The Traditional Mediterranean Diet: Health Benefits

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THE TRADITIONAL MEDITERRANEAN DIET:

The Scientific Basis for its Health Benefits

by Kevin C. Vigilante, MD, MPH, and Mary M. Flynn, PhD, RD

International Journal of Integrative Medicine, Vo3, No 2, Aug/Sep 2001

 

Note: The information on this website is not a substitute

for the advice of & treatment by a qualified professional.

 

The Mediterranean diet encompasses a broad range of cuisines native to the

entire area bounding the Mediterranean Sea. Despite this diversity, all these

cuisines that we collectively label " the Mediterranean diet " 1 share many common

characteristics. While not strictly vegetarian, these cuisines are traditionally

plant- & shy;based diets in which red meat is consumed only a few times a month.

Fruits, vegetables, bread, cereals, legumes, and nuts are eaten in abundance,

and red wine is a part of everyday life. Chicken and fish appear on the table in

low to moderate amounts, and dairy is consumed mostly in the form of yogurt and

cheese - and usually as a condiment.

 

Perhaps the most defining characteristic of this dietary approach is its use of

olive oil, which is the principal fat source and the culinary foundation of

these cuisines. Despite the high percentage of fat in this diet, the evidence

suggests that this is one of the world's healthiest cuisines and should be

considered a model for healthy eating.

EPIDEMIOLOGICAL EVIDENCE

In the early 1960s, Greece enjoyed the greatest longevity among all nations

tracked by the World Health Organization,2 despite endemic poverty, a poor

healthcare system, and pervasive smoking. About the same time, the Seven Country

Study3 analyzed the diets and mortality among 12,700 men divided into 11 cohorts

in 7 different countries: the United States, Finland, Japan, Italy, Greece,

Yugoslavia, and the Netherlands.

 

The study results indicated that the healthiest participants were in Japan and

Greece. However, when comparing the cohort from Greece with the Japanese, who

are well known for their low rates of heart disease, the Greeks were found to

have almost a 4-fold lower rate of heart disease. The Greeks achieved this low

level of heart disease risk despite consuming the diet with the highest amount

of fat (42%). However, the main source of dietary fat in Greece was olive oil.

 

In a 15-year follow up to this study,4 the greatest predictor of longevity was

the ratio of dietary monounsaturated fat to saturated fat.

RANDOMIZED TRIALS

Some have suggested that lifestyle patterns other than diet account for

Mediterranean health. However, the Lyon Heart Study5 suggests otherwise. This

study randomized approximately 300 cardiac patients to a Mediterranean-style

diet and a similar number to an American Heart Association-style diet. The 2

dietary regimens differed mainly in their fat source. The Mediterranean diet

emphasized mostly monounsaturated fats (olive oil and canola oil), while the

American Heart Association diet utilized polyunsaturated fats.

 

After 27 months, the ethics committee stopped the study because the

Mediterranean diet group had 70% fewer cardiac incidents. After following these

groups over 4 years,6 the Mediterranean advantage persisted with a 61% lower

rate of cancer and a 56% lower overall mortality. A retrospective analysis on

the consumption patterns of the 2 groups revealed that the major difference was

the fat source used. However, the Mediterranean group also ate more fruits,

vegetables, and cereal. This impressive outcome suggests that the Mediterranean

diet, and especially its fat source, influences health and disease processes on

a very fundamental level.

 

A BIOCHEMICAL RATIONALE

For years, the evidence has been mounting that the Mediterranean diet can reduce

the risk of chronic disease. However, it is only recently that we have begun to

understand why. The underlying benefit of this diet is likely derived from its

rich spectrum of phytochemicals.7 These biochemical compounds found in the plant

kingdom often protect plants from environmental, infectious, predatory, and

oxidative threats. When humans consume these phytochemicals, they may confer

similarly protective advantages, particularly, but not exclusively, as

antioxidants. In a happy synergy between form and function, health and

aesthetics, nature often endows the most colorful fruits and vegetables with the

highest concentration of phytonutrients. The Mediterranean cuisine is one of the

most colorful cuisines in the world.

 

SPECIFIC COMPONENTS OF THE MEDITERRANEAN DIET

Health benefits of olive oil

Olive oil consists of approximately 75% oleic acid (a monounsaturated fat), 15%

saturated fat, and 10% polyunsaturated fat. The benefits of olive oil are often

attributed to a salutary, but unexplained, influence on low-density lipoprotein

cholesterol (LDL) and high-density lipoprotein cholesterol (HDL). However, the

mechanisms of disease prevention extend far beyond an isolated influence on the

cholesterol profile.

 

Olive oil is extracted from the highly pigmented olive and is therefore

extremely rich in phytonutrients. Not only does olive oil reduce the absolute

levels of LDL when it replaces saturated fat, but it also plays a role in

preventing LDL oxidation. Researchers in one study found that the phenolic

compounds in olive oil were highly effective in preventing LDL oxidation when

LDL was exposed to ultraviolet light.8 Another study compared the ability of

phenolic compounds extracted from olive oil, extra virgin olive oil, and

processed olive oil to prevent LDL oxidation.9 The extracted phenolic compounds

prevented LDL oxidation in a dose-response relationship. Both kinds of olive oil

also prevented LDL oxidation; however, the extra virgin olive oil had a

significantly greater antioxidant effect. This suggests that processed

(non-virgin) olive oils lose some of their phenolic content in the refining

process.

 

Olive oil consumption has also been inversely related to the risk of certain

cancers, including breast,10,11 colorectal,12 esophageal,13 and prostate

cancer.14 One study found that lignans, which have been found to protect against

breast, colon, and prostate cancer, form a major component of the phenolic

fraction of olive oil.15

 

Other studies have attributed the anti-carcinogenic effect of olive oil to its

squalene content. In animal models, squalene appears to suppress tumor growth.16

Squalene has a strong inhibitory effect on HMG-COA reductase, thereby reducing

farnesyl pyrophosphate availability for " prenylation " of the ras oncogene, which

has been strongly associated with breast, colon, and pancreatic cancers.

Research suggests that the phenolic fraction of olive oil can suppress the

reactive oxygen species, free radicals generated in large amounts by the colonic

mucosa of cancer patients, and patients with ulcerative colitis or Crohn's

disease.17

Enhanced absorption

Not only does olive oil carry its own supply of potent phytochemicals, it also

enhances the absorption of phytonutrients from other sources. This is

particularly relevant in the case of carotenoids. Carotenoids are substances

found in fruits and vegetables with a deep color, which are prevalent in the

Mediterranean diet. There are at least 500 known carotenoids in nature, and many

protect against disease. For example, intake of lycopene, a carotenoid found in

tomatoes, has been inversely related to rates of prostate cancer.18 It also

seems to protect against other cancers and heart disease.19 However, lycopene,

like all carotenoids, including beta carotene, lutein, and zeaxanthin, is

lipophilic, that is, it requires dietary fat to be absorbed and transported.

Ingested carotenoids become part of the chylomicrons, microscopic particles of

emulsified fat found in the blood and lymph, which transport them throughout the

circulation.

 

Carotenoids consumed without dietary fat, or in the presence of factors that

interfere with dietary fat, will not be maximally absorbed. This may adversely

affect health. One estimate suggests that decreasing plasma lycopene by 10% in

the general male population would result in about 10,000 additional cases of

prostate cancer.20 Combining olive oil with colored vegetables, as is the

Mediterranean custom, assures that carotenoid absorption will be maximized.

 

Olive oil offers a distinct advantage over corn, safflower, sunflower, and

soybean oils. These predominately polyunsaturated fats have multiple double

bonds and are therefore predisposed to oxidation and free radical production.

Some of these fats are relatively rich in vitamin E. However, the pro-oxidant

environment these fats create --- especially when heated --- partially consumes

their vitamin E content. Corn, safflower, sunflower, and soybean oils contain

linoleic acid, which converts into arachidonic acid. Arachidonic acid is, in

turn, converted into inflammatory prostaglandins and leukotrienes, which could

increase the risk for atherosclerosis, arthritis, autoimmune conditions, and

other chronic conditions.

 

In contrast, olive oil is mostly monounsaturated, and therefore highly resistant

to oxidation even when heated. This means that there is significantly less

free-radical production and that vitamin E contained in olive oil is more

bioavailable.

 

Red wine

Phytonutrients

Multiple epidemiological studies, including the Copenhagen Heart Study,21 the

Nurses' Health Study, the Framingham study, and an American Cancer Society

study22 have associated moderate alcohol consumption with health and longevity.

Many of these studies did not distinguish between different types of alcohol,

and the benefits of alcohol were often attributed to its effects on HDL.

However, these effects are probably too modest to explain the magnitude of the

health benefits that have been observed. In the case of red wine, however, an

alternative explanation reaches far beyond its alcohol content: the

phytonutrient content of the grapes in red wine is delivered in a highly

concentrated form.

 

Red wine is endowed with an extraordinary array of phytonutrients. Many of them

are flavonoids, which are, in turn, part of the larger category of polyphenols.

These substances include anthocyanin, caffeic acid, catechin, ellagic acid,

ferulic acid, fisetin, leucocyanidol, p-coumaric, quercitin, and resveratrol.

These powerful antioxidants protect against LDL oxidation and other pathologic

sequelae of the oxidative process.

 

RED WINE: MORE THAN AN ANTIOXIDANT

 

Many of the phytonutrients in red wine have functions that extend beyond their

antioxidant role. For instance, certain wines, particularly American reds,

contain salicylic acid, which inhibits platelet aggregation, and its metabolite

gentisic acid, which also has anti-inflammatory properties.23 Salicylic acid is

in turn derived from cinnamic acid, which has been shown to have antimutagenic

effects.24 The quercetin and resveratrol in red wine promote vasodilatation and

suppress platelet adhesion by enhancing the synthesis of nitric oxide.25

Resveratrol, a COX II inhibitor, seems to further inhibit platelet aggregation

by promoting prostacylin and minimizing thromboxane.26 Caffeic acid has been

shown to block the production of carcinogenic heterocyclic amines,27 compounds

formed when meat is seared and browned.28 P-coumaric helps prevent the formation

of potentially carcinogenic nitrosamines, which arise during the digestion of

processed meats.29 These carcinogen-neutralizing effects

underscore the importance of the Mediterranean habit of consuming wine with

food.

 

Red wine versus other alcoholic beverages

Polyphenols inhibit proliferation of vascular smooth muscle cells,30 an

important step in atherogenesis. A study reported in the British Medical

Journal31 suggests that moderate alcohol consumption may promote insulin

sensitivity. White wine, and alcohol consumption in general, has been associated

with increased breast density on mammograms, a significant risk marker for

breast cancer. However, red wine consumption was associated with decreased

breast density.32 In addition, the polyphenols contained in red wine may inhibit

proliferation of breast cancer cell lines in a dose - and time-dependent

manner.33 These findings may help explain why alcohol consumption is associated

with breast cancer in northern European countries but not in Mediterranean

countries, where red wine is the principle alcoholic beverage.

 

A study at the University of Wisconsin compared the capacity of red wine, white

wine, and other alcoholic beverages to inhibit platelet aggregation in humans.

It found that red wine achieves this effect at much lower doses (J. Folts,

personal communication, University of Wisconsin, January 1999). Other alcoholic

beverages require a highly intoxicating dose to achieve a similar effect.

However, platelet inhibition only lasts 24 to 48 hours.34 This finding

demonstrates why the Mediterranean habit of drinking wine on a daily basis is

important to its therapeutic effect.

 

A study at the University of Tokyo compared the vasodilatory effects of red and

white wine in human subjects.30 It found that only red wine produced the

desired effect. In addition, purple grape juice has been found to inhibit LDL

oxidation, inhibit platelet aggregation, and promote vasodilation in much the

same way as red wine.34 These results strongly suggest that the phytonutrients

described above, not the alcohol, mediate the benefits of red wine.

Fruits, vegetables, and nuts

Multiple epidemiological studies have demonstrated the protective effect of

fruits and vegetables. The Mediterranean diet encompasses an enormous variety of

highly colorful fruits and vegetables. Each plant food in this diet brings to

the table its own complement of phytonutrients.

 

Along with the olive and the grape, broccoli --- which is also plentiful in the

Mediterranean diet --- has been one of the more well-studied plant foods. It is

a very rich source of phytonutrients, including allyl sulfide, anthocyanin,

catechin, chlorogenic acid, ferulic acid, fisetin, geraniol, isoprenoids,

limonene, lutein, lycopene, oleuropein, resveratrol, squalene, tangeritin, and

urosolic acid, to name a few. In addition to being powerful, all-purpose

antioxidants, many of these compounds have demonstrated antimutagenic effects in

both in vitro and animal studies. Some of the better known anticarcinogenic

compounds in broccoli are sulphorophane, which is found to be highly

concentrated in broccoli sprouts, and indol-3-carbinol, which is being evaluated

by the NCI's Division of Cancer Prevention as a potential chemopreventive

agent.35 Indol-3-carbinol is found in other cruciferous vegetables, such as

broccoli rabe, kale, and cauliflower. One would expect additive or perhaps even

synergistic contributions from the scores of other fruits and vegetables common

to the Mediterranean diet.

 

Nuts, especially walnuts, are common condiments and snacks in the Mediterranean

diet. Even in small numbers, they may significantly affect health. The Nurses'

Health Study found that women who ate 5 oz of nuts a week had 35% fewer heart

attack.36 Walnuts are a good source of omega-3 fatty acids. Other sources of

this beneficial fat are cold-water fish, canola oil, and purslane, a leafy green

herb commonly consumed in Greece.

 

Omega-3 fatty acids are associated with lower rates of heart disease. One

commonly advanced explanation is that omega-3 polyunsaturated fats are

precursors to noninflammatory prostaglandins, while the omega-6 polyunsaturated

fats, found in corn oil and other seed oils, are precursors to the inflammatory

prostaglandins. Omega-3 and omega-6 fats compete in metabolic pathways. By

increasing the omega-3-to-omega-6 ratio, a less inflammatory milieu is created.

 

THE THERAPEUTIC ACTIVITY OF BEANS

 

Beans are avidly consumed in the Mediterranean and appear to contribute to

health. A study of the dietary habits of elderly Greeks found that those who

departed from traditional ways of eating suffered significantly higher rates of

chronic disease.37 The biggest difference in their new diet, as compared with

the traditional Mediterranean diet, was a reduced intake of beans and a greater

intake of meat. The improved health of the traditional cohort could be

attributed to a substitution effect in which beans merely replaced meat.

However, evidence suggests that beans have inherent health benefits. Beans are

not highly pigmented, but they do carry a complement of phytonutrients. They are

also important sources of dietary fiber. Even though recent results from the

Nurses' Health Study have raised doubts about the role of fiber in preventing

colon cancer,38 fiber is still associated with cardiac health.39

 

The importance of what Mediterraneans don't eat

Perhaps just as important as what Mediterraneans do eat is what they don't eat.

This is especially true when it comes to meat, which is consumed infrequently.

In addition to saturated fat, meat carries with it a host of other substances

that may pose a threat to health.40 Heterocyclic amines are known to be

carcinogenic and are readily formed when meat is seared and browned.28

Carcinogenic nitrosamines are associated with the digestion of processed meats.

Some researchers have proposed that because iron easily oxidizes, meat

consumption increases the oxidative burden. Meat also contains iron and

methionine, which is a precursor to homocysteine and which may pose a

cardiovascular threat.

 

Mediterraneans do not traditionally consume large amounts of seed oil, such as

corn, safflower, sunflower, and soybean oils. Once thought to be healthy

replacements for saturated fats, growing evidence indicates that these

polyunsaturated fats may pose problems of their own. Animal data suggest that

they promote carcinogenesis. There is evidence that women who consume these fats

instead of olive oil have higher rates of breast cancer.41 In addition to having

multiple double bonds, which predispose seed oils to oxidation, as noted above,

they are highly refined. It is likely that whatever limited phytochemical

content they possess is reduced further in the refining process.

 

Mediterraneans traditionally consume very little butter and milk, further

reducing their saturated fat intake. Also, trans-fats are not part of the

traditional Mediterranean diet. In contrast, the prevalence of trans-fatty acids

in the diet closely tracks the North American epidemic of heart disease over the

last 60 years.

 

Ease of transportation and international commerce have made the world " smaller "

and hence more homogeneous. Mediterraneans have begun to follow a diet more

similar to that of the North American population, including fast food. They are

already beginning to pay the price with higher rates of heart disease and

cancer. Therefore, it is important to make the traditional Mediterranean diet

our model of healthy eating.

CONCLUSION

Considerable evidence indicates that the Mediterranean diet lowers the risk of

cancer, heart disease, and other chronic illnesses. Recent research has revealed

the role of phytonutrients in health and disease. It is likely that the

Mediterranean diet mediates its effects through its rich phytonutrient content.

Limited intake of red meat, seed oils, dairy products, and trans-fats also

contributes to the health benefits of this diet.

 

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