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.
Examine Database: Mediterranean Diet
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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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References
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- ^Cowell OR, Mistry N, Deighton K, Matu J, Griffiths A, Minihane AM, Mathers JC, Shannon OM, Siervo MEffects of a Mediterranean diet on blood pressure: a systematic review and meta-analysis of randomized controlled trials and observational studies.J Hypertens.(2021-Apr-01)
- ^Filippou CD, Thomopoulos CG, Kouremeti MM, Sotiropoulou LI, Nihoyannopoulos PI, Tousoulis DM, Tsioufis CPMediterranean diet and blood pressure reduction in adults with and without hypertension: A systematic review and meta-analysis of randomized controlled trials.Clin Nutr.(2021-May)
- ^Shannon OM, Mendes I, Köchl C, Mazidi M, Ashor AW, Rubele S, Minihane AM, Mathers JC, Siervo MMediterranean Diet Increases Endothelial Function in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.J Nutr.(2020-May-01)
- ^Fatima K, Rashid AM, Memon UAA, Fatima SS, Javaid SS, Shahid O, Zehri F, Obaid MA, Ahmad M, Almas T, Minhas AMKMediterranean Diet and its Effect on Endothelial Function: A Meta-analysis and Systematic Review.Ir J Med Sci.(2023-Feb)
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- ^Soltani S, Jayedi A, Shab-Bidar S, Becerra-Tomás N, Salas-Salvadó JAdherence to the Mediterranean Diet in Relation to All-Cause Mortality: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies.Adv Nutr.(2019-Nov-01)
- ^Silvia Canudas, Nerea Becerra-Tomás, Pablo Hernández-Alonso, Serena Galié, Cindy Leung, Marta Crous-Bou, Immaculata De Vivo, Yawen Gao, Yian Gu, Jelena Meinilä, Catherine Milte, Sonia García-Calzón, Amelia Marti, Virginia Boccardi, Melissa Ventura-Marra, Jordi Salas-SalvadóMediterranean Diet and Telomere Length: A Systematic Review and Meta-AnalysisAdv Nutr.(2020 Nov 16)
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- ^Martha Clare Morris, Christy C Tangney, Yamin Wang, Frank M Sacks, Lisa L Barnes, David A Bennett, Neelum T AggarwalMIND diet slows cognitive decline with agingAlzheimers Dement.(2015 Sep)
- ^Martha Clare Morris, Christy C Tangney, Yamin Wang, Frank M Sacks, David A Bennett, Neelum T AggarwalMIND diet associated with reduced incidence of Alzheimer's diseaseAlzheimers Dement.(2015 Sep)
- ^Agarwal P, Leurgans SE, Agrawal S, Aggarwal NT, Cherian LJ, James BD, Dhana K, Barnes LL, Bennett DA, Schneider JAAssociation of Mediterranean-DASH Intervention for Neurodegenerative Delay and Mediterranean Diets With Alzheimer Disease Pathology.Neurology.(2023-May-30)
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- ^Hosking DE, Eramudugolla R, Cherbuin N, Anstey KJMIND not Mediterranean diet related to 12-year incidence of cognitive impairment in an Australian longitudinal cohort study.Alzheimers Dement.(2019-Apr)
- ^Dhana K, James BD, Agarwal P, Aggarwal NT, Cherian LJ, Leurgans SE, Barnes LL, Bennett DA, Schneider JAMIND Diet, Common Brain Pathologies, and Cognition in Community-Dwelling Older Adults.J Alzheimers Dis.(2021)
- ^Melo van Lent D, O'Donnell A, Beiser AS, Vasan RS, DeCarli CS, Scarmeas N, Wagner M, Jacques PF, Seshadri S, Himali JJ, Pase MPMind Diet Adherence and Cognitive Performance in the Framingham Heart Study.J Alzheimers Dis.(2021)
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- ^IARC Working Group on the Evaluation of Carcinogenic Risks to HumansPersonal habits and indoor combustionsIARC Monogr Eval Carcinog Risks Hum.(2012)
- ^GBD 2016 Alcohol and Drug Use CollaboratorsThe global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016Lancet Psychiatry.(2018 Dec)
Examine Database References
- Glomerular Filtration Rate - Khedidja Mekki, Nassima Bouzidi-bekada, Abbou Kaddous, Malika BouchenakMediterranean diet improves dyslipidemia and biomarkers in chronic renal failure patientsFood Funct.(2010 Oct)
- Liver Fat - Takumi Kawaguchi, Michael Charlton, Atsushi Kawaguchi, Sakura Yamamura, Dan Nakano, Tsubasa Tsutsumi, Maryam Zafer, Takuji TorimuraEffects of Mediterranean Diet in Patients with Nonalcoholic Fatty Liver Disease: A Systematic Review, Meta-Analysis, and Meta-Regression Analysis of Randomized Controlled TrialsSemin Liver Dis.(2021 Aug)
- Liver Fat - Akhlaghi M, Ghasemi-Nasab M, Riasatian MMediterranean diet for patients with non-alcoholic fatty liver disease, a systematic review and meta-analysis of observational and clinical investigations.J Diabetes Metab Disord.(2020-Jun)
- Liver Fat - Veera Houttu, Susanne Csader, Max Nieuwdorp, Adriaan G Holleboom, Ursula SchwabDietary Interventions in Patients With Non-alcoholic Fatty Liver Disease: A Systematic Review and Meta-AnalysisFront Nutr.(2021 Jul 22)
- Liver Fat - Haigh L, Kirk C, El Gendy K, Gallacher J, Errington L, Mathers JC, Anstee QMThe effectiveness and acceptability of Mediterranean diet and calorie restriction in non-alcoholic fatty liver disease (NAFLD): A systematic review and meta-analysis.Clin Nutr.(2022-Sep)
- Insulin Resistance - Maryam Ghadimi, Reihaneh Mohammadi, Elnaz Daneshzad, Bobak Moazzami, Zinat MohammadpourEffectiveness of dietary interventions on cardio-metabolic risk factors in patients with nonalcoholic fatty liver disease: a systematic review and meta-analysis of randomized controlled trialsAnn Gastroenterol.(2021)
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- Total cholesterol - Del Bo' C, Perna S, Allehdan S, Rafique A, Saad S, AlGhareeb F, Rondanelli M, Tayyem RF, Marino M, Martini D, Riso PDoes the Mediterranean Diet Have Any Effect on Lipid Profile, Central Obesity and Liver Enzymes in Non-Alcoholic Fatty Liver Disease (NAFLD) Subjects? A Systematic Review and Meta-Analysis of Randomized Control Trials.Nutrients.(2023-May-09)
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- Blood Pressure - Cowell OR, Mistry N, Deighton K, Matu J, Griffiths A, Minihane AM, Mathers JC, Shannon OM, Siervo MEffects of a Mediterranean diet on blood pressure: a systematic review and meta-analysis of randomized controlled trials and observational studies.J Hypertens.(2021-Apr-01)
- Blood Pressure - Ndanuko RN, Tapsell LC, Charlton KE, Neale EP, Batterham MJDietary Patterns and Blood Pressure in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled TrialsAdv Nutr.(2016 Jan 15)
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- Blood Pressure - Schwingshackl L, Chaimani A, Schwedhelm C, Toledo E, Pünsch M, Hoffmann G, Boeing HComparative effects of different dietary approaches on blood pressure in hypertensive and pre-hypertensive patients: A systematic review and network meta-analysis.Crit Rev Food Sci Nutr.(2019)
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- Blood Pressure - Long Ge, Behnam Sadeghirad, Geoff D C Ball, Bruno R da Costa, Christine L Hitchcock, Anton Svendrovski, Ruhi Kiflen, Kalimullah Quadri, Henry Y Kwon, Mohammad Karamouzian, Thomasin Adams-Webber, Waleed Ahmed, Samah Damanhoury, Dena Zeraatkar, Adriani Nikolakopoulou, Ross T Tsuyuki, Jinhui Tian, Kehu Yang, Gordon H Guyatt, Bradley C JohnstonComparison of Dietary Macronutrient Patterns of 14 Popular Named Dietary Programmes for Weight and Cardiovascular Risk Factor Reduction in Adults: Systematic Review and Network Meta-Analysis of Randomised TrialsBMJ.(2020 Apr 1)
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- Endothelial Function - Fatima K, Rashid AM, Memon UAA, Fatima SS, Javaid SS, Shahid O, Zehri F, Obaid MA, Ahmad M, Almas T, Minhas AMKMediterranean Diet and its Effect on Endothelial Function: A Meta-analysis and Systematic Review.Ir J Med Sci.(2023-Feb)
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- Joint Pain (General) - Katja A Schönenberger, Anne-Catherine Schüpfer, Viktoria L Gloy, Paul Hasler, Zeno Stanga, Nina Kaegi-Braun, Emilie ReberEffect of Anti-Inflammatory Diets on Pain in Rheumatoid Arthritis: A Systematic Review and Meta-AnalysisNutrients.(2021 Nov 24)
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- Gestational Diabetes Risk - Liu L, Zhou Y, He LMediterranean diet for the prevention of gestational diabetes: a meta-analysis of randomized controlled trials.J Matern Fetal Neonatal Med.(2022-Dec)
- Gestational Diabetes Risk - Yang J, Song Y, Gaskins AJ, Li LJ, Huang Z, Eriksson JG, Hu FB, Chong YS, Zhang CMediterranean diet and female reproductive health over lifespan: a systematic review and meta-analysis.Am J Obstet Gynecol.(2023-Dec)
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- Body Mass Index (BMI) - López-Gil JF, García-Hermoso A, Sotos-Prieto M, Cavero-Redondo I, Martínez-Vizcaíno V, Kales SNMediterranean Diet-Based Interventions to Improve Anthropometric and Obesity Indicators in Children and Adolescents: A Systematic Review with Meta-Analysis of Randomized Controlled Trials.Adv Nutr.(2023-Jul)
- Waist circumference - Papadaki A, Nolen-Doerr E, Mantzoros CSThe Effect of the Mediterranean Diet on Metabolic Health: A Systematic Review and Meta-Analysis of Controlled Trials in Adults.Nutrients.(2020-Oct-30)
- Verbal Fluency - David G Loughrey, Sara Lavecchia, Sabina Brennan, Brian A Lawlor, Michelle E KellyThe Impact of the Mediterranean Diet on the Cognitive Functioning of Healthy Older Adults: A Systematic Review and Meta-AnalysisAdv Nutr.(2017 Jul 14)
- Memory - McBean L, O'Reilly SDiet quality interventions to prevent neurocognitive decline: a systematic review and meta-analysis.Eur J Clin Nutr.(2022-Aug)
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- Crohn's Disease Symptoms - Limketkai BN, Godoy-Brewer G, Parian AM, Noorian S, Krishna M, Shah ND, White J, Mullin GEDietary Interventions for the Treatment of Inflammatory Bowel Diseases: An Updated Systematic Review and Meta-analysis.Clin Gastroenterol Hepatol.(2023-Sep)