Mediterranean diet

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This article is about the dietary recommendation that became popular in the 1990s. For food of the areas around the Mediterranean Sea, see Mediterranean cuisine.
Mediterranean diet
Gazpacho ingredients.jpg
Olive oil and vegetables
Criteria R1, R2, R3, R4, R5
Reference 884
Inscription history
Inscription 2013

The Mediterranean diet is a modern nutritional recommendation originally inspired by the dietary patterns of Greece, Southern Italy, and Spain in the 1940s and 1950s.[1] The principal aspects of this diet include proportionally high consumption of olive oil, legumes, unrefined cereals, fruits, and vegetables, moderate to high consumption of fish, moderate consumption of dairy products (mostly as cheese and yogurt), moderate wine consumption, and low consumption of non-fish meat and non-fish meat products.[2]

In 2013, UNESCO added the Mediterranean diet to the Representative List of the Intangible Cultural Heritage of Humanity of Italy (promoter), France, Spain, Portugal, Greece, Cyprus, and Croatia.[3][4]

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.[6] In both North Africa and the Middle East, sheep's tail fat and rendered butter (samna) are the traditional staple fats, with some exceptions.[7] Indeed, one researcher concludes: "It appears that currently there is insufficient material to give a proper definition of what the Mediterranean diet is or was in terms of well defined chemical compounds or even in terms of foods.... The all embracing term 'Mediterranean diet' should not be used in scientific literature...."[8]

The most commonly understood version of the Mediterranean diet was presented, among others, by Dr Walter Willett of Harvard University's School of Public Health from the mid-1990s on.[9][10][11][12][13][14] 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.[15]

Olive oil is part of the Mediterranean diet, although not of all Mediterranean cuisines: in Egypt, Malta, and Israel, olive oil consumption is negligible,[5] and in other areas, it is not predominant.[6][7] 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.[16] 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.[17]


Although it was first publicized in 1975 by the American biologist Ancel Keys and chemist Margaret Keys (his wife and collaborator),[18] the Mediterranean diet failed to gain widespread recognition until the 1990s. Objective data showing that Mediterranean diet is healthful originated from results of epidemiological studies in Naples and Madrid [19] confirmed later by the Seven Countries Study, with first publication in 1970,[20] and a book-length report in 1980.[21]

The 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.[22]

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.[23]

Health effects[edit]

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.[24]

The Mediterranean diet often is 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.

Research has shown that people who adopt a strict Mediterranean diet and take regular exercise, often find this helps keep their weight under control. Mediterranean-style meals packed with fruit, vegetables and grains can be quite filling, which reduces any desire to top up with extra calories.[25]

Dietary factors are only part of the reason for the health benefits enjoyed by certain Mediterranean cultures. Physically active lifestyle or labour is also beneficial.[26][27] 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 an active lifestyle and Mediterranean diet to a less physically active lifestyle and a diet influenced by the Western pattern diet, significantly increases risk of heart disease.[28][29][30] 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.[31]

A 2011 systematic review found that a Mediterranean diet appeared to be more effective than a low-fat diet in bringing about long-term changes to cardiovascular risk factors, such as lowering cholesterol level and blood pressure.[32]

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.[33][34] 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.[35] 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.[36] It has been hypothesized that some components of the Mediterranean diet may provide protection against skin cancer.

A 2013 Cochrane review found limited evidence that a Mediterranean diet favorably affects cardiovascular risk factors.[37]

The global spread of the Mediterranean diet may be contributing to the marked increase of gluten-related disorders, such as coeliac disease and non-celiac gluten sensitivity, as it includes high levels of gluten.[38][39]

Nutritional evaluation[edit]

Fruits and vegetables: The Mediterranean diet provides 6–12 servings per day. The Canada Food Guide recommends 7–10.[40]

Grain products: The Mediterranean diet provides 4–6 servings per day. The Canada Food Guide recommends 6–8.[40]

Milk and alternatives: The Mediterranean diet provides 1–3 servings of low fat dairy products per day. The Canada Food Guide recommends 2.[40]

Meat and alternatives: The Mediterranean diet provides 1–2 servings of poultry, fish, and shellfish per day. The Canada Food Guide recommends 2–3.[40]

Other: The Mediterranean diet recommends one glass of red wine daily. The Canada Food Guide has no recommendation relevant to this.[40]

Medical research[edit]

A meta-analysis published in BMJ 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.[41]

A 2010 meta-analysis published in the The American Journal of Clinical Nutrition found that the Mediterranean diet conferred a significant benefit with regard to the risk of chronic diseases, such as cardiovascular disease and cancer.[42]

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]

A meta-analysis published in the American Journal of Clinical Nutrition in 2013 compared Mediterranean, vegan, vegetarian, low-glycemic index, low-carbohydrate, high-fiber, and high-protein diets with control diets. The research concluded that Mediterranean, low-carbohydrate, low-glycemic index, and high-protein diets are effective in improving markers of risk for cardiovascular disease and diabetes.[44]

In 2014, two meta-analyses found that adherence to a Mediterranean diet was associated with a decreased risk of type 2 diabetes.[45][46] Another 2014 systematic review and meta-analysis found that adherence to the Mediterranean diet was associated with a decreased risk of cancer mortality.[47]


When Ancel Keys and his team of researchers studied and characterized the Mediterranean diet and compared it with the eating habits of the US and the most developed countries during that period, some identified it as the "Diet of the Poor". According to the famed Portuguese gastronomist Maria de Lourdes Modesto who met with Keys, Portugal was included in their observations and studies, and Keys considered Portugal had the most pure "Mediterranean" diet.[dubious ] However, Salazar, the dictator of Portugal, did not want the name of Portugal included in the diet of the poor.[48]

Still today the name of the diet is not consensual among Portuguese gastronomists. After the Mediterranean diet became well-known, some studies evaluated the health benefits of the so-called "Atlantic diet", which is similar to Keys' "Mediterranean" diet, but with more fish, seafood, and fresh greens. Virgílio Gomes, a Portuguese professor and researcher on food history and gastronomy says, Portuguese cuisine is really an "Atlantic cuisine".[48] The Southern European Atlantic Diet is the traditional diet of Northern Portugal and Galicia (Spain) has been associated with a lower risk of non-fatal acute myocardial infarction.[49]

See also[edit]


  1. ^ Alberto Capatti et al., Italian Cuisine: A Cultural History, p. 106.; Silvano Serventi and Francoise Sabban, Pasta, p. 162.
  2. ^ "Get your Meds: the Mediterranean Diet and Health", Ellen Gooch, Epikouria Magazine, Fall 2005
  3. ^ "UNESCO Culture Sector, Eighth Session of the Intergovernmental Committee (8.COM) – from 2 to 7 December 2013". Retrieved April 3, 2014. 
  4. ^ "UNESCO - Culture - Intangible Heritage - Lists & Register - Inscribed Elements - Mediterranean Diet". Retrieved April 3, 2014. 
  5. ^ a b A. Noah, A. S. Truswell, "There are many Mediterranean diets", Asia Pacific Journal of Clinical Nutrition 10:1:2-9 (2001) doi:10.1046/j.1440-6047.2001.00198.x
  6. ^ a b Massimo Alberini, Giorgio Mistretta, Guida all'Italia gastronomica, Touring Club Italiano, 1984
  7. ^ a b Tapper, Richard; Zubaida, Sami (2001). A Taste of Thyme: Culinary Cultures of the Middle East. Tauris Parke Paperbacks. p. 43. ISBN 1-86064-603-4. 
  8. ^ A. Ferro-Luzzi, "The Mediterranean Diet: an attempt to define its present and past composition", European Journal of Clinical Nutrition 43:13-29 (1989) as quoted in Noah, op.cit.
  9. ^ Burros, Marian (29 March 1995). "Eating Well". The New York Times. Archived by Webcite
  10. ^ "Health implications of Mediterranean diets in light of contemporary knowledge. 1. Plant foods and dairy products." Kushi LH, Lenart EB, Willett WC Am J Clin Nutr 1995 Jun;61(6 Suppl):1407S-1415S.
  11. ^ "Health implications of Mediterranean diets in light of contemporary knowledge. 2. Meat, wine, fats, and oils." Kushi LH, Lenart EB, Willett WC" Am J Clin Nutr 1995 Jun;61(6 Suppl):1416S-1427S.
  12. ^ "The Mediterranean diet: science and practice". Willett WC. Public Health Nutr. 2006 Feb;9(1A):105-10.
  13. ^ "Mediterranean diet and incidence of and mortality from coronary heart disease and stroke in women". Fung TT, Rexrode KM, Mantzoros CS, Manson JE, Willett WC, Hu FB. Circulation. 2009 Mar 3;119(8) 1093-100.
  14. ^ Walter C. Willett, Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating, Free Press. 2005. ISBN 0-7432-6642-0
  15. ^ Willett WC; Sacks, F; Trichopoulou, A; Drescher, G; Ferro-Luzzi, A; Helsing, E; Trichopoulos, D (June 1, 1995). "Mediterranean diet pyramid: a cultural model for healthy eating". American Journal of Clinical Nutrition 61 (6): 1402S–6S. PMID 7754995. 
  16. ^ Keys A., Menotti A., Karvonen M. J.; et al. "(December 1986). "The diet and 15-year death rate in the seven countries study". Am. J. Epidemiol 124 (6): 903–15. 
  17. ^ Covas M. I. (2007). "Olive oil and the cardiovascular system". Pharmacol. Res. 55 (3): 175–86. doi:10.1016/j.phrs.2007.01.010. PMID 17321749. 
  18. ^ Ancel Keys, Margaret Keys, How to eat well and stay well the Mediterranean way, Doubleday, 1975
  19. ^ * António José Marques da Silva, La diète méditerranéenne. Discours et pratiques alimentaires en Méditerranée (vol. 2), L'Harmattan, Paris, 2015 ISBN 978-2-343-06151-1, pp. 52-54
  20. ^ Ancel Keys, ed. (April 1970). "Coronary heart disease in seven countries". Circulation 41 (4 Suppl): I1–211. doi:10.1161/01.CIR.41.4S1.I-1. PMID 5442782. 
  21. ^ Ancel Keys (ed), Seven Countries: A multivariate analysis of death and coronary heart disease, 1980. ISBN 0-674-80237-3.
  22. ^ Bruno Simini (1 January 2000) "Serge Renaud: from French paradox to Cretan miracle" The Lancet 355:9197:48 doi:10.1016/S0140-6736(05)71990-5
  23. ^ Castelvetro. G., The Fruits, Herbs, and Vegetables of Italy, London, Viking, 1989, translated from the original published in 1614.
  24. ^ Mitrou PN, Kipnis V, Thiébaut AC, Reedy J, Subar AF, Wirfält E, Flood A, Mouw T, Hollenbeck AR, Leitzmann MF, Schatzkin A (2007-12-10). "Mediterranean dietary pattern and prediction of all-cause mortality in a US population: results from the NIH-AARP Diet and Health Study". Arch Intern Med 167 (22): 2461–8. doi:10.1001/archinte.167.22.2461. 
  25. ^ Patient UK (June 2013). "How to Follow the Mediterranean Diet". 
  26. ^ Cardiovascular disease risk factors: epidemiology and risk assessment. Dahlöf B. Am J Cardiol. 2010 Jan 4;105(1 Suppl):3A-9A.
  27. ^ "Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism". Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bittner V, Franklin BA, Gulanick M, Laing ST, Stewart KJ; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Nutrition, Physical Activity, and Metabolism. "Circulation". 2007 Jul 31;116(5) 572-84.
  28. ^ "Cardiovascular disease risk factors and dietary habits of farmers from Crete 45 years after the first description of the Mediterranean diet". Vardavas CI, Linardakis MK, Hatzis CM, Saris WH, Kafatos AG. Eur J Cardiovasc Prev Rehabil. 2010 Aug;17(4) 440-6.
  29. ^ "Heart disease risk-factor status and dietary changes in the Cretan population over the past 30 y: the Seven Countries Study". Kafatos A, Diacatou A, Voukiklaris G, Nikolakakis N, Vlachonikolis J, Kounali D, Mamalakis G, Dontas AS" Am J Clin Nutr 1997 Jun;65(6) 1882-6.
  30. ^ "Inter-cohort differences in coronary heart disease mortality in the 25-year follow-up of the seven countries study". Menotti A, Keys A, Kromhout D, Blackburn H, Aravanis C, Bloemberg B, Buzina R, Dontas A, Fidanza F, Giampaoli S, et al. Eur J Epidemiol. 1993 Sep;9(5) 527-36.
  31. ^ "Mediterranean diet and the incidence of cardiovascular disease: A Spanish cohort". Martínez-González MA, García-López M, Bes-Rastrollo M, Toledo E, Martínez-Lapiscina EH, Delgado-Rodriguez M, Vazquez Z, Benito S, Beunza JJ. Nutr Metab Cardiovasc Dis. 2010 Jan 20.
  32. ^ Nordmann, AJ; Suter-Zimmermann, K; Bucher, HC; Shai, I; Tuttle, KR; Estruch, R; Briel, M (September 2011). "Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors.". The American Journal of Medicine 124 (9): 841–51.e2. doi:10.1016/j.amjmed.2011.04.024. PMID 21854893. 
  33. ^ Brown JM, Shelness GS, Rudel LL (December 2007). "Monounsaturated fatty acids and atherosclerosis: opposing views from epidemiology and experimental animal models". Curr Atheroscler Rep 9 (6): 494–500. doi:10.1007/s11883-007-0066-8. PMID 18377790. 
  34. ^ Rudel LL, Kelley K, Sawyer JK, Shah R, Wilson MD (November 1, 1998). "Dietary monounsaturated fatty acids promote aortic atherosclerosis in LDL receptor-null, human ApoB100-overexpressing transgenic mice". Arterioscler Thromb Vasc Biol. 18 (11): 1818–27. doi:10.1161/01.atv.18.11.1818. PMID 9812923. 
  35. ^ Wong A (2008). "Incident solar radiation and coronary heart disease mortality rates in Europe". Eur J Epidemiol. 23 (9): 609–14. doi:10.1007/s10654-008-9274-y. PMID 18704704. 
  36. ^ Global Perspectives of Contemporary Epidemiological Trends of Cutaneous Malignant Melanoma
  37. ^ Rees, K; Hartley, L; Flowers, N; Clarke, A; Hooper, L; Thorogood, M; Stranges, S (12 August 2013). "'Mediterranean' dietary pattern for the primary prevention of cardiovascular disease.". The Cochrane database of systematic reviews 8: CD009825. doi:10.1002/14651858.CD009825.pub2. PMID 23939686. 
  38. ^ Volta U, Caio G, Tovoli F, De Giorgio R (2013). "Non-celiac gluten sensitivity: questions still to be answered despite increasing awareness". Cellular and Molecular Immunology (Review) 10 (5): 383–392. doi:10.1038/cmi.2013.28. ISSN 1672-7681. PMC 4003198. PMID 23934026. Many factors have contributed to the development of gluten-related pathology, starting with the worldwide spread of the Mediterranean diet, which is based on a high intake of gluten-containing foods. In the Mediterranean area, the mean daily gluten consumption is particularly high (approximately 20 g and even higher in some countries). 
  39. ^ Guandalini S, Polanco I (Apr 2015). "Nonceliac gluten sensitivity or wheat intolerance syndrome?". J Pediatr 166 (4): 805–11. doi:10.1016/j.jpeds.2014.12.039. PMID 25662287. The increase in world-wide consumption of a Mediterranean diet, which includes a wide range of wheat-based foods, has possibly contributed to an alarming rise in the incidence of wheat (gluten?)-related disorders.1, 2 
  40. ^ a b c d e "Eating Well with Canada's Food Guide". Health Canada. Retrieved 27 February 2014. 
  41. ^ Sofi F, Cesari F, Abbate R, Gensini GF, Casini A (2008). "Adherence to Mediterranean diet and health status: meta-analysis". BMJ (Clinical research ed.) 337 (sep11 2): a1344. doi:10.1136/bmj.a1344. PMC 2533524. PMID 18786971. 
  42. ^ Sofi, F; Abbate, R; Gensini, GF; Casini, A (November 2010). "Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis.". The American journal of clinical nutrition 92 (5): 1189–96. doi:10.3945/ajcn.2010.29673. PMID 20810976. 
  43. ^ Kastorini C-M, Milionis H, Esposito K, Giugliano D, Goudevenos J, Panagiotakos D. (2011). "The Effect of Mediterranean Diet on Metabolic Syndrome and its Components". Journal of the American College of Cardiology 57 (11): 1299–1313. doi:10.1016/j.jacc.2010.09.073. PMID 21392646. 
  44. ^ Ajala O., English P., Pinkney J. (2013). "Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes". The American Journal of Clinical Nutrition 97 (3): 505–516. doi:10.3945/ajcn.112.042457. 
  45. ^ Schwingshackl, L; Missbach, B; König, J; Hoffmann, G (22 August 2014). "Adherence to a Mediterranean diet and risk of diabetes: a systematic review and meta-analysis.". Public health nutrition 18: 1–8. doi:10.1017/S1368980014001542. PMID 25145972. 
  46. ^ Koloverou, E; Esposito, K; Giugliano, D; Panagiotakos, D (July 2014). "The effect of Mediterranean diet on the development of type 2 diabetes mellitus: a meta-analysis of 10 prospective studies and 136,846 participants.". Metabolism: clinical and experimental 63 (7): 903–11. doi:10.1016/j.metabol.2014.04.010. PMID 24931280. 
  47. ^ Schwingshackl, L; Hoffmann, G (15 October 2014). "Adherence to Mediterranean diet and risk of cancer: a systematic review and meta-analysis of observational studies.". International Journal of Cancer. Journal International Du Cancer 135 (8): 1884–97. doi:10.1002/ijc.28824. PMID 24599882. 
  48. ^ a b Moreira, José Augusto (October 10, 2012). "Mediterrânica ou atlântica, eis a questão". Público (in Portuguese). 
  49. ^ Guallar-Castillón P1, Oliveira A, Lopes C, López-García E, Rodríguez-Artalejo F. (February 2013). "The Southern European Atlantic Diet is associated with lower concentrations of markers of coronary risk". PubMed 226 (2): 502–9. doi:10.1016/j.atherosclerosis.2012.11.035. PMID 23261168. 

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