The Mediterranean Diet: An Evidence-Based Approach

By Victor R Preedy and Ronald Ross Watson

The Mediterranean Diet: An Evidence-Based Approach, Second Edition provides authoritative material on the many facets surrounding the complex interrelationships between diet, nutrition, health and well-being. The book discusses historical, cultural and scientific foundations, with chapters delving into nutritional adequacy, agricultural practices, food culture, mortality, quality of life, children and adolescents, behavior, cardiovascular diseases, diet quality, nutritional knowledge, nuts, minerals, olive oil, hydroxytyrosol, water, antioxidant nutritional status, ketogenics, adiposity, metabolic syndrome, type 2 diabetes, cardiovascular risk, nutrigenetics, epigenetics, the link between epigenetics and pregnancy, gene polymorphisms bone health, insulin signaling inflammatory gene expression, and more.

• Provides supportive evidence to embrace a holistic approach in understanding the Mediterranean diet, from the cell to the well-being of geographical populations
• Addresses concepts, overviews, components of the diet, and medical, health and nutritional aspects
• Contains coverage of emerging fields of diet science and important discoveries relating to diet and nutrition

• Language: English
• Publisher: Academic Press
• Release date: Jul 7, 2020
• ISBN: 9780128195789

Book preview

book.

Section A

The Mediterranean diet: Concepts and overviews

Chapter 1

The Mediterranean diet: History, concepts and elements

Jordi Salas-Salvadó; Christopher Papandreou    Human Nutrition Unit, Department of Biochemistry and Biotechnology, Pere i Virgili Research Institute, Rovira i Virgili University, Tarragona, Spain

Abstract

This chapter initially provides an historical overview of the Mediterranean diet followed by its definition based on foods consumption and nutrients intake. Characteristics of this diet such as freshness, variety, frugality, and palatability are described as well as whether people in Mediterranean countries are still following this dietary pattern. Information about the most recent Mediterranean diet pyramid is also provided suggesting the types and frequency of foods that should be enjoyed every day and how many servings of those foods should be consumed. Finally a brief paragraph about the health benefits of this diet is included.

Keywords

Mediterranean diet; Culinary; Nutrients; Plant foods; Diet pyramid

Chapter outline

Origins of the Mediterranean diet

Definition of the Mediterranean diet

Nutritional characteristics of the Mediterranean diet

The Mediterranean diet: Fresh, seasonal and local ingredients

Other characteristics of the Mediterranean diet (variety, frugality and palatability)

Are we abandoning the Mediterranean diet?

The Mediterranean diet pyramid

The Mediterranean diet: UNESCO intangible cultural heritage of humanity

The Mediterranean diet is good for health: Origins

References

Origins of the Mediterranean diet

The word Mediterranean, of Latin origin, means the sea in the middle of the earth, a description that evokes the image of a location enclosed between different lands and people that throughout history has been the axis on which Southern Europe has communicated with Northern Africa and part of Western Asia.

The rich and diverse cultures that grew in these lands were transmitted from place to place by seafarers. Phoenicians, Romans, and Greeks enabled diverse worlds to establish contact with each other. At the same time these worlds had certain common characteristics that stemmed from their geographical location and, of course, their climate. Two features that united these places were food and how it was prepared/cooked.

Despite the differences inherent to each region owing to their political, ethnic, or religious borders, the Mediterranean basin enjoyed a common dietary pattern. Cereals, fruits, vegetables, olive oil, and other products formed the core of the diet in all these regions.¹

Cereals are considered the most consumed food group accounting for an important part of the total calories consumed in Mediterranean civilizations. The first cultivation of wheat occurred about 10,000 years ago, as part of the Neolithic Revolution, which saw a transition from hunting and gathering of food to settled agriculture. These earliest cultivated forms were diploid (einkorn) and tetraploid (emmer) wheats, and their genetic relationships indicate that they originated from the southeastern part of Turkey.² Evidence discovered on the shores of Palestine shows that by the end of the Upper Paleolithic grinding materials were used to facilitate the ingestion of cereals, one of the axes of the Mediterranean diet.³ The growth in population and the proliferation of settlements increased agricultural activity and production in Mesopotamian and ancient Egypt civilizations, and there is also evidence of the consumption of lentils, peas, and other leguminous plants.

Innumerable representations on the walls of tombs, depicting every stage of the wheat production cycle, indicate that wheat was a staple product in Egyptian civilization.⁴ The majority of the Egyptian population lived mainly on several varieties of bread made from barley or wheat as well as heneket, an energy-providing beer brewed in every household from white barley to which figs, dates, lupins, honey, and miscellaneous other ingredients could be added.⁵ Cereals conform a basic component of the diet of the ancient Greeks, especially durum wheat and barley, both of which were used to prepare many types of bread and porridge and cakes.

Nuts, harvested by hominids since the dawn of humankind, are another fundamental element of the Mediterranean diet. The first evidence of the existence of almonds, for example, dates from Israel during the Pleistocene.⁶ The Acheulian site of Gesher Benot Ya‘aqov (Israel) has revealed a unique association of edible nuts with pitted hammers and anvils, which indicates a nut-cracking activity and supports the hypothesis that the pitted stones served as nut-cracking tools.⁶ Cultivated in the early Bronze Age, almonds have also been found at the tomb of Tutankhamun in Egyp.⁷ and the palace of Knossos in Crete.⁸ Another example is the pistachios Pistachio nuts that are mentioned in the Bible (Genesis 43:11) as precious gifts carried from Canaan to Egypt by the sons of Jacob. Pistachios were used as a source of energy in ancient Greece. Amphoras discovered in 2004 on the Greek Aegean Island of Chios reveal the presence of DNA from Pistacia vera and Pistacia lentiscus, suggesting that nuts were traded there around the fourth century BCE.9, 10

We also have evidence that wine was consumed at the time of the pharaohs.¹¹ Large earthenware jars from the earliest dynasties are known to have stored wine, and this beverage is mentioned in lists of offerings and religious texts. In Greek culture, gatherings centered around wine became something of a ritual. The word symposio, which we translate as banquet, actually means a meeting of drinkers..¹² At these events wine was mixed with water (since drinking it neat was considered barbarian), poems were recited, and conversations were held to the accompaniment of music and dance.

Samples of olive pollen extracted from archeological remains show that the cultivation of olive oil became intensive in the Peloponnese in the 20th century BC. Originating in Asia Minor, Crete, and Cyprus, the olive tree, along with its fruit and juice, was extended throughout the Mediterranean basin by the Phoenicians, Greeks, and Romans. One of the vegetable fats used by ancient Egyptians was olive oil, which was known by the name merehet.¹³ A tomb dating to the Old Kingdom shows every detail of the olive oil production process. On this tomb we see a group of five workers using a linen press to grind a vegetal product, drain the oil off into a container below the press, and pour it into pitchers. It was in ancient Greece, however, where olive oil was regularly used in food. Greek mythology illustrates the importance of the olive tree in the dispute between gods Athena and Poseidon over the sovereignty of Athens: Athena offers the olive tree to the city and becomes its protector.¹⁴ Its use was so common that it became a component of numerous dishes and ointments. Thanks to Dioscorides it was introduced into the field of medicine when he declared that it was good for the stomach.¹⁵

Vegetables and fruits are also very common consumed in the ancient Egypt by general population and pharaohs’ as some images have been found in tombs and were used as medicines in the papyrus Ebbers. The Greeks believed that a vegetarian diet was healthy, while meat was said to produce illness and obesity if consumed in excess. We also know that a wide range of plants, either cooked or used in salads, formed part of the Greek diet. Antiphanes, a playwright probably from Rhodes, called the Greeks phyllotrôges, or leaf eaters.¹⁶ Fruit and nuts, which were not differentiated so much as they are today, were eaten as dessert. Pears, peaches, figs, hazelnuts, pine nut, almonds, and pistachios are widely mentioned in much Greek culinary literature.

The main foods consumed in Imperial Rome were basically the same as those that form the diet of people in Mediterranean countries today (except foods that came from the New World), that is, cereals, legumes, fruits, and vegetables.¹⁷ Apples, of which there were 23 known varieties, were the most popular fruit. Dried figs were often eaten in place of bread. Almonds, hazelnuts, and pistachios were also part of the Roman diet.

Ancient cuneiform records noted spice and herb use in Mesopotamia. Thyme, sesame, cardamom, turmeric, saffron, poppy, garlic, cumin, anise, coriander, silphium, dill, and myrrh were cultivated in the fertile Tigris and Euphrates valleys. Spices and herbs have been used by ancient Greeks for both culinary and health purposes. Hippocrates used herbs for remedy purposes.¹⁸ A widespread practice in Roman cuisine was the use of spices and herbs. Most foods were seasoned with a multitude of herbs and spices, probably to disguise the sometime inadequate condition of the food. Many foods were imported into the big cities from a long way off and on arrival were stored in silos with few measures of preservation.

The sad, dreary diet of the European Middle Ages contrasts with the joyous range of flavors and foods that arrived from the Southern Mediterranean via the Muslim conquests. A multitude of ingredients arrived from the Orient, including aubergines, artichokes, and asparagus, and were added to the daily diet. However, we not only did learn to eat new products but also picked up new agricultural techniques that made harvests profitable.

Doctors and scholars of the Islamic world, such as Maimonides, Avenzoar, and Averroes, became interested in studying food and proposed foods as the basis for preventing disease.¹⁹ Each food was described and its preventive and medical properties related to health protection. These scholars introduced the idea that eating too much is harmful and causes illness and recommended dieting or fasting as a way of treating illness.²⁰

The first great globalization generated by the discovery of America led to the arrival of new foods, which were easily assimilated into Mediterranean culinary tradition. Potatoes, surely one of the most important foods for the future of humankind, arrived in Europe from the Americas. Though consumed to a lesser extent in the Mediterranean region, potatoes became an essential contributor of energy for many countries in Northern Europe. Essential vegetables for salads and sofritos, such as peppers and tomatoes, quickly took root in their new lands and become protagonists in our cuisine.

Today we value Mediterranean cuisine not only for the quality and variety of its products but also for how these products are cooked, for example, the sofrito (onions, tomato, and garlic slowly sautéed over a low heat), and how they are eaten—seated around a table presided over by the mamma, that is, the grandmother, matriarch, high priestess, and provider of a good we offer to the world and are obliged to save and preserve for the benefit of future generations.

Definition of the Mediterranean diet

The traditional Mediterranean diet may be defined as the diet that emerged in the 1950s and 1960s in certain regions of the Mediterranean basin, especially Crete (Greece) and Southern Italy. There was no unique model for the Mediterranean diet, like today, and clear differences existed in the food consumption patterns among different countries. However, olive oil was a commonly consumed food in most Mediterranean populations.

Scientists may disagree on some of the points we list below. However, most agree that the Mediterranean diet is characterized by the following:

(1)An abundance of plant foods, including

–unprocessed cereals, especially whole grains, which are consumed in various forms such as bread, pasta, couscous and rice;

–various fruits;

–all kinds of vegetables and their varieties served raw (in salads), boiled, or cooked;

–legumes such as chickpeas, lentils, and beans;

–nuts such as pistachios, hazelnuts, almonds, walnuts, and pine nuts, as well as seeds;

–herbs and spices used in the preparation of numerous recipes.

(2)Olive oil as the main source of fat, which is used for dressing, seasoning, or cooking most dishes, especially salads, vegetables and legumes.

(3)Moderate consumption of fish and seafood, eggs, and fermented dairy products such as yogurt, kefir, and sheep’s and goat’s cheese.

(4)Low consumption of red meat and a preference for poultry or rabbit.

(5)Low consumption of processed foods such as industrial bakery products, processed meats, sugary drinks, creams, and butters.

(6)Moderate consumption of red wine, taken particularly at mealtimes by adults in countries whose religion or customs do not prohibit it.

Following various meetings attended by scientists involved in the PREDIMED study, a 14-point questionnaire was drawn up to evaluate one’s degree of adherence to the Mediterranean diet.

In Table 1 you can verify your own degree of adherence to this dietary pattern. The researchers validated and used this questionnaire to encourage participants to increase their score and so their adherence to this dietary pattern.

Table 1

Nutritional characteristics of the Mediterranean diet

A definition of the Mediterranean diet in terms of its nutrients is as follows:

1.It is balanced, since it provides an optimal number of macronutrients (proteins [15%–20% of energy intake], carbohydrates [35%–40% of energy intake], and fats [35%–45% of energy intake]).

2.It is of normal protein content, with a higher proportion of proteins of vegetable origin compared with other western dietary patterns.

3.It has a high presence of complex carbohydrates and fiber from vegetables, so its glycemic load is low.

4.It has a high content of monounsaturated fats (≥   50% of total fat), especially from olive oil and nuts (oleic acid), and of polyunsaturated fats, especially from fish, seafood, and nuts (omega-3 fatty acids), all of which have widely recognized cardiovascular benefits.

5.It has a low content of unhealthy saturated fats and trans fats, mainly from animal products or resulting from food processing.

6.It has a moderate salt content, given the low amount of processed foods.

7.It has a high content of micronutrients (vitamins and minerals) and other antioxidant and inflammatory substances of vegetal origin (e.g., polyphenols), which have multiple cardioprotective properties or, via multiple processes, have preventive properties against chronic noncommunicable diseases such as cancer or neurodegenerative diseases.

The Mediterranean diet: Fresh, seasonal and local ingredients

It is highly likely that the Mediterranean climate has enabled the cultivation of a wide range of rapidly available foods. Except for animal products and certain vegetables that can be stored (such as wheat, other cereals, and legumes), the diet of Mediterranean populations has traditionally been characterized by the consumption of fresh, seasonal fruits such as cherries, strawberries, peaches, melons, and watermelons in late spring and early summer; figs, pomegranates, and grapes in late summer; and pears, oranges, and apples in winter.

Nuts are collected between August and November and consumed in their natural form in those and certain later months. Those that are not consumed can be stored or used for confectionery, where they are often mixed with honey or sugar to make piñatas, nougats, alfajores, panellets, marzipan, and numerous other sweets produced in the Mediterranean countries of Europe, the Middle East, and Africa.

As fruits, vegetables, and salads were difficult to preserve and so could not be distributed easily, their harvests had to be consumed among family and neighbors. In the 1960s no one could imagine that it would be possible to eat asparagus in autumn or cherries in December, as we do today. Now these foods can be obtained at times of year that were once unimaginable (being produced at great distances and even on other continents) because they are now transported and preserved in refrigerated containers. In fact the Mediterranean’s geographical conditions (diverse terrains near the sea or mountains, distinct seasons, little but torrential rain, and a scarce and poorly distributed supply of water) meant that its agriculture developed on small family-run plots that were adapted to microclimates and water access. Despite their small size, these plots grew a wide range of foods that varied according to the season. Since ancient times, therefore, the Mediterranean diet has been determined by these day-to-day conditions. In addition, given the year-round availability of fish and seafood along the coastal areas, Mediterranean peoples have always had access to a wide range of those products, so why preserve and store them? Moreover, because populations living a certain distance from the coast have also had easy access to fish in rivers and streams, fish has always contributed to the habitual diet of a significant proportion of the Mediterranean population.

This from farm to table concept has undoubtedly helped to promote consumer food safety since it means that foods are better preserved, microbiological and chemical contaminations are avoided, and, above all, the nutritional wealth of the products is preserved. Many scientific studies demonstrate that fresh, seasonal, and local foods usually contain more antioxidant vitamins and other minority substances of plant origin that are seen to possess multiple health properties that help to explain the importance of these foods for the prevention of numerous diseases.

Other characteristics of the Mediterranean diet (variety, frugality and palatability)

In addition to the preparation method, another essential characteristic of the traditional Mediterranean diet is the wide range of foods available. If we look carefully at traditional recipes of dishes prepared in Mediterranean countries, we find that each country’s cuisine possesses a huge variety of dishes and preparations and employs a large number of ingredients. For example, although stews, paellas, couscous, harissa, salads, and multiple other dishes may vary from one land or region to another, in most cases the recipes use the same ingredients and the same culinary base. One example of this is the sofrito, a slow-cooked sauce made of olive oil, tomato, garlic, onion, and often aromatic herbs that is prepared in the frying pan. The sofrito is used in numerous Mediterranean countries, including Portugal, Spain, France, Italy, and Greece and serves as the preparation for a multitude of dishes, such as rice, legumes, pasta, couscous, and fish or meat stews.

Frugality is another characteristic of the Mediterranean diet. In the 1960s the amount of food consumed was low in relation to the level of physical activity, which was high because most of the population was engaged in agricultural activity. Moreover, the use of foods especially of plant origin means that the Mediterranean diet is of low energy density. One exception is the high consumption of vegetable products that are rich in fat, such as olive oil and nuts. These foods, which are high in calories, have not been found to increase weight when consumed in accordance with the Mediterranean dietary pattern. Indeed, many epidemiological population studies have shown that the consumption of these foods is associated with a lower prevalence of obesity and a lower increase in weight over time.

Finally the Mediterranean diet is considered to be highly palatable, that is, to have certain organoleptic characteristics of taste, aroma, and texture that are difficult to obtain from other ingredients. It has been observed, for example, that diets that are low in fat and salt and that in recent years have been advocated by important scientific societies and health institutions around the world are much more difficult to maintain over time than a diet like the Mediterranean, which is rich in vegetable fat. This is easy to understand if we provide some simple examples: Who could eat salads without olive oil over a long period of time? Which is more appetizing, a sandwich with oil or one without? As we can see, the use of olive oil has always facilitated the consumption of vegetables, cereals, and legumes, all of which are typical of the Mediterranean diet.

Are we abandoning the Mediterranean diet?

Unfortunately, people in Mediterranean countries are gradually moving away from the traditional Mediterranean dietary pattern. At the same time, people in certain developed, non-Mediterranean countries have been encouraged by the high number of scientific studies that demonstrate the advantages of the Mediterranean diet for maintaining good health to incorporate typical Mediterranean foods such as olive oil, wine, and nuts into their own diets.

The food availability data collected each year by the Food and Agriculture Organization of the United Nations show that over the last 40 years the total consumption of energy has been gradually increased in both Northern and Eastern Europe.²¹ However, it is in Mediterranean countries in particular where this increase in caloric availability has occurred (the increase in total caloric intake is above 20%).²¹ In Mediterranean countries in the last 40 years, energy from fats has increased by 48.1%, while in the same period energy from carbohydrates has dropped by 20.5%. During this period, Mediterranean countries have experienced a reduction in available energy from foods typical of the Mediterranean diet, for example, cereals (−   29.9%) and wine (−   55.2%), and an increase in calories from foods that are not so typical, for example, milk (+   77.8%) and dairy desserts (+   23.6%).²¹

Numerous data are also available from epidemiological studies that evaluated the consumption of food and nutrients in Mediterranean populations during the 1950s, 1960s, and 1970s. These data, especially from regions or countries such as Greece, Malta, Italy, and Spain, confirm the rapid transition in just a few short years from the traditional Mediterranean food pattern toward a more western one. We should also point out that numerous studies have shown that the people in Mediterranean countries who have most preserved Mediterranean dietary traits are the elderly. Young adults and children make up the population that is most distancing itself from the traditional Mediterranean dietary pattern. This alerts us to the danger that in a few years this cultural and gastronomic asset may be lost and warns us of the possible consequences this development may have on our health, environment, and economy.

The greatest changes that have taken place in the last few decades can be summarized by an increased consumption of (a) foods of high energy density; (b) processed foods rich in salt and saturated fats, such as snacks, processed meats, and cold cuts; (c) cereal-based foods with a low glycemic index, such as breakfast cereals, potatoes, sugary drinks, and sweets; (d) dairy-based foods such as milk and cow’s cheese, butters, creams, dairy desserts, and ice cream; and (e) red meat and its derivatives. At the same time the diet of Mediterranean populations has undergone a reduction in the consumption of (a) fresh and seasonal foods (fruits, salads, vegetables, etc.), (b) barely processed foods, (c) whole grains, (d) legumes, and (e) wine. One example of changes in the diet of a Mediterranean population is the Cretan population of the Seven Countries Study. Increases in the intake of saturated fat and decreases in monounsaturated fat occurred in the aforementioned population over a 30-year period.²²

These changes are caused by the expansion of western culture as the model for an urban and technological society and by the rapid process of food globalization as a means for promoting cultural and culinary exchange under the influence of world regions that have previously been so distant.

One example is provided by legumes, which can now be consumed in their processed form (packaged and preserved in salt) or cooked (after soaking them for at least one night, as has occurred since time immemorial). Because of the daily rush, we now eat what we can find (in the bar or fridge, etc.), so it is easy to understand why students do not eat fresh vegetables. A few years ago, we used to plan what we would eat in the week ahead, for example, in Spain (e.g., every day, salad as an accompaniment and fruit as a dessert; Monday and Wednesday, legumes; Thursday, paella; and Sunday, chicken and maybe a homemade pastry for pudding as a special treat). Nowadays we devour whatever we can find in our path. Dairy products, cheese, and cold meats are always in our fridge because they tend to keep for at least a week. Lettuce and certain fruits, on the other hand, go off quickly, so they are available less and less. For the same reason, food vending machines rarely offer fruit or salads among their range of products.

Finally, some authors report that another determining factor in the progressive abandonment of the Mediterranean diet is the pricing market. Some people believe that a diet based on Mediterranean food products is more expensive. Although few studies have been conducted to determine whether the Mediterranean diet is beneficial from the financial point of view, most studies conclude the following: (a) Some key foods of the Mediterranean diet (e.g., virgin olive oil) are more expensive than similar foods consumed in non-Mediterranean countries (e.g., corn, soybean, or sunflower oil). (b) increased adherence to the Mediterranean diet may slightly increase the total cost of one’s diet in comparison with other, less healthy, dietary patterns. (c) However, increased adherence to the Mediterranean diet would benefit society from the cost-effectiveness perspective (if we analyze the direct and indirect costs and benefits associated with health and well-being).

The Mediterranean diet pyramid

Food pyramids are tools for educating people about nutrition. Some years ago the Oldways Preservation & Exchange Trust, a well-known American noncommercial organization, designed the first Mediterranean diet pyramid. This specified foods that, in the context of the dietary pattern of Mediterranean countries, were consumed on a daily basis (the base of the pyramid), those that were consumed on a weekly basis (in the middle of the pyramid), and those that were not so typical of the Mediterranean diet (at the top of the pyramid). Later, several organizations designed their own pyramid to graphically represent their recommendations for their target population and promote the concept of a healthy diet based on current knowledge.

The most recent and widely accepted Mediterranean diet pyramid is that promoted by the Mediterranean Diet Foundation, a Spanish nonprofit organization that aims to promote the Mediterranean dietary pattern (see Fig. 1). In 2010, in collaboration with numerous scientific organizations, this foundation agreed a new pyramid based not only on foods but also on other aspects of the lifestyle of people in Mediterranean countries. This pyramid shows which foods should be consumed daily, weekly, and occasionally depending on the individual and how many servings of those foods should be consumed.

Fig. 1 Mediterranean diet pyramid: a lifestyle for today. Guidelines for adult population.

It is a scientific update of the classic healthy eating pyramid adapted to the various nutritional and sociocultural contexts of the Mediterranean region. This graphic tool offers new strategies for achieving a balanced lifestyle—not just a healthy dietary pattern—in the context of the cultural and food globalization that defines modern times.

Taking into account a whole series of trends and issues that have arisen as a result of the abrupt sociocultural changes that have taken place around food and that affect people’s health, traditional social structures, and the natural environment, this pyramid makes numerous recommendations on diet, lifestyle, sociocultural aspects, the environment, and health. Understanding the Mediterranean Diet as a broad vision that goes beyond a simple traditional protocol, it depicts a series of graphically represented innovations such as the concept of main meals based on vegetables, frugality and moderation to prevent obesity, and cultural elements that are typical of the Mediterranean lifestyle, including conviviality, culinary activities, physical activity, and adequate rest, always as a complement to the recommended proportions and frequency of consumption.

With this project the Mediterranean Diet Foundation and the group of experts who collaborated to produce the updated Pyramid aim to take into account—in addition to the nutritional aspects that affect people’s health—all the cultural aspects that are required to achieve the Mediterranean Diet lifestyle, while also respecting the customs of the various Mediterranean countries (e.g., with regard to wine consumption).

The Mediterranean diet: UNESCO intangible cultural heritage of humanity

In 2013, United Nations Educational, Scientific, and Cultural Organization (UNESCO) agreed that the Mediterranean diet should be recognized as an Intangible Cultural Heritage of Humanity in Cyprus, Croatia, and Portugal, 3 years after it had been recognized in Spain, Greece, Italy, and Morocco.²³ This recognition has been made possible by the demonstration, transmitted from generation to generation mainly among families, that the Mediterranean diet provides populations in the Mediterranean basin with a sense of common belonging and represents both a distinctive feature of their identity and a common space conducive to exchange and dialogue.

The UNESCO declaration was made not only to raise awareness of the importance of healthy and sustainable food practices in other parts of the world but also to stimulate intercultural dialogue, bear witness to human creativity, and promote respect for cultural, environmental, and biological diversity.

This initiative is therefore an instrument for promoting the Mediterranean diet that aims to provide greater visibility to this intangible heritage in general by recognizing traditions and knowledge that reflect the cultural diversity of the communities that practice them without attributing any criterion of excellence or exclusivity.

According to UNESCO, measures intended to safeguard the Mediterranean diet should focus on activities aimed at raising awareness, transmission, documentation, revitalization, and adoption of legislative measures and place special emphasis on reinforcing cooperation mechanisms between interested communities and states.

The UNESCO declaration states:

The Mediterranean diet involves a set of skills, knowledge, rituals, symbols and traditions concerning crops, harvesting, fishing, animal husbandry, conservation, processing, cooking, and particularly the sharing and consumption of food. Eating together is the foundation of the cultural identity and continuity of communities throughout the Mediterranean basin. It is a moment of social exchange and communication, an affirmation and renewal of family, group or community identity. The Mediterranean diet emphasizes values of hospitality, neighbourliness, intercultural dialogue and creativity, and a way of life guided by respect for diversity. It plays a vital role in cultural spaces, festivals and celebrations, bringing together people of all ages, conditions and social classes. It includes the craftsmanship and production of traditional receptacles for the transport, preservation and consumption of food, including ceramic plates and glasses. Women play an important role in transmitting knowledge of the Mediterranean diet: they safeguard its techniques, respect seasonal rhythms and festive events, and transmit the values of the element to new generations. Markets also play a key role as spaces for cultivating and transmitting the Mediterranean diet during the daily practice of exchange, agreement and mutual respect.

This declaration clearly shows that the Mediterranean diet is much more than a healthy dietary pattern.

The Mediterranean diet is good for health: Origins

In the 1960s Dr. Ancel Keys and colleagues assessed the diets of 13,000 middle-aged men aged 40–59 living in Southern Italy, Greece (Crete and Corfu), Yugoslavia, Finland, Netherlands, Japan, and the United States and observed that the cohort of Crete had the lowest coronary heart disease (CHD) prevalence and incidence.²⁴ Among the reasons proposed for this finding was the consumption of a diet that was low in saturated fat and high in monounsaturated fat. Since then, there is a substantial body of evidence to support the efficacy of the Mediterranean diet in chronic disease prevention and management. A previous meta-analysis pooling data from prospective studies and randomized control trials found that a Mediterranean dietary pattern is associated with lower risks of cardiovascular disease incidence and mortality, including CHD and myocardial infarction.²⁵ Beneficial effects of the Mediterranean diet have also been demonstrated for a broad range of associated conditions, including metabolic syndrome, type 2 diabetes, cognitive function decline, depression and anxiety, autoimmune diseases, cancer, nonalcoholic fatty liver disease and obstructive sleep apnea.26–29 Some of the proposed benefits of the Mediterranean diet pertain to the dietary pattern as a whole. This encompasses the variety of foods included and the combination, preparation, and consumption of these foods that contribute to the synergistic effect of the food matrix.³⁰

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19 Huetos Solano M.D., Salas Salvadó J. Alimentación, dietética y nutrición en al-Andalus. In: Salas Salvadó J., García Lorda P., Sánchez Ripollés J.M., eds. La alimentación y la nutrición a través de la historia. Barcelona: Editorial Glosa; 2005:217–246.

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21 Balanza R., García-Lorda P., Pérez-Rodrigo C., Aranceta J., Bonet M.B., Salas-Salvadó J. Trends in food availability determined by the Food and Agriculture Organization’s food balance sheets in Mediterranean Europe in comparison with other European areas. Public Health Nutr. 2007;10(2):168–176.

22 Kafatos A., Diacatou A., Voukiklaris G., et al. Heart disease risk-factor status and dietary changes in the Cretan population over the past 30 y: the seven countries study. Am J Clin Nutr. 1997;65(6):1882–1886.

23 UNESCO, n.d. Mediterranean diet—intangible heritage—Culture Sector—UNESCO. Available from: https://ich.unesco.org/en/RL/mediterranean-diet-00884.

24 Keys A. Coronary heart disease in seven countries. Circulation. 1970;41(Suppl 1):1–211.

25 Grosso G., Marventano S., Yang J., et al. A comprehensive meta-analysis on evidence of Mediterranean diet and cardiovascular disease: are individual components equal?. Crit Rev Food Sci Nutr. 2017;57(15):3218–3232.

26 Sofi F., Abbate R., Gensini G.F., Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr. 2010;92(5):1189–1196.

27 Schwingshackl L., Schwedhelm C., Galbete C., Hoffmann G. Adherence to Mediterranean diet and risk of Cancer: an updated systematic review and meta-analysis. Nutrients. 2017;9(10).

28 Ryan M.C., Itsiopoulos C., Thodis T., et al. The Mediterranean diet improves hepatic steatosis and insulin sensitivity in individuals with non-alcoholic fatty liver disease. J Hepatol. 2013;59(1):138–143.

29 Papandreou C., Schiza S.E., Bouloukaki I., et al. Effect of Mediterranean diet versus prudent diet combined with physical activity on OSAS: a randomised trial. Eur Respir J. 2012;39(6):1398–1404.

30 Widmer R.J., Flammer A.J., Lerman L.O., Lerman A. The Mediterranean diet, its components, and cardiovascular disease. Am J Med. 2015;128(3):229–238.

Chapter 2

Mediterranean diet: A long journey toward intangible cultural heritage and sustainability

Lluís Serra-Majema,b,c,d; F. Xavier Medinae    a Research Institute of Biomedical and Health Sciences, University of Las Palmas de Gran Canaria (ULPGC), Las Palmas de Gran Canaria, Spain

b Preventive Medicine Service, Centro Hospitalario Universitario Insular Materno Infantil (CHUIMI), Canarian Health Service, Las Palmas de Gran Canaria, Spain

c Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition (CIBEROBN), Carlos III Health Institute, Madrid, Spain

d International Foundation of Mediterranean Diet (IFMED), Barcelona, Spain

e Department of Food and Nutrition, Faculty of Health Sciences, and UNESCO Chair on Food, Culture and Development, Universitat Oberta de Catalunya (UOC), Barcelona, Spain

Abstract

The United Nations Educational, Scientific and Cultural Organization (UNESCO) recognized in 2010 the Mediterranean diet (MD) as intangible cultural heritage of humanity. A few years later, in 2013, this recognition was extended to three new countries: Croatia, Cyprus, and Portugal. This recognition as world heritage, with the consequent increased visibility and acceptance of the Mediterranean diet around the world, was the result of a process internationally coordinated from Spain by the Mediterranean Diet Foundation which made this food pattern experience an unprecedented historical moment, including a better knowledge of the Mediterranean diet worldwide. This knowledge should also be translated into an increase in sustainability, reducing the environmental impact by production and transportation of food resources in all the Mediterranean area. To this end the Mediterranean diet should be seen as a healthy and environmentally sustainable food model and a cultural heritage that confers identity and belonging through the different Mediterranean cuisines. It is a cultural heritage that must be preserved and promoted from different areas of the cultural, health, agricultural, political and economic agenda.

Keywords

Mediterranean diet; United Nations Educational, Scientific and Cultural Organization (UNESCO); Culture; Heritage; Sustainability

Chapter outline

Introduction

Mediterranean diet: An intangible cultural heritage

Mediterranean diet and health

Mediterranean diet and sustainable environment

Mediterranean diet 4.0: Pursuing a sustainable model for the Mediterranean area

The new Mediterranean diet pyramid

Cultural and lifestyle aspects

Moderation

Conviviality

Culinary activities

Physical activity

Final considerations

Summary points

References

Further reading

Abbreviations

CH4 

methane

CIHEAM 

International Centre for Advanced Mediterranean Agronomic Studies

CIISCAM 

Interuniversity Research Centre for Mediterranean Food Cultures

CO2 

carbon dioxide

CVD 

cardiovascular diseases

FDM 

Mediterranean Diet Foundation

GHG 

greenhouse gases

LCA 

life cycle assessment

MD 

Mediterranean diet

MDP 

Mediterranean dietary pattern

N2O nitrous oxide

PREDIMED 

Mediterranean diet in the primary prevention of CVD

SCP 

Spanish current dietary pattern

SCPCS 

SCP estimated from the Household Consumption Surveys

SCPFB 

SCP estimated from food balance sheets

UNESCO 

United Nations Educational, Scientific and Cultural Organization

WDP 

Western dietary pattern

Introduction¹

The Mediterranean diet as a culinary system is a cultural, historical, social, territorial, and environmental heritage transmitted (and in constant evolution) from generation to generation for centuries, and it takes part, as a Mediterranean Food System,² in the lifestyles of the Mediterranean people throughout their history.³ A plural and complex legacy passed and evolved in a temporal and spatial constant flow, a living heritage, unique and outstanding cultural spaces, uses promoting respect for cultural diversity and human creativity, expression of sociability and communication between their villages and individuals, a way to reinforce individuals identities in their places of origin, an integrative element of communities with the nature and the history, a local defense mechanism of the agriculture and sustainable rural development, and the landscape and environment of the Mediterranean area.⁴, ⁵

Mediterranean diet: An intangible cultural heritage

Since last November 16, 2010, the Mediterranean diet was inscribed on the UNESCO’s Representative List of Intangible Cultural Heritage of Humanity⁶ (in 2013, this inscription was enlarged with the inclusion of three additional countries: Croatia, Cyprus, and Portugal). The objective of this initiative was to safeguard the immense legacy representing the cultural value of the Mediterranean diet and to share its values and benefits internationally.⁷

The culmination of this institutional process was fruit of the seed that had been sown in civil society, in 2004—1 year after the approval of the convention and 2 years before it came into force—in the Mediterranean Diet Foundation (FDM in its Spanish abbreviation), which hosted the first formal proposal to present this nomination upon an original idea from L. Serra-Majem, the President of the FDM from April 1996 to November 2012. The proposal was decided after an arduous negotiation by the different stakeholders and persons involved in the decision process, who were very skeptical at the beginning of the process. At that time the former Spanish Ministry of Agriculture, Fisheries and Food, patron of the FDM, played a fundamental role and was a vital link between civil initiatives and the institutions. The Ministry took on a firm commitment with this initiative as did the Ministry of Italy, which showed the same support favoring the transnational profile of the nomination right from the beginning. The implication of Greece first, and Morocco a short time later, would firmly seal this joint endeavor. The presence and commitment of the Ministries of Culture confirmed another noteworthy aspect of this nomination: institutional transversality.³, ⁸

This process was conceived and had been germinating in civil society from the outset and had the privilege of counting on the involvement of national, regional, and local institutions and received the support of the scientific community. Both angles were fundamental, and synchrony between all was decisive. It continued to receive the support and commitment of all the sectors that for many years had worked in favor of the Mediterranean heritage.⁸, ⁹ Besides, after publicly expressing the wish to present the Mediterranean diet nomination, there was a genuine explosion of support from institutions and all types of associations, thus consolidating the transversal nature of the project. This elation came to demonstrate that a close bond and genuine identification persisted between the Mediterranean societies and governments and their cultural and food heritage.², ¹⁰

The first event in which the proposal of the nomination was publicly presented took place on October 1, 2005, during the Year of the Mediterranean. The solemn setting of the University of La Sapienza in Rome provided an ideal context for the third Euro-Mediterranean Forum on the Dialogue through the civilization and peoples of the Mediterranean: food cultures, counting on the extensive participation of international scientists. It was there that the conference and the proposal of the nomination of the Mediterranean Diet were delivered by Serra-Majem after convincing initially skeptical colleagues from other countries.¹¹ The proposal of the nomination received the unanimous support of the third forum that included it in its final Declaration, The 2005 Rome Call: To take into account that the Mediterranean Diet besides its health implications also has cultural and economic implications, therefore all Mediterranean countries need to agree and contribute to the process of preservation and promotion. To start the process of the recognition of the Mediterranean Diet Food Cultural Heritage behind the UNESCO, as an initial and shared common position to be coordinated from the Barcelona counterpart as an extension of the 1995 Barcelona Declaration, in collaboration with all the Mediterranean country representatives.¹¹

The following year, in Barcelona in March 2006, during the sixth International Congress on the Mediterranean Diet, the international scientific community, continuing on from the Rome Call, renewed their unanimous support for the presentation of the nomination and the formalization and immediate commencement of the process and made an appeal to all the Mediterranean institutions and organizations to follow suit and support the initiative.⁸

In October 2007, on World Food Day, the FDM International Scientific Committee met in Barcelona and approved the Declaration of Barcelona on the Mediterranean Diet as intangible cultural heritage.³ That same year, in December, the former Spanish Ministry of Agriculture, Fisheries and Food held the first trans-Mediterranean institutional meeting in Madrid, in which Spain, Greece, Italy, and Morocco agreed upon the preparation of the nomination based on a strategic document prepared by the FDM and created their respective national teams. The following spring, in April 2008, at the Italian Ministry of Agricultural, Food and Forestry Policies in Rome, the four states formalized the process through the Declaration of Rome and designated the FDM as the technical transnational coordinator of the nomination.⁸, ⁹ Taking into account that the statement by UNESCO was a culturally based statement, the writing of the candidacy was entrusted in 2008 to two food anthropologists¹² who had worked critically on the Mediterranean diet for years: Isabel González Turmo and F. Xavier Medina. After this decision the candidacy was focused on the cultural aspects as the main axis.

The transversality of the Mediterranean diet and its environmental, economic, social, and cultural transcendence confer the inscription a unique dimension. The derived duty to safeguard goes beyond the strict framework, whether institutional or otherwise, of culture and demands the same transversality in its management.⁶, ¹⁰

Indeed the element inscribed is the Mediterranean diet that constitutes a set of skills, knowledge, practices, and traditions ranging from the landscape to the table, including crops, harvesting, fishing, conservation, processing, preparation, and, particularly, consumption of food […].⁶ This unique lifestyle determined by the Mediterranean climate and space is also shown through the associated festivities and celebrations.³ Besides, through their social and cultural functions and their significance, it embodies landscapes, natural resources, and associated occupations as well as the fields of health, welfare, creativity, intercultural dialogue, and at the same time values such as hospitality or conviviality, sustainability, or biodiversity.¹³ All of this composes the transversal cultural complex that, understood as a complete lifestyle, we call the Mediterranean diet.

It is important to remark that it is the whole concept of the Mediterranean diet that has been inscribed, not each of its components, whether tangible or intangible. Neither the olive oil nor the moussem of cherries, the market of Mistras, or the Capponata in and of themselves. However, they are all individual examples of substantial components of the inscribed element. That is, a necessary constitutive part of the Mediterranean diet takes part of this element recognized as intangible cultural heritage of humanity, but none of them nor any other in the framework of this nomination and inscription bears this recognition at an individual level.⁶

The inscription of the Mediterranean diet has put numerous and important questions on the table. We cannot pretend to have solutions, responses, or strategies readily available for all nor address them exhaustively. What is important is to confer on them the importance they deserve and work without delay to achieve them.⁸

The first question that arises is that of the geographical limits of the Mediterranean area, which we could call the continent of our heritage. Another thing is that, in practical terms or regarding the application of certain norms or regulations, certain limits can be agreed upon, supported by the combination of various scientific and technical parameters.

Another question of utmost importance refers to the content of the Mediterranean diet, namely, its tangible and intangible components. This is the inventory that is both an indispensable process and tool that is constantly being updated. This is a complex activity that does not start from zero as many sources are available today. It is demanding, because the management of the tangible (utensils, artifacts, etc.), the intangible (festivities, knowledge, skills, etc.), and the landscapes and spaces will be a constant concern. The task proposed is undoubtedly complex and should be addressed without delay through the pooling of concepts, selection criteria, processes, methodologies, and inventories, with corresponding records and supports, to reach a consensus about all these items and more, that should allow us to become deeply acquainted with and define the content, so as to be able to value and decide what and how it is to be protected. A permanent surveillance system appears to be an indispensable associated tool in the medium term, because this is live heritage, whose evolution should be observed and analyzed carefully, without interruption, and, just as important if not more, be appropriately accompanied by the coherence, consensus, and respect that this implies. It includes both the bearers and the spatial-temporal contexts or the tangible supports of the intangible manifestations of this heritage.¹⁴–¹⁹ However, there is at the present moment a deficit, especially in the government and public policies level, to act practically in relation to safeguarding the Mediterranean diet. Dedicated efforts of this nature are still urgent.²⁰

Responses will evidently be necessary concerning landscapes, techniques, elaborations, products, festivities, etc. The question is not simple. However, the difficulty and exigency of any project are always accompanied by the vector of progression and improvement.⁸ The key for a respectful and sustainable future of the Mediterranean diet will be in the capacity and commitment to invest resources, intelligence, and perseverance in sufficient quantities which are applied efficiently. The convention points out the importance of intangible cultural heritage as a guarantee of sustainable development. This criterion of sustainability is not exclusive of or inseparable from products, resources, spaces, or uses. We should also apply it to processes, decisions, and attitudes. Along these lines the questions that we have just put forward will find appropriate and sustainable responses.²¹

The recognition of the Mediterranean diet as intangible cultural heritage of humanity by the UNESCO was never a finalistic objective; it is not the completion of any goal, but the necessary impulse for a worthwhile outcome in the future, a future that will undoubtedly require a great deal of clarity, composure, and perseverance. The nomination process was perfectly delimited and with clearly marked stages. The future that begins on the day of the inscription is a succession of wide horizons in an unlimited time frame. The distance is enormous and commands a great deal of respect.

The Mediterranean is an area of great complexity, due to both endogenous and exogenous vectors, and the Mediterranean diet is a cultural complex of capital importance that holds in its transversality and multifaceted nature some of the most defining and probably unique features. Throughout the whole process of the proposal, we have always defended this complexity as an important value, a great capital, and fruit of a history reaching back thousands of years; of processes of civilization, trade, and exchanges; of apprenticeships and transmissions; of tradition and innovations; and of convergences and collisions which are perhaps unique. This complexity is one of the great strengths and potentialities of the Mediterranean diet as a vector of regional development and at the same time is one of its factors of survival and perpetuity. It is also, however, an Achilles heel, discreet but vulnerable. The challenge of safeguarding the Mediterranean diet is enormous, but beyond foreseeable difficulties or the complexity of the objectives, the sum of efforts and commitments both encourages and strengthens.⁷, ¹³, ¹⁹, ²⁰

In 2013 the inscription of the Mediterranean diet as intangible cultural heritage by UNESCO added three additional countries: Croatia, Cyprus, and Portugal, starting a process of enlargement that is still open to other Mediterranean countries in the future.²²

Mediterranean diet and health

Public health also represents a major element in the sustainability appraisal of the Mediterranean diet. The Mediterranean diet besides its benefits (CVD, diabetes, and cancer) has other numerous health advantages that are currently fields of research such as obesity²³—with a relevant social component²⁴—and cardioabesity,²⁵ immunity, allergic diseases, the psyche, or even quality of life.²⁶–³⁰ The Mediterranean diet has an international projection and is stated as one of the healthiest and the most sustainable eating patterns in the planet. It is a key player in the public health nutrition field globally but specially so in the Mediterranean area.²⁰, ²⁹, ³¹

Relevant prospective epidemiological studies and some clinical or community trials, such as the PREDIMED study,²⁸ in the last decades have been exponentially increasing the level and the quality of the evidence around the Mediterranean diet. From the first systematic review of the evidence from the Mediterranean diet interventions conducted a few years ago, the Mediterranean diet showed favorable effects on lipoprotein levels, endothelium vasodilatation, insulin resistance, metabolic syndrome, antioxidant capacity, myocardial and cardiovascular mortality, and cancer incidence in obese patients and in those with previous myocardial infarctions.²⁶

From the second published systematic review, a meta-analysis by Sofi et al. in 2008,²⁸ revisited in 2010 and 2013,²⁷, ³² the evidence on the relationship between Mediterranean diet and health status. Some interesting figures have been reported: a two-point increase in the Mediterranean diet adherence score was significantly associated with a 9% reduction in overall mortality, 10% reduction in cardiovascular disease mortality, 6% reduction in neoplasm incidence or mortality, and a 13% reduction in the incidence of Parkinson’s disease and Alzheimer’s disease in the general population.

Furthermore, PREDIMED trial³³ results pointed out that the Mediterranean diet, especially rich in virgin olive oil, is associated with higher levels of plasma antioxidant capacity. The plasma total antioxidant capacity is related to a reduction in body weight after 3 years of intervention in a high cardiovascular risk population with a Mediterranean-style diet rich in virgin olive oil. As well, further PREDIMED results suggest there is no rationale to maintain the fear that Mediterranean food items rich in fats of vegetable origin (olive oil or tree nuts) may cause weight gain or be responsible for an increased risk of obesity, provided that the energy intake does not exceed energy expenditure.³⁴

In the elderly population the reviewed evidence is promising as well. In fact in the PREDIMED study the Mediterranean diet was associated to a lower incidence of type II diabetes, both in the nut and the oil virgin olive oil groups.³⁴ And recently, its uses in the primary prevention of CVD have finally been demonstrated.²⁸

The Mediterranean diet is the heritage of millennia of exchanges in the Mediterranean basin region that has defined and characterized the eating habits of the countries in those regions. But currently, it is progressively being rapidly transformed⁵ due to many factors of the Western-type economy and urban and technological society and the globalization of production and consumption. This food culture is now facing three serious threats: (1) fast food culture based on meat, refined grains, potatoes, ice cream, candies, and beverages high in sugar; (2) the economic crisis affecting in particular the most disadvantaged groups and affecting key food groups of the Mediterranean diet such as fruits, vegetables, virgin olive oil, nuts, and fish, reducing their consumption, or inversely, increasing consumption of refined grains, potatoes and/or sugars; and (3) the promotion of high-protein diets, also prescribed by doctors and specialists, as a tool for weight loss or maintenance, with a major impact on health.³⁵

The erosion that these threats can cause, especially economic, must be countered with actions based on nutrition education, with the commitment that neither cost nor unfounded food choices cannot and should not be a barrier to the availability of basic foods comprising the Mediterranean diet: olive oil, fruits, vegetables, grains, dairy, nuts, or fish. Governments thus need to make commitments to take appropriate actions that preserve this traditional and cultural knowledge and lead to the diversity of foods and diets, and not only for the health benefits that could be obtained in the short and long term.

Mediterranean diet and sustainable environment

Food systems’ environmental consequences are on the public health agendas.³⁶ Foods are produced, processed, distributed and consumed, and all these factors have consequences both on human health and on the environment.¹³, ²¹, ³⁶ In fact, food production is inevitably also a driver of environmental pressures, particularly in relation to climate change, water use, and toxic emissions.³⁷ For example, regarding the emissions of greenhouse gases (GHG), such as CO2, CH4, and N2O, which are responsible for global warming, agriculture is one of the main contributors for the previously mentioned latter two gases and other parts of the food system that contributes carbon dioxide emissions from the use of fossil fuels in processing, transportation, retailing, storage, and preparation. Food items differ substantially in their environmental footprint, which among many other descriptors can be measured as energy consumption, agriculture land use, water consumption, or GHG emissions.³⁸ Animal-based foods are by far more land and energy intensive compared with foods of vegetable origin.³⁹ Thus dietary patterns can vary substantially in resource consumption and their impact on the environment and on the health of a given population.³⁸

Regarding the environmental contribution of the different food groups, most of the literature, even though from different settings and types of analysis, converges generally in the global statements. Plant-based foods were the least contributors to the selected environment footprints. Although, as expected, in the Mediterranean dietary pattern (MDP) where meat and dairy presented a lower weight, in terms of water consumption and to a lesser extent energy consumption, vegetables had a much higher contribution compared with the other patterns.⁴⁰ Plant foods based on vegetables, cereals, and legumes stood out with the lowest GHG emissions even if processing and substantial transportation were involved.²⁰, ³⁸ In a recent study, legumes were included in the vegetable group since they have similarly low environmental impact values as indicated in other studies and since LCA data on its own weren’t available. In fact, legumes are stated as alternatives to animal protein foods due to their low environmental impact and long durability.³⁸ However, some foods of vegetable origin contribute substantially, together with dairy in the case of the MDP and SCP, to either water consumption (vegetable oils especially and to some extent nuts) or land use (cereals and vegetable oils) in their production. Both in the SCP and in the WDP, vegetable oils also contributed importantly to water consumption and energy consumption footprints. Animal-based foods were found to be causing the highest environmental cost in all dietary patterns. As in some studies, in the Spanish context, meat and dairy were the foods that most contributed to environmental footprints,⁴¹, ⁴² although with a lower absolute contribution than the WDP. Regarding GHG emissions and land use, undoubtedly meat resulted as the food item that had the greatest impact, with a large difference as compared to other foods, both in the WDP and SCP. It was observed that a reduction in meat consumption decreased GHG emissions⁴³ and land use and subsequently increased the availability of land for other uses.⁴³ Even though there is high production variability,³⁸ 80% of global agricultural land use is related to livestock production and is cited as accounting for more than half of the GHG emissions from agriculture.⁴⁴ Meanwhile, dairy as one of the main sources of animal protein in the MDP was the top contributor in terms of energy consumption for the three dietary patterns and showed a similar weight as vegetable oils concerning water consumption in the WDP. In the MDP, dairy products were the food group that presented the highest footprint in all four analyzed footprints as meat in the MDP has a lower weight in frequency and amount. Regarding GHG emissions, fish also had a notable environmental contribution in all the dietary patterns.³³

The most relevant dietary distinctions in terms of environmental cost are between animal-based and plant-based diets but the various ways foods are grown, processed, and transported are also contributing factors. The largest environmental impact of food production from the farm level to consumers is in general associated with the primary production of agricultural products. In terms of energy consumption, differences are substantial in greenhouse production versus open-air cultivation of a certain crop as well as in canned or frozen produce versus fresh produce.⁴⁵, ⁴⁶ Besides the energy involved in agricultural production, the amount of energy used