How was the Mediterranean Diet developed?
The Mediterranean Diet came about in the 1950s when Dr. Ancel Keys and his colleagues looked at health of residents of Crete (1). Later they compared the health of Americans to those in countries like Italy and Greece. They noticed people in these Mediterranean countries had fewer heart attacks and strokes, had less obesity, fewer cases of Type 2 diabetes and less early death. They also noticed that their diets were very different from Western diets. The traditional diet in Mediterranean countries is highly plant based. It includes fruits, vegetables, whole grains, fish, legumes, nuts and seeds. These populations also use lots of extra virgin olive oil and red wine. They occasionally eat poultry, dairy and eggs, and rarely eat red meat. This traditional diet is what the Mediterranean diet is based on.
What is the Mediterranean Diet?
The Mediterranean Diet isn’t really a diet, but a lifestyle. It is not restrictive in the sense that calories are unimportant. The quality and type of food you eat is what matters most. It’s about increasing the amount of healthy food you eat while limiting the foods that are less healthy. It is a way of eating that decreases inflammatory foods while increasing foods that are nutritious.
What is inflammation?
Inflammation is your body’s natural response to injury. It is your body’s way of healing itself from damage. Inflammation comes from reactions in your immune system. Inflammation can be helpful for short periods; if you have an infection or break a bone, for example. Your immune system recognizes the damaged cells and this creates a set of reactions called the inflammatory cascade. Inflammatory messengers called cytokines are released from the injured cells and call out to the immune system. The immune system sends white blood cells to remove damaged tissue. Your immune system also sends cells that help heal the damaged tissue and return you to normal function. This is an acute inflammatory response and usually resolves quickly.
Chronic inflammation can occur over several months or years in response to long-term or repeated damage to cells. The inflammatory cascade takes place as long as the signal from dysfunctional cells is present. This long-term reaction has been linked to heart disease, cancer, autoimmune diseases, joint pain, fatigue and mental health concerns. The anti-inflammatory nature of the Mediterranean Diet is thought to explain its health benefits.
The Mediterranean Diet is usually explained using this pyramid:
The Mediterranean diet is low in red meats with limited intake of white meats and dairy products. These foods are thought to cause more inflammation in the body because they are higher in saturated fats.
What is meat and what does it do for us?
In most Western diets, meat comes from the muscles of mammals and birds. They are typically from domesticated animals raised on farms due to agricultural advances. Based on the animal it comes from and how it is prepared, there are different categories of meat:
Red meat includes beef (from cows), pork (from pigs), lamb, veal (from calves), goat, bison, elk and venison (from deer). Red meat gets its colour because the muscle fibres of these animals contains high levels of the protein myoglobin. Myoglobin carries oxygen within the muscle tissues and is high in iron which gives it its red colour.
White Meat includes chicken, turkey, duck, goose, quail and pheasant. This meat is lighter in colour than red meat.
Processed meat includes hot dogs, sausage, bacon, cold cuts and jerky. These products have been salted, cured, smoked, dried or otherwise processed. This enhances their flavour but also changes their health profile.
Meat contains many nutrients that are important for health. Meat is a source of phosphorus, zinc, selenium, vitamin A, iron, choline, B vitamins (including B12) and many others. Meat is also an excellent source of protein which is essential for many aspects of health.
Why is protein important?
Meat is approximately 25-30% protein after cooking. Protein is required to build all the cells in your body, specifically structural tissues like hair, skin, nails, bones, muscles, cartilage and blood. Your body requires protein to build and repair these and other tissues. It is also required to make enzymes, hormones and neurotransmitters.
Amino acids are the building blocks of protein and there are 20 amino acid in total. We need all 20 to manufacture proteins. Our bodies are able to make 11 of them from various molecules already found in the body. These are called non-essential amino acids. Essential amino acids are those that body cannot make on its own. We need to ingest these from food in order to make proteins. Animal proteins are complete proteins which means they contain all 9 essential amino acids. We can also get protein from plants, but these are typically incomplete proteins. This means they don’t contain all the essential amino acids we need to build protein. This is why people who don’t eat animal products need to pair certain foods together to ensure they are getting the right balance of amino acids.
If meat has all these good things in it, what makes it unhealthy?
Meat may have lots of good qualities and necessary components for health but that’s only part of the story.
Red meat has been linked to several types of cancer such as esophageal (2), stomach (2), prostate (3), kidney (4), breast (5, 6) and colon (7) cancers. Cooking and preparation methods may contribute to this negative impact.
Since meat comes from animal muscles, there is fat in them. When meats are grilled, barbequed or smoked at high temperatures, this fat is released onto the hot cooking surface. This produces polycyclic aromatic hydrocarbons (PAHs) which can seep into the meat. PAHs are toxic and are carcinogenic, or cancer-causing (8, 9, 10). Reducing meat’s smoke exposure and wiping away fat drippings can help reduce PAH formation by almost 90% (10). When meat is heated to high temperatures and forms a dark crust, heterocyclic aromatic amines (HAAs) are produced. This dark crust is what we know as charring or grill lines and improves the flavour profile of meats. Longer cooking and cooling times increase HAA content (11). Cooking meat for shorter periods, not letting it rest as long and not letting it get crispy or charred may decrease toxicity. Nitrates and nitrites are found in processed meats and may have negative health effects. They have been linked to cancer, specifically stomach cancer, but this relationship is not completely clear (12).
The relationship between cooking meat at high temperatures and cancer risk seems to be stronger for red and processed meats than white meat (13, 14, 15). Heme iron is also naturally higher in red meat compared to white meat and may contribute to certain types of cancers (16) as well.
The Mediterranean Diet limits sugar
The Mediterranean Diet is also low in sugar which is known to cause inflammation, weight gain and diabetes. It discourages the intake of processed foods that are full of chemicals, preservatives, sugars, salts and modified ingredients.
The Mediterranean Diet encourages lots of nutritious food!
It focuses on fruits, vegetables, fish, whole grains and plant-based proteins, which are full of vitamins, minerals, antioxidants, water and fibre. These components are important for preventing disease and improving health.
What are antioxidants?
Antioxidants are a built-in protection mechanism for our cells. They protect our cells from damage caused by free radicals. Free radicals are unstable molecules that are naturally formed by many metabolic processes in the body. They also come from things that put stress on the body:
· Environmental pollutants and toxins
· Cigarette smoke
· High blood sugar levels
· Radiation (UV light, nuclear exposure, etc)
· Intense and prolonged periods of exercise
Antioxidants neutralize these molecules to prevent them from damaging cells they come in contact with. Excessive free radical damage has been linked to chronic conditions including cardiovascular disease, certain types of cancer and premature aging. Antioxidants are necessary to keep our cells healthy and prevent this type of damage.
Where do we find antioxidants?
Antioxidants are found in many foods we consume. They are particularly high in fruits and vegetables. Plant-based diets are thought to be effective in preventing disease in part because of their antioxidant content (17). Berries, nuts, dark chocolate, green tea, coffee, fruits and vegetables have high antioxidant content (18, 19,). Consuming these foods regularly provides your body with lots of free radical protection. The Mediterranean Diet encourages the intake of many antioxidant-rich foods which may be why it promotes long-term health.
What is fibre and why should we eat more of it?
Fibre is the indigestible part of carbohydrates. It is found in many foods including fruits, vegetables, whole grains and legumes. There are two types of fibre:
· Insoluble fibre does not dissolve in water. It provides bulk to the stool.
· Soluble fibre dissolves in water and helps feed the good bacteria, or probiotics, that live in your digestive system. These bacteria have the enzymes required to break down fibre, but humans don’t. Fibre feeds these bacteria and is called a prebiotic. Probiotic bacteria are important for colon health, weight management, blood sugar control, immune function and brain function (20, 21, 22, 23, 24, 25).
Fibre also slows digestion because it takes longer to break down than other foods. This may make you feel fuller longer after eating and be helpful for weight loss (26). Fibre-rich foods also tend to cause a smaller increase in blood sugar after eating. This may be helpful for preventing or treating diabetes (27). Certain types of fibre have also been shown to bind cholesterol for elimination and reduce these levels in the blood (28, 29). This may contribute to reduced risk of heart disease (30).
The Mediterranean Diet is naturally high in fibre because of the foods it encourages. Many foods that are highly processed lose their fibre content. Fruits, vegetables, nuts, seeds, legumes and whole grains are plentiful in the Mediterranean Diet.
Physical Activity and Communal Eating
We know that diet and exercise work together but they are usually recommended separately. The Mediterranean diet promotes regular physical activity which is important for preventing heart disease, encouraging weight loss and regulating blood sugar.
Eating with others helps bring a sense of community to the food we eat. This keeps us accountable and consistent with our dietary habits and makes it more likely they will continue long term. Communal eating, or sharing a meal with others, is related to lower levels of stress and greater positive emotions. In children and teens, eating dinner together as a family may improve self-esteem, problem solving skills and school grades. It is also associated with lower rates of teen smoking, drinking and drug use. Meals that are prepared and consumed together are more likely to be healthy. You are also less likely to overeat when you are mindful during your meals instead of distracted by technology.
The Mediterranean Diet highlights hydration
Our bodies are over 65% water and water is involved in almost all metabolic processes in the body. Water is very important to overall health and detox and should be included in every healthy diet. Proper hydration affects brain function and not drinking enough water has been associated with headaches (31), memory (32), anxiety (32), mood (32), fatigue (32) and brain performance (33). Adequate water intake is also important for digestion and proper bowel function (34). Drinking water increases fullness and boosts metabolism (35) which may make it helpful for weight loss as well.
The Mediterranean Diet encourages wine consumption. Wait! What??
Ethanol is the active ingredient in alcohol. It is produced by yeast when they break down the sugars in grapes (to make wine) or grains (to make beer). Ethanol is what impairs brain function, changes behavior and mood and generally makes people look silly.
Consumption of red wine in moderation is recommended as part of the Mediterranean diet. This may seem a little strange since we typically think of alcohol as bad for us. The health effects of alcohol can be complicated and conflicting though.
Red wine is full of antioxidants (36) which reduce inflammation and prevent chronic disease. Moderate intake of ethanol decreases the risk of cardiovascular disease (37) on its own. The antioxidants in red wine appear to provide even more protection against cardiovascular disease (38), stroke (39) and diabetes (40).
So I can drink as much wine as I want??
Don’t get too excited just yet. As with most things, moderation is key! Alcohol is removed from the body by the liver. Excessive alcohol consumption can lead to liver diseases including fatty liver (link), cirrhosis and liver failure (41). Chronic use can also damage the brain and increase the risk of dementia (42). Alcohol can contribute to weight issues when consumed in excess. It is full of empty calories and heavy drinking may be related to weight gain (43). Heavy drinking increases the risk of cardiovascular disease (44) and certain types of cancers (45) as well.
The Mediterranean Diet recommends one 5-ounce glass of red wine per day for women and 2 per day for men. This is consistent with the recommendations based on standard drinks per day.
Who might benefit from the Mediterranean Diet?
The dietary habits of the Mediterranean Diet can have important health benefits and have lots of research behind them. Most people can benefit from the Mediterranean diet since it focuses on eating whole foods with positive health properties. The Mediterranean Diet is especially helpful for people with heart disease. It is also helpful for people with conditions such as obesity, high blood pressure, high cholesterol and diabetes, which contribute to heart disease. It is best used in preventing these conditions but may also be helpful after these conditions have occurred.
The Mediterranean Diet is best known for improving heart health. Studies have shown a decreased risk of heart attack, stroke and cardiovascular disease compared to low-fat diets (46). Those with high blood pressure, blood lipid issues or obesity are thought to respond best (46). The Mediterranean diet also improves cardiovascular risk factors including high blood sugar levels, blood pressure, cholesterol levels and inflammatory markers (47). This may be why this diet decreases the risk of heart attack, stroke, diabetes and early death.
How do cholesterol, triglycerides and blood sugar levels impact your health?
Cholesterol is a fat-like substance made by your liver. It is also found in foods you eat and is absorbed through your digestive system. It is packaged into particles called lipoproteins that carry cholesterol in the body. There are two types of lipoproteins, high-density lipoprotein (HDL) and low-density lipoprotein (LDL). LDL delivers cholesterol to the cells that use it to create hormones, bile and vitamin D. If your body has more LDL than it needs, it can build up in the walls of your blood vessels to form plaques. As this plaque builds up, the blood vessel becomes narrower which restricts blood flow. This is why LDL cholesterol is linked to heart disease and stroke, and why it is known as “the bad cholesterol”. HDL removes cholesterol from your cells and plaques that have formed and takes it back to the liver to be excreted. This is why HDL is known as “the good cholesterol” and benefits your cardiovascular system. Increasing HDL cholesterol while reducing LDL and total cholesterol can benefit your blood vessels. This can reduce your risk of heart attack and stroke. The Mediterranean diet has been shown to decrease LDL levels which is a change that did not occur with low-fat diets (3).
Triglycerides are a type of fat molecule found in the blood. Fat is a very efficient form of storage for extra energy in the body. Your body converts extra calories and blood sugar into triglycerides to be stored as fat in your cells. When your blood sugar and energy stores are low, you can break down triglycerides for energy. High triglyceride levels may work with high cholesterol to form plaques in the arteries and cause hardening of the blood vessels. This is how triglycerides contribute to your risk of heart attack and stroke. High triglycerides are usually seen in conditions such as obesity, Type 2 diabetes, liver or kidney disease and metabolic syndrome.
Blood sugar comes from the food we eat. Our bodies break down food into glucose molecules that our cells can use for energy. The spike in blood sugar that occurs after you eat triggers the release of insulin from the pancreas. Insulin is a hormone that acts as a signaling messenger in the body. Insulin allows your cells to take in glucose from the bloodstream to use within the cell. We are also able to store extra glucose as glycogen in the liver and muscles, or as fat in the rest of the body. When insulin is released in large amounts over an extended period of time your cells can become resistant to the signal. This means your body needs a higher level of insulin to move glucose into its cells. At some point, your body cannot maintain these high levels of insulin so glucose builds up in the bloodstream. This is how insulin resistance is related to prediabetes, metabolic syndrome and Type 2 diabetes (48). Poor blood sugar control and obesity are related to many other chronic illnesses such as heart disease, stroke, cancer, high blood pressure and high cholesterol. Maintaining control over blood sugar levels is key to preventing these chronic diseases.
Eating according to the Mediterranean Diet helps keep blood sugar, cholesterol and triglyceride levels in check. This may be why it is helpful in preventing or treating cardiovascular diseases.
The Mediterranean diet may also reverse metabolic syndrome (49). This condition is a combination of high blood pressure, high blood sugar, excess midsection fat and abnormal cholesterol or triglyceride levels. This combination increases the risk of heart disease, stroke and diabetes. This improvement may be because of weight loss, decreased inflammation in the blood vessels and improved insulin response (50).
Abdominal fat in particular has been linked to chronic diseases including heart disease (51), diabetes (52) and high blood pressure (52). Abdominal fat, or central obesity, also makes insulin resistance more likely. Fat held in the abdomen is hormonally active and makes hormones called adipokines that are thought to reduce the body’s tolerance to glucose. Abdominal fat also releases hormones called resistins which further contribute to insulin resistance. The Mediterranean Diet helps control blood sugar levels and reduce abdominal fat which means it is likely helpful for Type 2 diabetes and other conditions related to abdominal obesity such as Metabolic Syndrome, heart disease and stroke.
The Mediterranean diet has also been shown to cut the risk of developing Type 2 diabetes by more than half (53)! In people who already have diabetes, this diet improved blood sugar and insulin levels better than low-carb or low-fat diets (54). It may also delay or prevent the need for medications (55).
The Mediterranean diet may also be beneficial in preventing cancer, Parkinson’s Disease and Alzheimer’s Disease (57). This is thought to be because it emphasizes intake of fruits and vegetables, unsaturated fats and antioxidants while limiting intake of saturated fats, sugar, salt and chemicals.
What makes the Mediterranean Diet work?
The Mediterranean diet is not as restrictive as some other diets. It recommends a spectrum of the amount of each food you eat and how often. There are very few foods it eliminates completely, and these are typically foods that are highly processed. It offers lots of variety, flavor and options from many food groups. It revolves around eating more healthy foods and fewer of the unhealthy foods that create inflammation in the body. This is what allows the Mediterranean diet to be maintained long term. This diet becomes a lifestyle and can continue to cause healthy changes long term. It is useful in preventing disease and creating the conditions for healthy aging for many years. This allows you to create sustainable changes for your health.
Not all fat is created equal
Fat as we know it is actually made up of many smaller molecules called fatty acids. There are several types of fatty acids, each with their own properties.
Saturated fatty acids are made up of consecutive carbon molecules bound together by single bonds. These fats are often solid at room temperature. They are found in fatty meats, lard, full-fat dairy products, coconuts, coconut oil, palm oil and dark chocolate. Saturated fats were initially thought to be related to increased rates of heart disease because of their impact on cholesterol. The Mediterranean Diet limits consumption of animal products and the saturated fats that are found in them. This was thought to explain its positive effects. Saturated fats raise LDL levels but they also raise HDL levels. Even though LDL has been linked to cardiovascular diseases, this may not be the whole story. There are actually subtypes of LDL, each with different properties (57).
Small, dense LDL is able to enter blood vessel walls easily because of its size. These are the LDL molecules thought to increase the risk of heart disease. Small, dense LDL is also more likely to become oxidized (58) which is what creates the inflammation associated with plaque formation. Large LDL are much less dense so they have a difficult time penetrating the artery walls. They are also less likely to become oxidized. Elevated small, dense LDL is associated with a 3-fold increase in cardiovascular disease compared to large LDL (59). Saturated fats have been shown to change the profile of LDL to favour large LDL (60). This means eating saturated fats may not be the cause of heart disease after all.
If saturated fats aren’t as bad as we thought, what makes the Mediterranean Diet so good for heart disease?
Unsaturated fats have a different chemical structure than saturated fats. They are still made up of carbon molecules but they have one or more double bonds. Mono-unsaturated fatty acids (MUFAs) have one double bond in the chain. Poly-unsaturated fatty acids (PUFAs) have multiple double bonds. These double bonds are what makes these fats liquid at room temperature. Unsaturated fats are found in foods like fish, avocadoes, nuts, seeds and vegetable oils. Unsaturated fats are classified by the location of the double bond within their chain, as either Omega3, Omega6 or Omega9. These fatty acids cannot be made by the body so they must be consumed in the diet. The each have different properties with different effects on health.
Omega 3 fatty acids are anti-inflammatory (61) while Omega 6 fatty acids create inflammation in the body. Most people who eat according to a Western diet have an excess of Omega 6s and not enough Omega 3s (62). This unbalanced ratio has been linked to cardiovascular disease and other inflammatory conditions. Omega6s are typically found in vegetable-based oils that have become easily available with modern agriculture. Soybean, corn, canola, peanut and flaxseed oil all contain high levels of Omega6s and should be avoided when trying to reduce Omega6 consumption. Although olive oil contains both Omega3 and Omega6 fatty acids, the amount of Omega6 is much lower compared to other vegetable oils. It also has high Omega3 content which contributes to its anti-inflammatory effect.
The Omega-3 content in many of the foods in the Mediterranean Diet is what makes this lifestyle beneficial for health. These are found in fish, avocadoes, olive oil, nuts and seeds. Increasing the amount of Omega 3s in your diet decreases the risk of having a heart attack and dying from one (63). They prevent inflammation that occurs in the blood vessels. This inflammation is what causes plaque to build up inside the vessels. The plaque can clog arteries and cuts off the blood supply to the heart or brain to cause a heart attack or stroke. It also narrows the blood vessels in the rest of the body which increases blood pressure.
The Mediterranean Diet also limits trans fats
Trans fats are found in manufactured products and are not naturally present in our environment. They are created by the hydrogenation of oils which turns liquid oils into solids. This increases the shelf life and flavour profile of foods. They are typically found in shortenings and margarines, crackers, cookies and other packaged foods as well as fried foods. These have been shown to have a negative impact on cardiovascular health. Their consumption has been correlated with heart attack, stroke, heart disease and early death (64). The Mediterranean Diet encourages whole foods that are unprocessed and as natural as possible. This limits the intake of harmful trans fats and may further contribute to health.
What are the risks of the Mediterranean diet?
Although the Mediterranean diet is full of healthy choices that most people can benefit from, there are some negatives that you need to consider.
This diet requires a great deal of cooking at home to avoid many of the foods that should be limited. You need to have a good understanding of how to incorporate the unlimited foods while maintaining adequacy in your diet. Preparation is very important to being successful with the Mediterranean diet. Having healthy food readily available for meals and snacks is critical. Ensuring you are eating a variety of foods from all food groups is required as well.
The Mediterranean diet also emphasizes red wine consumption. Red wine can be beneficial because of its antioxidants and other minerals. Like any alcohol, it can have negative effects if consumed in large quantities. It should be avoided in people with a history of alcohol abuse or with liver or kidney issues. It may also interact with medications you are taking so it is important to ask your healthcare professional’s opinion in these cases.
It is also important to note that the Mediterranean diet may affect men and women differently. The risk of heart disease and diabetes is higher in men due to genetic and hormonal influences. This may be why studies have shown greater impact of these dietary changes on men’s health. Women are unlikely to be harmed by this diet, but it may not have the same positive influence for them.
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