The Prevention of Cardiovascular Disease through the Mediterranean Diet

By Almudena Sánchez Villegas and Ana Sanchez-Taínta

The Prevention of Cardiovascular Disease through the Mediterranean Diet presents dietary habits that will have maximum impact on cardiovascular health and other major chronic diseases. Data collected through the results of large clinical trials, such as PREDIMED, one of the longest trials ever conducted, has allowed researchers to conclude that the Mediterranean Diet provides the best evidence for health benefits.

Studies have shown that the Mediterranean Diet is able to reduce the risk of cardiovascular hard clinical events by 30%. This book explores the components of this diet, including the consumption of extra virgin olive oil, nuts, fresh fruits and vegetables, fatty fish, poultry and red wine for optimal health benefits.

• Analyzes the results of clinical trials that show that a healthy dietary pattern can prevent cardiovascular and other major chronic diseases
• Explores the components of The Mediterranean Diet in detail, allowing practitioners to pass this understanding on to patients for optimal health benefits
• Contains recipes, including modified versions for special populations or different cultures

• Language: English
• Publisher: Academic Press
• Release date: Sep 8, 2017
• ISBN: 9780128112601

Almudena Sánchez Villegas

Dr. Almudena Sanchez-Villegas is Professor of Preventive Medicine and Public Health at the University of Las Palmas. She is the author of more than 40 book chapters and co-editor of textbooks of Biostatistics and Public Health. She has written more than 80 scientific articles, editorials and letters in international peer-reviewed journals and has been principal investigator of two projects of national funding designed to determine the association between diet, activity physics, quality of life and mental health. She has participated as a collaborating researcher in other Spanish and European related nutritional epidemiology such as the PREDIMED and EURRECA projects funded by the European Union. She is part of the Center for Biomedical Research Network Pathophysiology of Obesity and Nutrition collaborating in the PREDIMED-PLUS trial.

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Chapter 1

A Healthy-Eating Model Called Mediterranean Diet

Almudena Sánchez-Villegas and Itziar Zazpe

Abstract

Mediterranean Diet refers to dietary patterns found in the olive tree-growing areas of the Mediterranean basin before the mid-1960s. The main characteristics of this pattern are: the high consumption of abundant plant foods; fresh and varied fruits as the main and usual dessert; olive oil as the main source of fat and commonly used for salads and cooking; frequent consumption of fish; moderate wine consumption with meals; low amounts of meat; and low to moderate consumption of dairy products. Over the last few decades, the Mediterranean Diet has been recognized for its nutritional composition and effects on human health because it shows an excellent profile of macronutrients and essential micronutrients. Several observational studies with longitudinal design as well as two important clinical trials (PREDIMED and Lyon Hearth Study) have demonstrated the favorable role of this dietary pattern in the primary and secondary prevention of cardiovascular disease.

Keywords

Mediterranean Diet; Seven Countries Study; olive oil; pyramid; nutritional adequacy; Predimed

1.1 Definitions and History of the Mediterranean Diet

The Mediterranean Diet is a widely used concept that has been used over the last few decades by doctors, researchers, nutritionists, dietitians, and experts from various fields, even though there is no clear consensus on its definition.

The healthy-eating model called the Mediterranean Diet dates back to the early 1960s, when Keys et al. traveled through southern European countries and started the Seven Countries Study. This study, which was the first piece of research into the Mediterranean Diet, began in 1958 and demonstrated that the mortality rate from coronary heart disease in southern Europe was two to three times lower than in northern Europe or the United States [1,2]. It also described low rates of coronary heart disease in the Mediterranean regions when contrasted with other study populations [2,3], and was the main source of information regarding traditional Mediterranean diets in the 1960s and 1970s [4].

In this context, the Mediterranean Diet was defined as the eating habits observed in Greece and Southern Italy in the late 1950s and early 1960s, when the effects of World War II had passed but the fast-food culture had not yet invaded the area [5].

Seen from another point of view the Mediterranean Diet could be also defined by its clearly beneficial health effects. The first results of the Seven Countries Study showed that there was an association between this traditional dietary pattern and a low incidence, and prevalence of mortality rates from coronary heart diseases, other cardiovascular diseases, and low all-cause mortality, including cancer [6].

In general, the term Mediterranean Diet refers to dietary patterns found in the olive tree-growing areas of the Mediterranean basin before the mid-1960s [7].

Although this concept is a clear combination of history, culture, and environment and implies a common dietary pattern in Mediterranean countries, there are however important differences in typical products, food cultures, traditions, and geographical and ecological environments between regions [8].

From these various approaches, it can be said that there is no single Mediterranean Diet and that there are major differences in the traditional eating habits of citizens from countries bordering the Mediterranean Sea: Italy, Greece, France, Spain, North Africa, and the Eastern basin [9].

Even the dietary practices within the same country can vary considerably. Notwithstanding these differences, however, olive oil has always had a central position in all Mediterranean countries or regions [10].

A recent review considers the Mediterranean Diet as an intangible and sustainable food culture transmitted from generation to generation over centuries, of landscapes, places, knowledge, know-how, technologies, products, food preparation and intake, myths and beliefs, accents, creativity, and hospitalities [11,12]. Indeed, since November 16, 2010, the Mediterranean Diet has been inscribed into UNESCO’s Representative List of Intangible Cultural Heritage of Humanity [13]. The objective of this initiative was to safeguard the immense legacy representing the cultural value of the Mediterranean Diet, as well as to share and disseminate its values and benefits internationally.

In conclusion, the Mediterranean Diet is essentially part of a lifestyle and requires the simultaneous consideration of other nondietary behavioral factors when assessing its beneficial health effects [14]. Unfortunately, over the last decades, current diets in Mediterranean countries are departing from the traditional Mediterranean Diet toward an unhealthier eating model. This is due to the widespread dissemination of Western-type culture, along with the globalization of food production and consumption, which is related to the homogenization of food behavior in the modern era [8,15].

Therefore, it may now be time to update the definition of the Mediterranean Diet [16,17].

1.2 Mediterranean Diet: Characteristics

In the mid-20th century Mediterranean peoples frequently consumed high amounts of plant foods (olive oil, fruits, vegetables, legumes, fruits, bread, cereal products, nuts, and seeds), food from animals in limited amounts (fish, meat, and milk and milk products), wine, and had a low intake of saturated fats [6].

Taking into account all these characteristics and using a somewhat reductionist approach, this dietary pattern can be considered to be mainly, but not dogmatically, an exclusively plant-based dietary pattern. However, it has been pointed out that the Mediterranean Diet is not a vegetarian diet, in spite of the fact that two of its most common and typical foods, olive oil and wine, are plant products [14].

Therefore, the traditional Mediterranean Diet favored the consumption of locally grown, seasonally fresh and minimally processed foods and was consumed by physically active people [10].

The main and typical foods of the traditional diet of Mediterranean countries are:

• Vegetables and fruits. These are important sources of minerals, vitamins, antioxidants, and fiber. Furthermore, the benefits of their consumption are amplified if they are cooked or dressed with olive oil. Other healthy vegetable options are raw foods such as salads.

• Grains. The nutritional composition of grains may vary depending on the variety and environmental growing conditions. In general, cereal grains are high in carbohydrates, low in fat, good sources of protein and provide varying amounts of fiber, vitamins, and minerals. Cereal products should contain whole grains, including wheat, oats, rice, rye, barley, and corn. Grains should also be consumed in minimally processed forms.

• Olives and olive oil. By definition, olive oil is a central component in the cuisine of the countries surrounding the Mediterranean Sea. This type of vegetable oil has a peculiar fatty acid composition (with a large proportion of monounsaturated fat—mainly oleic acid—and a relatively low proportion of saturated fat) and also contains other minor compounds (tocopherols and carotenoids among others) with antioxidant properties. Olive oil is the principal source of dietary fat used to dress salads and vegetables, and in cooking or baking. The variety extra-virgin olive oil is highest in health promoting fats, phytonutrients, and other important micronutrients.

• Nuts, legumes, and seeds. All of these foods are packed with vitamins and minerals. Nuts and seeds also provide healthy mono- and polyunsaturated plant oils as well as protein. Legumes, which include beans, are filling and also contain lean protein.

• Fish and shellfish are preferred over meat in the traditional Mediterranean diet, although the amount of fish consumed varies widely between and within Mediterranean countries. This group of foods is an important source of healthy protein and essential heart-healthy omega-3 fatty acids.

• Cheese and yogurt. Dairy products, from a variety of animals, principally in the form of yogurt and cheese, are consumed in low to moderate amounts.

• Eggs are an excellent source of high-quality protein and also contain a number of healthy nutrients, including B vitamins and protein.

• Meat. In general, the consumption of red meat and processed meats is lower in the Mediterranean population than the consumption of white meat, in spite of the fact that red meat is a good source of animal protein.

• Wine. Moderate wine drinking in the context of the meals has been a long-standing tradition in the Mediterranean basin, with the exception of Islamic populations of this area.

• Herbs and spices add flavors and aromas to foods, reducing at the same time the need to add salt or fat when cooking. Herbs and spices are very common in Mediterranean cuisine; they contain several health-promoting antioxidants and contribute to the differences between the broad varieties of culinary cultures.

1.3 Mediterranean Diet Pyramids

The first pyramid representing the Mediterranean Diet was published in 1995 (Fig. 1.1), in the context of the International Conference on the Diets of the Mediterranean organized by Oldways Preservation & Exchange Trust and the World Health Organization (WHO)/Food and Agriculture Organization (FAO) in collaboration with the Harvard T.H. Chan School of Public Health [6]. One objective of the group of international experts on diet was to develop a pyramid that summarized the Mediterranean diets consumed during the previous half century.

Figure 1.1 The Mediterranean Diet Pyramid: a cultural model for healthy eating.

This pyramid did not specify the relative frequency intake of foods or the proportion of energy obtained from them and in line with other pyramids it was divided into three levels of recommended consumption: daily (cereals and their derived foods, potatoes; fruits, vegetables, legumes and nuts, olive oil in varying amounts, and cheese and yogurt), a few times per week (fish, poultry, eggs, and sweet foods) and a few times per month (red meat). Physical activity and wine consumption in moderation and with meals were two main lifestyle factors which were typical of the Mediterranean areas in the early 1960s, and which were included in the pyramid. Moreover, certain lifestyle factors were considered to be noteworthy: delicious meals, carefully cooked food, eating in friendly company, lengthy meals, and postlunch siestas that provide relaxation.

Although in 2000 the Oldways Preservation & Exchange Trust published yet another pyramid of the Mediterranean Diet, it was not until 2009 when a new, updated and more colorful pyramid was created (Fig. 1.2) [18].

Figure 1.2 Mediterranean Diet Pyramid: a contemporary approach to delicious, healthy eating.

The team of scientists in charge created an entirely new pyramid graphic to better reflect the delicious and appetizing nature of typical Mediterranean foods. The changes focused on gathering plant foods (fruits, vegetables, grains—mostly whole grains—nuts, legumes, beans, seeds, olives and olive oil, and herbs and spices) into a single group to visually emphasize the importance of healthy plant foods in this health-promoting eating pattern. Another important change was the inclusion of fish and shellfish into the pyramid, recognizing the benefits of eating fish and shellfish at least twice a