the Mediterranean diet is described by its main components, which include a high intake of extra virgin olive oil, leafy green vegetables, fruits, whole grains, nuts, and legumes; a moderate intake of fish and other lean meat, dairy products, and red wine; and a low intake of saturated fat, eggs, sweets, and red meat.[1] The diet is generally considered to be a “plant-based diet” and contains high levels of several nutrients including polyphenols, fiber, and mono- and polyunsaturated fatty acids.
The Mediterranean diet
Several scales have been developed to assess individual and population adherence to the Mediterranean diet. The oldest of these is the Mediterranean Diet Scale (MDScale), developed in 1995 and revised since.[14] The MDScale includes nine components, including beneficial components (i.e., vegetables, legumes, fruits and nuts, cereal, and fish), detrimental components (i.e., meat, poultry, and high-fat dairy products), ethanol intake, and the ratio of monounsaturated to saturated fatty acids. A score of 0 is assigned to someone whose consumption of beneficial components is below the median and a score of 1 is assigned when consumption is at or above the median. For detrimental components, this is reversed: scores of 0 and 1 are assigned when consumption is at or above the median and below the median, respectively. For ethanol, a value of 1 is assigned to men and women who consume 10–50 grams and 5–25 grams per day, respectively. The total score ranges from 0 (minimal adherence) to 9 (maximal adherence).[14]
Other scales used internationally include the Mediterranean Food Pattern (MFP), the Mediterranean Diet Score (MD Score), the Short Mediterranean Diet Questionnaire (SMDQ), and the MedDiet Score.[15] While each score differs in its particularities, all of them assess the intake of similar dietary components, and there appears to be a strong correlation among all the scales for measuring adherence to the Mediterranean diet.[15]
The Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay — also known as the MIND diet — is a hybrid of the Dietary Approaches to Stop Hypertension diet (DASH) and Mediterranean diets that is specifically designed to prevent or slow the progression of cognitive decline and promote brain health. The MIND diet incorporates components of both diets, but also includes foods rich in certain vitamins, carotenoids, and flavonoids that are putatively associated with a lower risk for Alzheimer’s disease, dementia, and cognitive decline.
Specifically, the MIND diet comprises beneficial foods, including green leafy vegetables, other vegetables (e.g., green/red peppers, squash, carrots, broccoli, celery, potatoes, tomatoes, peas, beets, corn), berries, nuts, olive oil, whole grains, fish, beans, and poultry; and excludes detrimental foods, including butter/margarine, cheese, red meat and other processed meats, fried fast foods, and pastries and sweets. As with the DASH and Mediterranean diets, a small intake of wine (1 glass/day) is permitted and seen as healthful.[16]
In cohort studies, higher adherence to the MIND diet has been associated with a lower incidence of Alzheimer’s disease,[17][18] slower rates of cognitive decline,[16][19][20] and better global cognitive function.[21][22]
To date, only one long-term (3-year) randomized controlled study on the MIND diet has been conducted.[23] Results indicated that in older adults without cognitive impairment but with a family history of dementia, the MIND diet was no better than a standard calorie-restricted control diet for improving cognitive function. Similarly, there were no differences in MRI measures of white-matter hyperintensities, hippocampal volume, or total grey- and white-matter volumes between the MIND diet and control groups, suggesting that the MIND diet may not change brain structure or function over this period of time.
The most robust benefits of the Mediterranean diet have been observed for cardiovascular health. In particular, the Mediterranean diet reduces blood pressure[2][3] and improves endothelial function;[4][5] high adherence to the diet is associated with a lower risk for cardiovascular disease morbidity and mortality and longer telomere length (a recognized biomarker of aging).[6]
Evidence from randomized controlled clinical studies and observational studies also supports the benefits of the Mediterranean diet for glycemic control and diabetes risk, cancer incidence, cognitive decline, and overall lifespan/longevity.[7][8][9] Importantly, while these effects are stronger and more consistent among Mediterranean populations, benefits of the Mediterranean diet have been observed in non-Mediterranean countries as well.[10]
The Mediterranean diet does not explicitly recommend alcohol. However, moderate alcohol intake — in particular, red wine consumed with meals — is a recognized part of the dietary pattern.[24] Moderate intake is defined as up to 2 drinks per day for men and 1 drink per day for women, and is included as a component in most Mediterranean-diet-scoring indexes.
One study found that people who followed a “moderate Mediterranean drinking plan” including the consumption of red wine with meals had a lower mortality risk compared to people who abstained from alcohol and had low adherence to the Mediterranean diet.[25] Excluding moderate alcohol intake as a component of the Mediterranean diet reduces the overall association of the diet with mortality risk, with alcohol’s contribution being greater than a low red meat consumption or a high vegetable intake.[26]
These “health-protective” effects of alcohol (red wine) have been attributed to its polyphenol content (e.g., resveratrol), but this is mostly mechanistic speculation; most people don’t accept that alcohol exerts a health benefit per se. Alcohol — especially in large quantities — is toxic to the brain and can increase the risk of accidental deaths and certain types of cancer;[27] it’s one of the main risk factors for the global burden of disease.[28] Thus, while a few glasses of red wine can complement the healthy foods that comprise the Mediterranean diet, an individual’s risk factors, tolerance to alcohol, and personal/religious beliefs should all be taken into consideration. The Mediterranean diet can be incredibly health-promoting in the absence of alcohol.
One of the biggest problems with the Mediterranean diet is that it’s inconsistently defined. The modern Mediterranean diet has deviated from the traditional foods and culinary traditions that are native to the Mediterranean region, and several misconceptions have emerged about the diet due to its adoption in Western countries. This has led to the false labeling of certain foods and practices as “compatible with the Mediterranean diet.”[11]
First, the Mediterranean diet is not a purely vegetarian diet — it allows for the consumption of meat and fish. Second, certain foods — American-style pizza, for example — are sometimes mistaken as being part of a Mediterranean diet, but they’re actually substantial sources of calories, sodium, and fat. Third, the Mediterranean diet emphasizes moderate alcohol (wine) intake with meals, but the patterns of alcohol consumption in Western countries have strayed far from the concept of drinking red wine only during meals and spread out over the week. Finally, several foods are sometimes erroneously believed to be Mediterranean diet foods, including avocado, certain desserts, quinoa, margarine, potatoes, and tofu. Ultimately, there’s some confusion about what the Mediterranean diet is, making it difficult for individuals to apply this dietary approach to their lives and limiting the transferability of the Mediterranean diet to non-Mediterranean countries.
While all foods and nutrients comprising the Mediterranean diet likely interact to exert synergistic effects on health, some benefits may be attributed to specific dietary components.
Bioactive plant compounds like polyphenols and antioxidants are found in many common staples of the Mediterranean diet, including red wine, olive oil, coffee, tea, nuts, fruits, vegetables, herbs, and spices. Polyphenols upregulate the body’s natural antioxidant systems, reduce the production of pro-inflammatory cytokines, lower blood pressure via enhanced nitric oxide production, and decrease levels of systemic oxidative stress — all of which ameliorate recognized cardiovascular disease risk factors.[12] In support of this, a greater estimated intake of dietary polyphenols in participants consuming a Mediterranean diet has been associated with better cardiovascular outcomes, lower blood pressure, less inflammation, and a decreased risk for new-onset type 2 diabetes.[13] The high intake of “healthy” unsaturated fatty acids in the Mediterranean diet may also exert health-protective effects, as may the social and lifestyle practices associated with this diet.
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