Nutrition, Metabolism & Cardiovascular Diseases (2013) 23, 1163e1166

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier .com/locate /nmcd

VIEWPOINT

Towards an even healthier mediterraneandiet

R. Estruch a,b,*, J. Salas-Salvado b,c

aDepartment of Internal Medicine, Hospital Clinic, Institut d’Investigacio, August Pi i Sunyer (IDIBAPS),University of Barcelona, Barcelona, SpainbCIBER Obn, Physiopathology of Obesity and Nutrition, Institute of Health “Carlos III”, Government ofSpain, Santiago de Compostela, SpaincHuman Nutrition Unit, School of Medicine, Institut d’Investigacio Sanitaria, Pere Virgili (IISPV),University Rovira i Virgili, Reus, Spain

Received 24 July 2013; received in revised form 16 September 2013; accepted 23 September 2013Available online 11 October 2013

KEYWORDSMediterranean diet;Nutrition;Cardiovasculardisease;Cardiovascular riskfactors

* Corresponding author. Departmen932279365.

E-mail address: restruch@clinic.ub

0939-4753/$ - see front matter ª 201http://dx.doi.org/10.1016/j.numecd.

Abstract Dietary guidelines to promote good health are usually based on foods, nutrients,and dietary patterns predictive of chronic disease risk in epidemiologic studies. However,sound nutritional recommendations for cardiovascular prevention should be based on the re-sults of large randomized clinical trials with “hard” end-points as the main outcome. Such ev-idence has been obtained for the Mediterranean diet from the PREDIMED (Prevencion con DietaMediterranea) trial and the Lyon Heart Study. The traditional Mediterranean diet was thatfound in olive growing areas of Crete, Greece, and Southern Italy in the late 1950s. Their majorcharacteristics include: a) a high consumption of cereals, legumes, nuts, vegetables, andfruits; b) a relatively high-fat consumption, mostly provided by olive oil; c) moderate to highfish consumption; d) poultry and dairy products consumed in moderate to small amounts; e)low consumption of red meats, and meat products; and f) moderate alcohol intake, usuallyin the form of red wine. However, these protective effects of the traditional Mediterraneandiet may be even greater if we upgrade the health effects of this dietary pattern changingthe common olive oil used for extra-virgin olive oil, increasing the consumption of nuts, fattyfish and whole grain cereals, reducing sodium intake, and maintaining a moderate consumptionof wine with meals.ª 2013 Elsevier B.V. All rights reserved.

t of Internal Medicine, Hospital Clınic, Villarroel, 170, 08036 Barcelona, Spain. Tel./fax: þ34

.es (R. Estruch).

3 Elsevier B.V. All rights reserved.2013.09.003

1164 R. Estruch, J. Salas-Salvado

Dietary guidelines to promote good health are based onfoods, nutrients, and dietary patterns predictive of chronicdisease risk in epidemiologic studies. A systematic reviewof the evidence supporting the causal link between dietaryfactors and coronary heart disease (CHD) ranked the Med-iterranean diet (Mediet) as the most likely dietary model toprovide protection against CHD [1]. In prospective cohortstudies, increasing adherence to Mediet has been consis-tently beneficial in the prevention of CHD, as well as all-cause mortality [2,3].

A secondary prevention trial, the Lyon Diet Heart Study,showed remarkable reductions in CHD event rates andcardiovascular mortality in patients who survived amyocardial infarction and were allocated to a Medietenriched with alpha-linolenic acid compared with a controldiet [4]. Recently, the results of a large intervention trialevaluating the effects of a Mediet in the primary preventionof cardiovascular disease, the PREDIMED (PREvencion conDIeta MEDiterranea) study, were published [5]. In thisstudy, high-unsaturated fat Mediets supplemented withextra-virgin olive oil or nuts reduced the incidence of anaggregate of cardiovascular disease events by 30%,compared to a control diet (Fig. 1). Interestingly, theMediets recommended in the PREDIMED trial conferred asubstantial benefit with regard to classical and emergentcardiovascular risk factors after only 3 months [6].

The Table 1 enclosed summarizes the main dietary rec-ommendations to the participants included in the arms ofthe PREDIMED trial. Mediet intervention recommendationswere based on the traditional dietary pattern found in olivegrowing areas of Crete, Greece, and Southern Italy in thelate 1950s. The major characteristics of this diet are: a) a

Hazard Ratios (95% CI)*

EVOO : 0.70 (0.53-0.91); P = 0.009 Nuts : 0.70 (0.53-0.94); P = 0.016

Figure 1 KaplaneMeier estimates of incidence of all majorcardiovascular events (acute myocardial infarction, stroke orcardiovascular death) in the three intervention groups: Medi-terranean diet þ Extra-virgin olive oil (green line), Mediterra-nean diet þ nuts (red line) and control group (black line).*Hazard ratios stratified by center (Cox model with robustvariance estimators) CV denotes cardiovascular; EVOO, extra-virgin olive oil. (For interpretation of the references tocolour in this figure legend, the reader is referred to the webversion of this article.)

high consumption of cereals, legumes, nuts, vegetables,and fruits; b) a relatively high-fat consumption, mostlyprovided by olive oil; c) moderate to high fish consumption;d) poultry and dairy products consumed in moderate tosmall amounts; e) low consumption of red meats, and meatproducts; and f) moderate alcohol intake, usually in theform of red wine [7].

However, some changes have been included in the newversions of the traditional Mediet to improve its healthyeffects [7]. Olive oil continues to be the predominant fat.The presumed antiatherogenic properties of olive oil havebeen attributed to its high oleic acid content, but in recentyears converging evidence indicates that polyphenols,present mainly in virgin and extra virgin olive oil,contribute to the benefits of its consumption [8]. Since theatherogenic effects of oleic acid seems to be really weak inthe recent literature [9], nowadays researchers believethat most of healthy effects of extra virgin olive oil are dueto its polyphenolic content. Lower quality olive oils (refinedolive oil) lose antioxidant and anti-inflammatory capacitiesbecause they are deprived of polyphenols. In fact, pheno-lics have shown strong antioxidant and anti-inflammatoryactivities in experimental and human studies. Moreover,consumption of phenolic-rich virgin live oil linearly reducedthe cholesterol/HDL ratio and oxidized LDL levels [10].

Mediet is also rich in fatty fish. This fact may explain therapid emergence of the differences in cardiovascularevents observed among groups in the PREDIMED trial [5](Fig. 1). Since traditional Mediet was rich in fish only inthe coast areas, regular fatty fish intake should be regardedas another tool to make healthier the classical Mediet.

Traditional Mediet is rich in low-glycemic index and low-glycemic load foods, such aswhole grains and other fiber-richproducts. High consumption of whole grains has also beenassociated with lower risk of diabetes mellitus, CHD andcancer [11]. Conversely, refined grain may increase the riskof diabetes, obesity, CHD, and other chronic diseases [12]. Ina sub-study of the PREDIMED trial that analyzed 2213 high-risk participants, subjects in the highest quartile of whitebread consumption, but not those who consume whole grainbread, showed a significant increase in body weight andwaist perimeter [13]. Thus, nutritional recommendationsshould include changing refined cereal products for wholegrain cereals even in the Mediet.

Another important, albeit frequently ignored, issue in theMediet definition is sodium intake. High sodium intake hasbeen associated with high blood pressure and salt-preservedfoods were associated with greater risk of stomach cancer,CHD and total mortality [14]. In the PREDIMED trial, sodiumintake decreased significantly throughout the study (mean of0.6e0.9 g/day of salt) from a moderate baseline intake(5e6 g/d of salt) in both Mediet groups. However, these fig-ures continue to be higher than the tolerable upper intakelevel of sodium according to the USDA recommendations.Thus, sodium intake should also be included in the additionalrecommendations to follow a healthy diet such as Mediet.

Finally, another specific component of the Mediet iswine, consumed in moderation, mainly with meals. Thereare several campaigns against alcohol beverages, includingwine and beer, due to their toxic effects if consumed inhigh amounts. However, there is ample scientific evidencethat regular light-to-moderate alcohol consumption is

Table 1 Summary of dietary recommendations to participants in the Mediterranean and control diet groups [4].

Mediterranean diet Low-fat diet (control)

Recommended Goal Recommended Goal

1. Olive oila �4 tbsp/d 1. Low-fat dairy products �3 serv./d2. Tree nuts and peanutsb �3 serv./wk 2. Bread, potatoes, pasta, rice �3 serv./d3. Fresh fruits �3 serv./d 3. Fresh fruits �3 serv./d4. Vegetables �2 serv./d 4. Vegetables �2 serv./wk5. Fish (specially fatty fish), seafood �3 serv./wk 5. Lean fish and seafood �3 serv./wk6. Legumes �3 serv./wk7. “Sofrito”c �2 serv./wk8. White meat instead of red meat Preferable9. Wine with meals (optionally, only for habitual drinkers) �7 glasses/wk

Discouraged Goal Discouraged Goal

1. Soda drinks <1 drink/d 1. Vegetable oils (including olive oil) �2 tbsp/d2. Commercial bakery, sweets, pastriesd <3 serv./wk 2. Commercial bakery, sweets, pastriesd �1 serv./wk3. Spread fats <1 serv./d 3. Nuts and fried snacks �1 serv./wk4. Red and processed meats <1 serv./d 4. Red and processed fatty meats �1 serv./wk

5. Visible fat in meats and soupse Always remove6. Fatty fish, seafood canned in oil �1 serv./wk7. Spread fats �1 serv./wk8. “Sofrito”c �2 serv./wk

a Including oil used for frying or salads, or consumed from meals eaten out of home. In the group allocated to Mediterranean diet withextra-virgin olive oil, the goal was to consume �50 g per day (4 tbsp z 40 g/d) of the polyphenol-rich olive oil supplied, instead of theordinary refined variety, which is poor in polyphenols.b In participants allocated to the Mediterranean diet with nuts the recommended consumption was one daily serving (30 g, distributed

as 15 g walnuts, 7.5 g almonds and 7.5 g hazelnuts).c “Sofrito” is a sauce made with tomato and onion, and/or garlic, slowly simmered with olive oil.d Commercial bakery, sweets or pastries (not homemade), including cakes, cookies, biscuits or custard.e Remove visible fat (or the skin) of chicken, duck, pork, lamb or veal meats before cooking and the fat of soups, broths, and cooked

meat dishes before consumption.

Towards an even healthier mediterranean diet 1165

associated with a lower risk of CHD and all-cause mortality,as opposed to binge drinking. It has been proposed that,among the different alcoholic beverages, red wine might bemore cardioprotective than spirits [15]. Red wine containsalcohol and non-alcoholic compounds, mainly polyphenols.The results of clinical studies comparing the effects of redwine (alcohol plus polyphenols), dealcoholized red wine(polyphenols alone), and spirits (alcohol alone) show thatpart of the cardiovascular benefit of alcoholic beverages isdue to their alcoholic content (ethanol), but other effectsshould be attributed to non-alcoholic components, mainlypolyphenols [15].

In conclusion, sound nutritional recommendations forcardiovascular prevention should be based on the results oflarge randomized clinical trials with “hard” end-points as themain outcome. Such evidence has been obtained for theMediet from the PREDIMED trial [3] and the Lyon Heart Study[4]. However, these protective effects of the traditionalMediet may be even greater if we upgrade the health effectsof this dietary pattern, changing the commonolive oil used forextra-virgin olive oil, increasing the consumption of nuts,fatty fish and whole grain cereals, reducing sodium intake,andmaintaining amoderate consumption of wine withmeals.

Acknowledgments

CIBERobn is an initiative of ISCIII, Spain.

References

[1] Mathers CD, Loncar D. Projections of global mortality andburden of disease from 2002 to 2030. PLoS Med 2006;3:e442.

[2] Serra-Majem L, Roman B, Estruch R. Scientific evidence ofinterventions using the Mediterranean diet: a systematic re-view. Nutr Rev 2006;64:S27e47.

[3] Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence onbenefits of adherence to the Mediterranean diet on health: anupdated systematic review and meta-analysis. Am J Clin Nutr2010;92:1189e96.

[4] Estruch R, Ros E, Salas-Salvado J, Covas MI, Corella D, Aros F,et al. Primary prevention of cardiovascular disease with aMediterranean diet. N Engl J Med 2013;368:1279e90.

[5] deLorgeril M, Salen P, Martin JL, Monjaud I, Delaye J,Mamelle N. Mediterranean diet, traditional risk factors, andthe rate of cardiovascular complications after myocardialinfarction: final report of the Lyon Diet Heart Study. Circula-tion 1999;99:779e85.

[6] Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado J,Ruiz-Gutierrez V, Covas MI, et al. for the PREDIMED Study In-vestigators. Effects of a Mediterranean-style diet on cardio-vascular risk factors: a randomized trial. Ann Intern Med 2006;145:1e11.

[7] Bach-Faig A, Berry EM, Lairon D, Reguant J, Trichopoulou A,Dernini S, et al. Mediterranean diet pyramid today. Scienceand cultural updates. Public Health Nutr 2011;14:2274e84.

[8] Lopez-Miranda J, Perez-Jimenez F, Ros E, De Caterina R,Badimon L, Covas MI, et al. Olive oil and health: summary ofthe II International Conference on Olive Oil and Health

1166 R. Estruch, J. Salas-Salvado

consensus report, Jaen and Cordoba (Spain) 2008. Nutr MetabCardiovasc Dis 2010;20:284e94.

[9] Jakobsen MU, O’Reilly EJ, Heitmann BL, Pereira MA, Balter K,Fraser GE, et al. Major types of dietary fat and risk of coronaryheart disease: a pooled analysis of 11 cohort studies. Am J ClinNutr 2009;89:1425e32.

[10] Covas MI, Nyyssonen K, Poulsen HE, Kaikkonen J, Zunft HJ,Kiesewetter H, et al. The effect of polyphenols in olive oil onheart disease risk factors: a randomized trial. Ann Intern Med2006;14:333e41.

[11] Haas P, Machado MJ, Anton AA, Silva AS, De Francisco A.Effectiveness of whole grain consumption in the prevention ofcolorectal cancer: metaanalysis of cohort studies. Int J FoodSci Nutr 2009;21:1e13.

[12] Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T,Mitchell P, et al. Glycemic index, glycemic load, and chronic

disease riskea meta-analysis of observational studies. Am JClin Nutr 2008;87:627e37.

[13] Bautista-Castano I, Sanchez-Villegas A, Estruch R, Martınez-Gonzalez MA, Corella D, Salas-Salvado J, et al. Changes inbread consumption and 4-year changes in adiposity in Spanishsubjects at high cardiovascular risk. Br J Nutr 2013;110:337e46.

[14] Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A,Lightwood JM, Pletcher MJ, et al. Projected effect of dietarysalt reductions on future cardiovascular disease. N Engl J Med2010;362:590e9.

[15] Chiva-Blanch G, Arranz S, Lamuela-Raventos RM, Estruch R.Effects of wine, alcohol and polyphenols on cardiovasculardisease risk factors: evidences from human studies. AlcoholAlcohol 2013;48:270e7.