Mediterranean diet

So maybe the Mediterranean Diet is not that fantastic?

Advanced Mediterranean Diet

 Scientific breakthroughs, mostly over the last decade, should allow us to fine-tune the traditional Mediterranean diet, leading to greater improvements in health and longevity.  Specific modifications to the traditional Mediterranean diet will ensure that you get the optimal amount of various foods that have been clearly associated with lower rates of disease and longer lifespan.  Please consider the following modifications—which we’ll call the Advanced Mediterranean Diet—as you eat Mediterranean-style:

How much fish?  Two servings per week, to prevent sudden death and heart attacks.

What kind of fish? Cold-water fatty fish (albacore tuna, salmon, mackerel, sardines, trout, sea bass, swordfish, herring, anchovies, halibut, pampano).  Many of these fish were not available to the Mediterraneans of the mid-20th century.

How many nuts?  Three to five 1-ounce servings per week.

How much olive oil?  Aim for a minimum of seven to 14 tablespoons weekly.

How much fruits and vegetables?  At least 5 servings daily, to reduce risk of cancer, heart attacks, and stroke.

How much legumes?  Four servings per week, to prevent coronary artery disease.

How much wine, for those who choose to drink?  No more than one glass (4-5 ounces) daily for women and two glasses for men, to prolong lifespan and reduce coronary artery disease and dementia.  Before taking up the wine habit, carefully consider the pros and cons.

How much whole grain?  Three servings daily, to reduce risk of premature death, coronary artery disease, diabetes mellitus, and cancer.

The traditional Mediterranean diet was generally high-fiber but how much fiber do we need?  Twenty-five to 30 grams daily, to prevent diverticulosis, constipation, irritable bowel syndrome, and hemorrhoids.

The Advanced Diet encourages usage of heart-protective omega-3 polyunsaturated fatty acids in vegetable oils, especially flaxseed, canola, and soybean oils.  These were not significant contributors to the traditional diet.

Full-fat versions of dairy products were the norm in the traditional diet.  We now believe that the saturated fats in them contribute to hardening of the arteries (atherosclerosis), so the Advanced Diet favors the low-fat versions.  For the same reason, the Advanced Diet favors leaner (lower fat) cuts of meat, poultry, and game.

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It is time to stop counting calories, and time instead to promote dietary changes that substantially and rapidly reduce cardiovascular morbidity and mortality

Most heart attacks and ischaemic strokes are caused by complicated atheroma usually compounded by thrombosis suddenly reducing blood flow in a critical artery. Extensive evidence suggests that this atheroma silently builds up over many decades. However, arterial stiffening can be seen even in children who are obese, and aortic fatty streaks are visible in some teenagers and young adults.1 Yet, most cardiovascular events do not manifest until after the age of 60 years. The general perception is thus of a slow process that will therefore only reverse slowly, if at all. However, this perception is wrong. Extensive empirical and trial evidence reveals that substantial reductions in mortality can occur within months of quitting smoking, or making healthy dietary changes. These reductions apply to both individuals and to entire populations. In one American hospital, admissions for acute coronary syndromes decreased by 40% within 6 months of the introduction of local smoke free legislation.2 When the law was rescinded, coronary admissions rapidly returned to previous levels. The introduction of smoke-free legislation in Scotland in 2006 was soon followed by a 6% decrease in out of hospital cardiac deaths and a 17% decrease in hospital admissions within a year.3Even 30 min of secondhand smoke exposure has been proven to increase platelet activity and hence elevate cardiovascular risk.4

Similarly, changes in diet can rapidly improve outcomes of cardiovascular disease (CVD), as demonstrated by several randomised trials. In the DART trial, 2033 survivors of myocardial infarction who were advised to eat fatty fish had a significant 29% reduction in all-cause mortality compared with control patients, with survival curves separating within months. Likewise, in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarcto Miocardico (GISSI)-Prevention trial, 1 g of Ω-3 fatty acids significantly reduced all-cause mortality and cardiovascular mortality in 11 324 myocardial infarction survivors. Moreover, survival curves separated early, with a significant reduction in total mortality after just 3 months of treatment (p=0.037).5

The PREvencion con DIeta MEDiterranea (PREDIMED) primary prevention randomised controlled trial found that an energy unrestricted diet supplemented with extra virgin olive oil or nuts achieved an impressive 30% reduction in major cardiovascular events (NNT=61) in over 7500 high risk individuals initially free of CVD. This reduction occurred within 3 months.6 Furthermore, this solid RCT evidence builds on a wealth of existing data from observational, cohort and secondary prevention intervention studies.7 ,8 It also provides further strong causal evidence that simple diet interventions can rapidly and powerfully reduce CVD outcomes. In comparison with an American Heart Association recommended ‘low fat’ diet, a Mediterranean diet post myocardial infarction is a more powerful coronary intervention tool for mortality than aspirin, statins, or coronary stents, but without any significant difference in total cholesterol, triglycerides or HDL between the two groups.9 It is the abundant α-linoleic acid, polyphenols and Ω-3 fatty acids found in nuts, olive oil, oily fish and vegetables, that rapidly exert positive health effects by attenuating inflammation, atherosclerosis and thrombosis.10 Conversely, the consumption of trans-fats commonly found in fast food can rapidly increase C reactive protein and other inflammatory markers within weeks.11

Strategies that prevent excessive weight gain in children and adults through curbing the consumption of the amounts of unhealthful foods should also be welcomed. However, simply focusing on weight loss in obese subjects misses a key finding from analysis of PREDIMED subgroups: dietary intervention achieved consistently large reductions in CVD risk irrespective of weight. Furthermore, weight loss interventions are rarely sustained. The weight loss industry, which emphasises calorie restriction over good nutrition, generates $58 billion in revenue annually in the USA, even though long-term follow-up studies reveal that the majority of individuals regain virtually all of the weight that was lost during treatment irrespective of whether they maintain their diet or exercise programme.12 Shifting focus away from calories and emphasising a dietary pattern that focuses on food quality rather than quantity will help to rapidly reduce obesity, related diseases and cardiovascular risk.13 ,14 Rapid weight loss and regain that can occur from fad dieting is actually detrimental to health. Such ‘weight cycling’ contributes to hypertension, insulin resistance and dyslipidaemia resulting in increased mortality risk and worse cardiovascular outcomes.15 The look AHEAD (Action for Health in Diabetes) trial found no reduction in the composite endpoint (ie, death from cardiovascular causes, non-fatal myocardial infarction, non-fatal stroke, or hospitalisation for angina) with a low calorie diet (on top of increased physical activity) in patients with type 2 diabetes despite a maximum follow-up of 13.5 years and despite significant weight loss in the intervention group.16

In a randomised, controlled, double-blinded dietary intervention trial for blood pressure, compared to placebo, the daily ingestion of flaxseed (high in Ω-3, lignans and fibre) induced a significant 10 mm Hg systolic/7 mm Hg diastolic blood pressure reduction in hypertensive patients with peripheral arterial disease, within 6 months. The rate of stroke and myocardial infarction was cut in half in the flaxseed group compared to the placebo group. Furthermore, there was no significant difference in weight change between the two groups.17

The American Heart Association predicts that 8 million Americans will have heart failure by 2030. The total direct costs will triple from approximately $20 billion in 2012 to $70 billion in 2030.18 Recently, a small study suggested that a low-carbohydrate diet in patients with diabetes reversed echocardiographic markers of diastolic dysfunction within weeks of implementation.19 This finding is all the more valuable considering there is, to date, no proven pharmacological intervention that improves prognosis in diastolic heart failure, which affects 30–50% of all heart failure patients.19

An exaggerated belief in the (modest) benefits of pharmacotherapy,20 aggressively reinforced by commercial vested interests, can often mislead patients and doctors, and promotes overtreatment in chronic disease management, and may even distract from and undermine the benefits of simple lifestyle interventions.

Focusing on total energy consumed, as opposed to nutritional value, has been exploited by the food industry, which has added sugar to over 80% of all processed foods. One can of cola contains nine teaspoons of sugar. The EPIC study revealed that one can a day (approximately 150 calories) was associated with substantially increasing the risk of developing type 2 diabetes.21 Conversely, PREDIMED revealed that consumption of a handful of nuts, (30 g of walnuts, 15 g of almonds and 15 g of hazelnuts) or four tablespoons of extra virgin olive oil per day (approximately 500 calories) significantly reduced the risk of heart attack and stroke. A recent randomised pilot study of a calorie unrestricted very low carbohydrate/high fat diet in overweight patients with type 2 diabetes or prediabetes resulted in a significant improvement in glycaemic control and even discontinuation of diabetes medications within 3 months in comparison to a moderate carbohydrate, low-fat calorie-restricted diet (consistent with guidelines from the American Diabetes Association), with no adverse effect on blood lipids.22 A critical review in Nutrition also concluded that dietary carbohydrate restriction is the “single most effective intervention for reducing all of the features of the metabolic syndrome” and should be the first approach in diabetes management with the very low carbohydrate ketogenic diet (<10% carbs) revealing the greatest falls in glycated hemoglobin and reduction in the use of medications with benefits occurring even without weight loss.23

Primary and secondary care clinicians clearly have a duty to their individual patients and also to their local populations. Our continued collective failure to act is an option we cannot afford. Obesity alone is already costing the National Health Service (NHS) over £5 billion a year. Total costs of type 2 diabetes in the UK exceed £20 billion and are predicted to double in the next 20 years.24Similarly, in the USA, the cost of diabetes has risen 40% in the past 5 years, reaching $245 billion in 2012.25 The extensive Global Burden of Disease studies show that poor diet is consistently responsible for more disease and death than physical inactivity, smoking and alcohol combined.26 This global disease burden will clearly not be prevented by medications; it will require policy interventions that make healthier diet choices easier (the ‘default option’).27 The most powerful and effective policies include taxation on sugary drinks, and subsidies to increase the affordability and availability of healthier foods including nuts, vegetables and fruit, in addition to controls on the marketing of junk foods and clear package labelling. Increasing nut consumption among the American population by two servings per week could prevent 90 000 CVD deaths per year.28 Applying these population-wide policies might achieve rapid reductions in disease and hospital admissions visible even within the electoral term of most politicians. It is time to stop counting calories, and time to instead promote good nutrition and dietary changes that can rapidly and substantially reduce cardiovascular mortality. The evidence indeed supports the mantra that “food can be the most powerful form of medicine or the slowest form of poison”. Recommending a high fat Mediterranean-type diet and lifestyle to our patients, friends and families, might be a good place to start.

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Eat like a Greek!

It’s been a turbulent few years for the world of nutrition and diet. It looks like fat isn’t so bad after all (as long as it’s the right kind of fat), eating more vegetables is the way to go and strict diets just don’t work.

In comes the Mediterranean Diet, it’s been characterized as perhaps the healthiest diet in the world. Not an exaggeration, this diet that has appeared in certain areas of the Mediterranean, has literally hundreds of studies supporting it. Initially known for its heart healthy qualities, recent research has shown that its benefits go beyond the heart. It appears that this pattern of eating can protect from cancer, help you live longer, protect your brain and improve your mood. In addition, it is a sustainable diet, low on the food chain and affordable.

While numerous studies have made the diet more popular than ever, the various definitions of the diet make it a bit confusing not only for consumers but also health professionals. Is it the diet of all the Mediterranean or certain areas? How much fish are you supposed to eat? Can you eat a lot of pasta? What about olive oil, will it make you gain weight? And how do you choose good olive oil? Is the Mediterranean diet the same as Mediterranean cuisine? If you are looking for answers to these questions, you may find them all at one place.

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10 helpful tips on sustaining the Mediterranean diet and lifestyle.

• Always eat breakfast. Keep yogurt and fruit stocked in your refrigerator to eat on the go.
• When dining out, divide your meal in half. Do this the moment the plate hits the table and pack it up as leftovers.
• Keep a supply of chopped vegetables. Celery, bell peppers, carrots, and cucumbers are perfect for dipping in hummus.
• Visit your local farmers’ market. This will keep your refrigerator stocked with locally grown, seasonal vegetables.
• Snack on a handful of nuts or seeds. Almonds, walnuts, or sunflower seeds are better choices in place of chips, cookies, or other processed foods.
• Enjoy fruit for dessert. You can even add a little sweetness with a drizzle of honey or sprinkle of brown sugar on top. Keep fresh fruit around the house and at work so you have a healthy snack on hand when your stomach begins to growl.  
•  Savor your bites. Avoid eating in front of the television or while you’re answering email. Cherish your time with family and friends at the dinner table.
• Get your family involved. Ask children to help with food preparation. It allows you to spend quality time with one another.
• Avoid processed and refined foods. Minimize, or better yet, eliminate your consumption of packaged foods and sweets. 
• Switch to whole grains. Minimally processed grains, such as barley, bulgur, couscous, faro, millet, oats rice, and, polenta, are a central part of the Mediterranean diet.
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What is so healthy about the Mediterranean diet?

Heart and circulatory health

Following extensive medical research, there is strong evidence that the Mediterranean diet can improve heart and circulatory health.

The correlation between improved heart health and the Mediterranean diet is based on the higher intake of monounsaturated fats that are found in olive oil, nuts, and oily fish.
Followers of the Mediterranean diet plan swap saturated fats (pastry, animal fat, biscuits which increase the amount of LDL (or bad) cholesterol) for monounsaturated fats which help maintain healthy cholesterol levels by lowering the amount of bad cholesterol in the body.
This is positive because too much cholesterol can cause blocked arteries which lead to cardiovascular disease and high blood pressure.A four year study of 7447 people at high cardiovascular risk by The New England Journal of Medicine found that the risk of death from cardiovascular disease was reduced by a Mediterranean diet.
Digestive health
Dr Frankie Phillips, registered dietitian and nutritionist and spokesperson for the British Dietetic Association (BDA), praises the diet plan for encouraging people to up their intake of fruit and vegetables, and so increasing the amount of fibre in their diet.
“Adding more fibre is particularly important as last year’s National Diet and Nutrition Survey showed that, as a nation, we are eating half as much fibre as we should be.”
Fibre is essential for healthy digestion. “Increase fibre slowly with a spoonful of beans or an extra portion of vegetables each week,” says Dr Phillips. “If your diet is fibre-poor and you increase your intake too quickly, you may experience discomfort in your gut.”

Cognitive function
Industry experts conclude there is not enough evidence to support the link between a Mediterranean diet and improved cognitive function.
According to Alzheimers.org, the correlation is loosely based on the fact that inflammation in the brain is associated with dementia risk, and the Mediterranean diet reduces signs of this inflammation.
Weight loss
Cutting out processed foods to favour fruit, vegetables and pulses can lead to weight loss if portions are controlled. A 2008 study published in the New England Journal of Medicine that looked at 322 obese individuals, found that a Mediterranean diet is more effective for weight loss and improving symptoms of diabetes, when compared to a low-fat diet.
Prevention and management of Type 2 Diabetes
Given that obesity stands as one of the most common causes of Type 2 Diabetes, following a well-balanced Mediterranean diet can help prevent the condition by stopping weight gain.
A study in 2011 by the Human Nutrition Unit at Hospital Universitari de Sant Joan, Barcelona looked at 418 non-diabetic participants over four years.
Researchers found that a Mediterranean diet with calorie restriction can be effective in preventing the development of Type 2 Diabetes.
If diagnosed with Type 2 Diabetes, eating a high fibre diet - like the Mediterranean diet plan - is advised as it helps keep blood sugars steady.
A study by the University of Naples on newly diagnosed Type 2 Diabetes sufferers showed that a low-carb Mediterranean diet may delay or prevent the need for drug therapy in patients.

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mediterranean diet not statins reduce all cause mortality

“Nearly twenty years ago two landmark randomized clinical trials appeared in The Lancet which forever changed the course of medicine for patients with coronary heart disease (CHD). The 4S study employed a cholesterol-lowering statin drug and reported a 30% mortality reduction[1]. 

The Lyon Diet Heart Study utilized the Mediterranean diet and reported a 70% mortality reduction[2]. Subsequent studies of the Mediterranean diet have confirmed these findings and also shown a reduced risk of cancer, diabetes, and Alzheimer’s disease[3–6]. 

Subsequent statin studies have led the United States Food and Drug Administration to issue warnings regarding the increased risk of diabetes and decreased cognition with statin drugs. Paradoxically, statins have gone on to become a multi-billion dollar industry and the foundation of many cardiovascular disease prevention guidelines while the Mediterranean diet has often been ignored. 

We believe this statin-centric cholesterol-lowering approach to preventing CHD may be misguided.”

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