Diet mediterania

diet mediterania

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Martínez-González Correspondence to Miguel A. Martínez-González, MD, PhD, Department of Preventive Medicine and Public Health, Medical School, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain.

Email E-mail Address: [email protected] From the Department of Preventive Medicine and Public Health, IdiSNA, Navarra Institute for Health Research, University of Navarra, Pamplona, Spain (M.A.M.-G., A.G., M.R.-C.) CIBER Physiopathology of Obesity and Nutrition (CIBERobn), Carlos III Institute of Health, Madrid, Spain (M.A.M.-G., A.G., M.R.-C.) Department of Nutrition, Harvard T.H.

Chan School of Public Health, Boston, MA (M.A.M.-G.). Alfredo Gea From the Department of Preventive Medicine and Public Health, Diet mediterania, Navarra Institute for Health Research, University of Navarra, Pamplona, Spain (M.A.M.-G., A.G., M.R.-C.) CIBER Physiopathology of Obesity and Nutrition (CIBERobn), Carlos III Institute of Health, Madrid, Spain (M.A.M.-G., A.G., M.R.-C.) Miguel Ruiz-Canela From the Department of Preventive Medicine and Public Health, IdiSNA, Navarra Institute for Health Research, University of Navarra, Pamplona, Spain (M.A.M.-G., A.G., M.R.-C.) CIBER Physiopathology of Obesity and Nutrition (CIBERobn), Carlos III Institute of Health, Madrid, Spain (M.A.M.-G., A.G., M.R.-C.) The Mediterranean diet (MedDiet), abundant in minimally processed plant-based foods, rich in monounsaturated fat from olive oil, but lower in saturated fat, meats, and dairy products, seems an ideal nutritional model for cardiovascular health.

Methodological aspects of Mediterranean intervention trials, limitations in the quality of some meta-analyses, and other issues may have raised recent controversies. It remains unclear whether such limitations are important enough as to attenuate the postulated cardiovascular benefits of the MedDiet. We aimed to critically review current evidence on the role of the MedDiet in cardiovascular health.

We systematically searched observational prospective cohorts and randomized controlled trials which explicitly reported to assess the effect of the MedDiet on hard cardiovascular end points. We critically assessed all the original cohorts and randomized controlled trials included in the 5 most comprehensive meta-analyses published between 2014 and 2018 and additional prospective studies not included in these meta-analyses, totaling 45 reports of prospective studies (including 4 randomized controlled trials and 32 independent observational cohorts).

We addressed the existing controversies on methodology and other issues. Some departures from individual randomization in a subsample of the landmark Spanish trial (PREDIMED [Prevención con Dieta Mediterránea]) did not represent any clinically meaningful attenuation in the strength of its findings and the results of PREDIMED were robust in a wide range of sensitivity analyses.

The criteria for causality were met and potential sources of controversies did not represent any reason to compromise the main findings of the available observational studies and randomized controlled trials. The available evidence is large, strong, and consistent. Better conformity with the traditional MedDiet is associated with better cardiovascular health outcomes, including clinically meaningful reductions in rates of coronary heart disease, ischemic stroke, and total cardiovascular disease.

Diet has been traditionally considered as a main determinant of cardiovascular health. In fact, one of the 7 cardiovascular health metrics proposed in 2010 by the American Heart Association (Life’s simple 7) directly corresponds to a healthy diet. 1 But also, other 4 of the remaining 6 proposed health metrics (body mass index, blood pressure, total cholesterol, and blood glucose) are closely determined by dietary habits. Moreover, an additional health metric, physical activity, represents just the other side of the energy balance equation and it is indirectly related to dietary energy intake.

Therefore, a healthy diet is essential to meet most of the goals of Life’s simple 7 and to ensure cardiovascular health. In this context, the overall quality of the whole food pattern may be more important and more interpretable than analyses focused on single nutrients or foods.

The study of overall food patterns represents the current state of the art in the investigation of the nutritional determinants of cardiovascular health. 2, 3 This approach is advantageous because it limits confounding by individual dietary factors and it captures the synergistic effects of individual foods and nutrients. It may also provide a more powerful tool to assess the effect of dietary habits on cardiovascular health because the effect of a single dietary element is likely to be too small as to be detected in epidemiological studies or randomized controlled trials (RCTs).

In contrast, it seems logical that the cumulative effect of many different aspects of diet is likely to be considerably larger. 4 The Mediterranean diet (MedDiet) represents a salient overall dietary pattern in nutritional epidemiology that has been extensively studied, especially during the last 2 decades. The MedDiet is defined as a traditional eating pattern found among populations living in the Mediterranean Basin during the 50s and 60s of the 20th century, but, unfortunately, not today.

5 The main characteristics of the MedDiet at those times were a low consumption of meat and meat products, with very low consumption of red meat (beef, pork, and lamb were reserved only for special occasions), very low or null consumption of processed meats, butter, ice creams, or other whole-fat dairy products (only fermented dairy products, cheese and diet mediterania, were consumed in moderate amounts).

It presented a relatively fat-rich profile because of the abundant consumption of olive oil, together with a high consumption of minimally processed, locally grown, vegetables, fruits, nuts, legumes, and cereals (mainly unrefined). 6 An important source of protein was a moderate consumption of fish and shellfish, that was variable depending on the proximity to the sea. The main sources of fat and alcohol among persons in the traditional MedDiet are primarily extra-virgin olive oil (EVOO) and red wine, respectively.

The abundant use of olive oil, through salads, traditionally cooked vegetables, and diet mediterania, together with the diet mediterania consumption of red wine during meals makes this diet highly nutritious and palatable.

Red wine and EVOO contain several bioactive polyphenols (hydroxytyrosol and tyrosol, oleocanthal, and resveratrol) with postulated anti-inflammatory properties. 7 Postulated antiatherogenic properties of olive oil were supposedly attributed to its high content of monounsaturated fat (MUFA; oleic acid), 8 and some more recent investigations also suggest that bioactive diet mediterania, only present in the EVOO, but not in the refined-common variety of olive oil, may contribute to these cardioprotective actions.

9 EVOO is the product from the first pressing of the ripe olive fruit and contains many antioxidants (polyphenols, tocopherols, and phytosterols).

10 Lower-quality oils (refined or common olive oils) are believed to be devoid of most of these antioxidant, anti-inflammatory, or pleiotropic capacities because they are obtained by physical and chemical procedures that keep the fat but lead to the loss of most bioactive elements. In the Spanish landmark PREDIMED trial (Prevención con Dieta Mediterránea), with 7447 high-risk participants initially free of cardiovascular disease (CVD), a 5-year intervention with a MedDiet significantly diet mediterania the incidence of a composite major CVD end point that included nonfatal stroke, nonfatal coronary heart disease (CHD), and all fatal CVD events.

However, the results of that trial were recently retracted by the authors and simultaneously republished in the same journal. 11 They included many new analyses and comprehensively addressed some small departures from individual randomization.

Notwithstanding, many questions remain as to whether the MedDiet can confer benefits for cardiovascular health in both Mediterranean and non-Mediterranean populations. It is also uncertain how variations in the components of the MedDiet indices used in different studies may influence this association.

In addition, other potential sources of bias should be adequately addressed. In the first sections of this article, we will discuss some potential concerns about the beneficial cardiovascular effects of the MedDiet. In the following sections, we will address issues related to these concerns. The currently available evidence strongly supports the MedDiet as an ideal approach for cardiovascular health.

Is diet mediterania MedDiet a Concept Promoted Mainly or Partly for Geographic-Romantic-Nostalgic Reasons? Many of the investigators who are currently strong supporters of the MedDiet have born, live, or have an ancestry in Mediterranean countries.

diet mediterania

6, 12 This might represent a reason of concern because they may be diet mediterania when selecting the pieces of evidence that best fit in the picture of their preconceptions about what should be a healthy diet. 13 They are likely to include those aspects of their diet that they have loved since childhood and even they learnt from their grandparents or ancestors.

14 It is easy to think that there might be a sort of mixture of scientific and nonscientific reasons, some of them probably unconscious, in this group of investigators and these mixed motives may have contributed to the adoption of their strong positions and opinions on the cardiovascular benefits of the Diet mediterania.

As discussed below, this assertion is not supported by the fact that numerous studies conducted in non-Mediterranean populations have found similar benefits of Mediterranean-type dietary patterns on CVD risk. Is the MedDiet a Concept Based on Vested Commercial Interests of Olive Oil and Nut Companies? The potential biases in diet mediterania investigation related to research funding by the pharmaceutical industry have been largely studied and documented.

It is well-known that there is a significant association between industry sponsorship and pro-industry conclusions. But similar biases related to research funding by food industry have been only recently documented.

Pro-industry bias in pharmaceutical research might have adverse diet mediterania effects on millions of patients receiving medications, but pro-industry bias in nutrition research will have adverse health effects for absolutely everyone, with a substantially higher harm for public health. In addition, regulations are tighter for pharmaceutical research than for nutritional research.

15 In the jungle of academic-industry interactions scientific truth—nothing more, nothing less—should be the primary aim that all should pursue.

16 This statement has been frequently repeated in the scientific environments surrounding investigators on nutrition and cardiovascular health. The primary interests of multinational food companies are to increase their profits, and consequently, to make easier the most profitable food choices.

In contrast, the primary interest of public health is to make easier the healthiest choices. There is a clear clash of interests. Many published studies, particularly small trials with soft end points and reviews or commentaries, on the benefits of the MedDiet for cardiovascular health have been funded by food industries or were written after their presentation in an industry-funded meeting.

Although not to the same extent than for sugar-sweetened beverages, 17 this potential conflict of interest has been specifically criticized in relationship with the very concept of the MedDiet. Richard Smith, the former editor of the BMJ, wrote “a combination of vested interests, including the International Olive Oil Council and a public relations company Oldways, which promoted the diet, has—together with the natural seductiveness of the Mediterranean region—made the diet popular”.

18 These criticisms, however, do not hold water based on the fact that the vast majority of evidence on MedDiet has been funded publicly. We will discuss this issue in a later section. Should Refined Cereals Be a Part of the MedDiet? The currently available epidemiological evidence consistently supports the recommendation to consume less refined grains and replace them by whole grains. This replacement will reduce the risks of type 2 diabetes mellitus and CVD.

19–21 However, in the most frequently used operational definition of the MedDiet, 22 all cereals are included as a single positive item. No difference is made between refined and whole grain cereals.

The assumption that all grains, including refined grains, provide cardiovascular protection might be against diet mediterania current scientific evidence. Fung et al 23 modified the score developed by Trichopoulou and included only whole grain products in the alternative Mediterranean diet (aMedDiet) score.

Similarly, Panagiotakos et al 24 gave the greater adherence to the MedDiet to the highest consumption of whole grain s ( Table 1). This modification seems more consistent with current mainstream findings in nutrition science. The PREDIMED trial did not include the consumption of cereals in the MedDiet adherence screener. 25 This difference might cast doubts on the reliability of some MedDiet scores to capture a dietary pattern with the largest potential for cardiovascular health.

Table 1. Mediterranean Diet Scores Frequently Used in Cardiovascular Research Mediterranean Diet Score (Trichopoulou et al, 22 0 to 9 Points) Alternate Mediterranean Diet Score (Fung et al, 23 0 to 9 Points) Mediterranean Diet Score (Panagiotakos et al, 24 diet mediterania to 50 Points) MEDAS (MEDAS-PREDIMED, 25 0 to 14 Points) Positively weighted components Monounsaturated/saturated * Monounsaturated/saturated †Olive oil in cooking ‡ Olive oil as main culinary fat Vegetables * Vegetables †Vegetables ‡ ≥4 tablespoon §/d olive oil Fruits and nuts * Fruits †Fruits ‡ ≥2 servings/wk olive oil sauce with tomato, garlic, onion, or leek (sofrito) Legumes * Nuts †Legumes ‡ ≥2 servings/d vegetables Fish * Legumes †Fish ‡ ≥3 servings/d fruits Cereals * Fish †Whole grains ‡ ≥3 servings/wk nuts Whole grains †≥3 diet mediterania legumes ≥3 servings/wk fish Preference for poultry (chicken, turkey, or rabbit) > red meats (beef, pork, hamburgers, or sausages) Negatively weighted components Meat/meat products ‖ Red and processed meat ¶ Red and processed meat ‡ <1/d red/processed meats Dairy products ‖ Poultry ‡ <1/d butter/margarine/cream Full-fat dairy products ‡ <1/d carbonated/sugar-sweetened beverages <2/wk commercial bakery, cakes, biscuits, or pastries Alcohol 5–25 g/d (women) 5–15 g/d (women) >0 and <300 mL/d (5 points) ≥7 glasses #/wk of wine 10–50 g/d (men) 10–25 g/d (men) Can Alcohol Still Be Part of the MedDiet?

A moderate intake of alcohol has usually been considered a positive item in most of the MedDiet indexes ( Table 1). However, results from a recent study have pointed out alcohol consumption as one of the leading factors for global disease burden. 26 There is a view—based on some studies with inherent limitations—that alcohol, even when consumed moderately, increases the risk of many diseases.

27 Specifically, a dose-response relationship between alcohol and different types of cancer is likely to exist. 28 For this reason, some diet mediterania MedDiet scores have excluded alcohol intake to assess the relationship between adherence to MedDiet and breast cancer. 29 Thus, one question is whether moderate alcohol consumption should no longer be used in the operational definition of the MedDiet.

As discussed below, moderate consumption of wine with meals is still considered one of the components of MedDiet, although consumption of alcohol is not encouraged for individuals who do not drink. Do Dairy Products Play Any Role in the MedDiet? The role of dairy products in cardiovascular health is controversial.

However, metabolic benefits have been reported for some dairy products, specially fermented dairy products in a nonlinear relationship, 30 and a meta-analysis found significant reductions in stroke incidence associated with dairy product consumption. 31 Nevertheless, all dairy products are negatively weighted in the MedDiet score proposed diet mediterania Trichopoulou. 22 However, the aMedDiet and the MedDiet adherence screener excluded most dairy products giving them a null diet mediterania.

This is another source of discrepancy between the scores used in different studies which contributes to the consideration that the MedDiet is a broad term that varies across the literature. 32 In fact, Galbete et al 33 compiled 34 different published definitions of the MedDiet. Are Potatoes and Eggs a Part of the Definition of the MedDiet?

In most of these 34 definitions, 33 potatoes were excluded from the vegetable group when computing the MedDiet score. But potatoes were explicitly included together with vegetables in a small number of scores, such as those used by Tognon et al 34 and by Knoops et al.

35 In other 2 reports, they were also positively weighted (as supposedly beneficial) because they were included together with cereals. 36, 37 Usually, egg consumption is not included in definitions of the MedDiet, but some studies did include eggs together with meats 38 or as a separate item giving to egg consumption a negative weight.

39 In the landmark observational cohort study that first related the MedDiet with lower cardiovascular mortality, 22 authors explicitly stated that potatoes and eggs should be kept apart from the scoring system for the MedDiet, and therefore they should receive a null consideration.

Should Any Diet Rich in Fruit and Vegetables Be Classified as a Traditional MedDiet? Surprisingly, some meta-analyses classified as Mediterranean any dietary pattern which met at least 2 of 7 criteria.

The rationale for these criteria is more than debatable and this terminology is confusing because this would mean, for example, that any diet rich in fruit and vegetables could be called a Mediterranean-style diet. 40 What Are the Main Sources of Fat and Fat Subtypes in the MedDiet? In the most common definition of the MedDiet, 22 the ratio MUFA:saturated fat (SFA) is one of the 9 items used to build the score, but other scores have used instead the unsaturated:SFA ratio, including polyunsaturated fats to account for the fact that other sources of MUFA, 41 different from olive oil, are usually important in non-Mediterranean regions and the usual finding of beneficial cardiovascular effects when SFA is replaced by polyunsaturated fat.

In some other Mediterranean scores, instead of using the MUFA:SFA ratio, the authors selected diet mediterania the consumption of olive oil for this item. Even if olive oil might not correspond to the most important source of fat for cardiovascular health, use of olive oil as main culinary fat is an essential characteristic of the MedDiet.

The PREDIMED trial gave a special importance to EVOO as a source of bioactive polyphenols. These polyphenols are increasingly mentioned as contributors to the cardiovascular health benefits because of their anti-inflammatory properties.

42, 43 Interestingly, the 14-item questionnaire used in the PREDIMED was one of the scores that captured the highest intake of polyphenol antioxidant content in a comparison of 21 MedDiet indexes.

44 Are Polyphenols Consumed in Sufficient Amounts as to Have a Credible Effect? There are differences between Mediterranean and non-Mediterranean countries about the type of flavonoids and food sources.

45 But when a high polyphenol content of the MedDiet is invoked as partly responsible for the cardiovascular benefits of this food pattern, a relevant question is usually raised: what are the minimum amounts of bioactive polyphenols that can exert a sufficiently large pleiotropic effect as to yield meaningful clinical effects? One of the substudies of PREDIMED measured total polyphenol urinary excretion and the lower limit for the upper tertile of excretion was 32 mg gallic acid equivalent per gram of creatinine.

46 How is it possible that these polyphenols which are present only in minuscule amounts may be able to account for an impressive reduction in cardiovascular clinical events? This quantitative question that was critical when postulating resveratrol as the main element responsible for the potential protective effect of red wine has not been sufficiently investigated with respect to the total amounts of polyphenols present in the typical foods of the MedDiet.

However, polyphenols are only a part of the synergy among diet mediterania beneficial bioactive compounds in the MedDiet. Are the Sample-Specific Cutoff Points Used for Some MedDiet Scores Valid? The usual approach to derive scores of adherence to the MedDiet is to use the sample-specific medians of consumption of each food group, and to assign one point to those who are at or above the sex-specific median of the sample for items that are in line with the concept of the traditional MedDiet.

On the contrary, one point is given to those participants who are below the sex-specific median of consumption for items that are in opposition to the traditional MedDiet. In some other scores, the authors used tertiles (to give 2, 1, or 0 points) instead of using the dichotomization at the sample medians.

47 A potential problem with these scoring systems is that the medians (or other quantiles) are dependent on the sample characteristics and can compromise between-study comparisons or its generalizability.

Why So Many Disparate Scores? A relevant question seems to be the disparate classification and the many different actual exposures that have been collectively classified under the same term MedDiet. The most recent systematic review 33 assessed 70 original studies (including both cardiovascular and noncardiovascular outcomes). Among them, 14 studies used the definition of Trichopoulou, and 18 other studies used definitions (9 different versions), that were basically similar to the Trichopoulou definition.

22 The aMedDiet proposed by Fung 23 diet mediterania several closely related versions) was used by 14 studies. Other definitions and scores were less frequently used. This variability entails a potential for misclassification. There Are More Systematic Reviews Than Original Studies In 2016, an evaluation of the quality of systematic reviews relating the MedDiet with cardiovascular outcomes was published by Huedo-Medina et al.

32 They included 24 meta-analyses and systematic reviews in their evaluation. In 2015, Martínez-González et al 48 included 37 meta-analyses or systematic reviews assessing the association between adherence to the MedDiet and cardiometabolic outcomes.

Subsequently, in 2017 and 2018, 5 new meta-analyses or systematic reviews were published. 33, 49–52 Most of the available systematic reviews included <25 original studies. Therefore, paradoxically, the literature seems to contain more reviews than original studies ( Table 2). 32, 33, 48–59, 61–65, 68–70, 74–77, 81, 86, 87, 90–96, 100, 101, 122, 123 A summary description is shown in Table 2 and the overlapping original studies 22, 23, 34, 37–39, 41, 60, 66, 67, 71–73, 78–80, 82–84, 88, 97, 98, 102–104, 108–115, 117–121, 124–129 between systematic reviews are presented in Figure 1.

Table 2. Summary of the Reviews and Meta-Analyses Gathering Evidence About Mediterranean Diet and CVD Author Systematic Design (Assessed Designs) Outcomes Meta-Analyzed Diet mediterania Results (Meta-Analysis) de Lorgeril et al 53 No Narrative CHD Panagiotakos et al 54 Yes Case-control and prospective studies CHD Serra-Majem et al 55 Yes Trials CVD Willett 56 No Personal perspectives de Lorgeril et al 57 No Narrative Roman et al 58 Yes Any design, participants older than 65 CVD Sofi et al 59 Yes Cohort studies CVD mortality 22, 35, 60 0.91 (0.87–0.95) Martínez-González et al 61 No Narrative Chronic diseases Mente et al 62 Sofi 63 No Narrative Health outcomes Sofi et al 64 Yes Cohort studies Tyrovolas et al 65 Yes Observational studies CVD incidence or mortality 22, 23, 35, 60, 66, 67 0.90 (0.87–0.93) McKeown et al 68 No Narrative CVD and CHD Foroughi et al 69 Yes Observational studies, trials, reviews, and meta-analyses Stroke Psaltopoulou et al 70 Yes Observational Stroke 23, 71, 72, 73 0.84 (0.74–0.95) Rees et al 74 Yes Trials and primary prevention CVD Authors did not find any trial … de Lorgeril 75 No Narrative CVD Grosso et al 76 Yes Epidemiological studies CVD and risk factors Kontogianni et al 77 Yes Observational and trials Stroke 78, 79, 80 0.68 (0.58–0.79) Martínez-González et al 81 Yes Cohorts and trials CVD 82, 78 RCTs: 0.64 (0.53–0.79) 23, 34, 35, 38, 60, 66, 72, 83, 73, 84, 79, 85 Observational: 0.90 (0.86–0.94) Ros et al 86 No Narrative CVD Sofi et al 87 Yes Prospective studies CVD incidence or mortality 23, 34, 35, 36, 37, 60, 71, 88, 72, 83, 73, 79, 85, 89 0.90 (0.87–0.92) Trichopoulou et al 90 No Narrative Whayne 91 No Narrative Ischemic heart disease Sleiman et al 92 Yes Cross-sectional, prospective, and controlled clinical trials CVD, CVD mortality, and PAD Widmer et al 93 No Narrative CVD D’Alessandroet al 94 No Narrative CVD Shen et al 95 No Narrative CVD, AF, and CVD mortality Martínez-González et al 48 No Narrative CVD and CVD mortality Huedo-Medina et al 32 Yes Systematic reviews and meta-analyses CVD outcomes Liyanage et al 96 Yes RCTs CVD mortality 97, 98, 78, 99 0.90 (0.72–1.11) Coronary events 97, 98, 78 0.65 (0.50–0.85) Stroke 98, 78 0.66 (0.48–0.92) HF 97, 98 0.25 (0.05–1.17) Martínez-González diet mediterania al 100 No Prospective studies and RCT CVD Bloomfield et al 101 Yes Controlled trials CVD 78 Dinu et al 52 Yes Meta-analyses of observational studies and randomized trials CVD and health outcomes Rosato et al 49 Yes Observational studies CHD and MI 34, 66, 72, 83, 73, 102, 103, 104, 85, 105, 106, 71, 73, 79, 80, 104, 107, 23, 71, 72, 108, 103 0.70 (0.62–0.80) Unspecified stroke 23, 71, 108, 103 0.73 (0.59–0.91) i-stroke 35, 37, 88, 72 ,73, 109, 110, 104, 111, 112, 85 0.82 (0.73–0.92) h-stroke 1.01 (0.74–1.37) Unspecified CVD 0.81 (0.74–0.88) Martínez-González et al 50 Yes Clinical trials or prospective cohort studies CVD incidence or mortality 22, 23, 34, 35, 38, 97, 78, 60, 66, 88, 72, 83, 73, 79, 103, 113, 114, 111, 115, 85, 116 0.89 (0.86–0.91) Grosso et al 51 Yes Prospective studies and RCT CVD incidence 23, 38, 39, 117, 66, 71, 72, 67, 83, 73, 84, 79, 118 0.73 (0.66–0.80) CVD mortality 23, 34, 35, 38, 60, 88, 119, 83, 73, 84, 79, 102, 120 0.71 (0.65–0.78) CHD incidence 23, 66, 110, 85 0.72 (0.60–0.86) MI incidence 38, 72, 73 0.67 (0.54–0.83) Stroke incidence 23, 38, 71, 72, 73 0.76 (0.60–0.96) MI (RCT) 98, 78, 121 0.60 (0.44–0.82) Stroke (RCT) 78, 121 0.64 (0.47–0.86) CVD mortality (RCT) 82, 98, 78, 121 0.59 (0.38–0.93) Composite (RCT) 82, 98, 78, 121 0.55 (0.39–0.76) Diet mediterania et al 33 Yes Systematic reviews and meta-analyses CVD and chronic diseases Martinez-Lacoba et al 122 Yes Reviews and meta-analyses CVD and other health outcomes Salas-Salvadó et al 123 No Narrative CVD Some of the Available Meta-Analyses Were Rated as Low Quality The quality assessment conducted by Huedo-Medina et al 32 reported that on average, systematic reviews on MedDiet and cardiovascular health achieved a low-quality score and 60% of the 24 reviews presented limitations because they did not report the search details or used inappropriate statistical methods.

Only 42% used appropriate statistical methods to combine the findings.

diet mediterania

32 This weakness does not pertain to the original studies, but to the meta-analytic methods. Sources of Heterogeneity in Diet mediterania Rather than establishing an artificial summary estimate of the effect of the MedDiet on cardiovascular health across a set of several disparate studies, the primary aim of a meta-analysis should have been to identify and estimate the differences among study-specific effects (ie, an analytical goal).

130 This is especially important in the field of MedDiet and cardiovascular health because of the need to deal with studies using different definitions of exposure, different outcomes, different methodology, and different geographic or demographic origins.

The major goal should diet mediterania to assess whether these characteristics determine a different result. Diet mediterania 1 meta-analysis, 81 5 out of the 16 estimates were the main source of heterogeneity because they only assessed fatal outcomes.

When these 5 estimates were removed, the diet mediterania disappeared and the effect became slightly stronger. More recently, Rosato et al 49 assessed sources of heterogeneity and found an overall relative risk (RR) for CVD of 0.61 (95% CI, 0.44–0.86) for 2 studies conducted in Mediterranean regions and 0.84 (95% CI, 0.77–0.92) for the 8 original studies conducted outside the Mediterranean area ( P for heterogeneity=0.11).

Also, other candidate variables did not show any significance in the heterogeneity test. Galbete et al 33 reported that studies using the Trichopoulou MedDiet score 22 showed a stronger inverse association (RR, 0.87; 95% CI, 0.83–0.91 for high versus low adherence) compared with studies using the aMedDiet score (RR, 0.92; 95% CI, 0.89–0.94), with only marginal heterogeneity ( P=0.06). Publication Bias Statistically significant studies going in the expected direction are more likely to be published.

131 This fact is the source of publication bias that represents a major threat for the validity of systematic reviews. Huedo-Medina et al 32 criticized that only one-fourth of the systematic reviews that they evaluated assessed publication bias. Rosato et al 49 reported that diet mediterania Begg and Egger tests conducted to assess publication bias, respectively, gave P values of 0.087 and 0.034 for CHD, 0.13 and 0.008 for unspecified stroke, and 0.44 and 0.27 for unspecified CVD, showing a potential for publication bias for CHD and unspecified stroke.

This might represent a concern. However, most of these P values were not significant. Strengths and Limitations of the Lyon Trial: Too Good to Be True? The French Lyon Diet Heart study was a landmark trial in the study of diet and cardiovascular health. 97 It was a secondary prevention trial aimed at reducing the risk of cardiovascular deaths and recurrent myocardial infarction (MI) by diet modification in 605 patients, survivors of a previous MI and recruited between 1988 and 1992.

Patients were randomized to a Mediterranean-type diet (302 patients) or to a control group (303 patients). In the diet mediterania intervention group, patients were encouraged to increase their consumption of fruit (no day without fruit), vegetables, bread, and fish.

They were also advised to reduce the consumption of red meat (beef, pork, and lamb should be replaced by poultry), and to replace butter and cream by a special margarine, much richer in alpha-linolenic acid than olive oil (4.8% versus 0.6% of alpha-linolenic acid), but, with 48% oleic acid, low content of saturated fatty acids and, slightly higher content of linoleic acid (16.4% versus 8.6%) than olive oil.

Control subjects were allocated the usual care by their physicians, who recommended a diet similar to the low-fat step-1 diet of the American Heart Association. The results of the Lyon Diet Heart Study were impressive, but the intervention did not exactly correspond to the traditional MedDiet. The trial showed a dramatic reduction in major coronary events and deaths, that was maintained over a 4-year follow-up period. 82 In an interim analysis at 27 months of follow-up, there was a 73% reduction in coronary events and a 70% reduction in total mortality and the study was stopped early.

132 Other methodological limitations of the Lyon trial have been highlighted. 61, 133 As, apparently, there was no prespecified stopping rule, it is likely that early stopping of the trial would have led to an overestimation of the effect. 134 Baseline diet was only assessed in the experimental group but not in the control group and, consequently, it was impossible to assess the dietary changes that occurred in the control group.

Information on diet at the end of the trial was reported for only diet mediterania of the control group and only 48% of the experimental group. Very importantly, no sufficient consideration was given in the Lyon trial to the pivotal role of olive oil in the traditional MedDiet.

The fat composition among evaluated participants of the experimental group in the Lyon trial was 30.5% of diet mediterania intake as total fat (12.9% MUFA). This value for MUFA intake is below 15 to 20% MUFA content from olive oil usually present in the traditional MedDiet.

The Lyon trial included only subjects with a previous coronary event (it was a secondary prevention trial). Primary and secondary prevention trials are different because mortality or relapses of CHD are not diet mediterania related to CHD incidence but also to the quality and timeliness of medical care. 135 Scarce Reliability of the Indo-Mediterranean Trial Lancet published in 2002 the results of the Indo-Mediterranean trial 98 reporting a dramatic reduction in the incidence of cardiovascular outcomes in 499 patients randomly allocated to a diet rich in whole grains, fruits, vegetables, walnuts, and almonds as compared with 501 controls allocated to the consumption of a local diet similar to the low-fat Step I National Cholesterol Education Program diet.

But subsequently, in 2005, Lancet issued an expression of concern because diet mediterania the failure to locate original research records. 136 Though this study is still sometimes included diet mediterania both narrative and systematic reviews, it has been largely discredited, and it should be considered at least as a severely flawed investigation.

Deviations From the Individual Randomization Protocol in the PREDIMED Trial The Spanish PREDIMED trial included 7447 participants at high cardiovascular risk allocated to 1 of 3 diets: a MedDiet supplemented with EVOO, a MedDiet supplemented with mixed nuts, or a control diet (advice to reduce all subtypes of dietary fat).

The trial was planned for 6 years, but it stopped early after intervention for 4.8 years, as recommended by the Data and Safety Monitoring Board following stopping rules established a priori in the protocol.

11, diet mediterania, 137, 138 The incidence of CVD (MI, stroke, or cardiovascular death, totaling 288 events) in the MedDiet groups was lowered by ≈30% when compared diet mediterania the control diet.

PREDIMED is a landmark study and it remains to date as the largest dietary intervention trial diet mediterania assess the effects of the MedDiet on CVD prevention. However, a review published in June 2017 identified the PREDIMED trial as having distributions that were significantly different from those expected from randomization. 139 This report prompted the Investigators of PREDIMED to take the initiative to contact the editors of The New England Journal of Medicine.

After July 2017, the investigators of PREDIMED identified 2 departures from the reporting or application of the protocol: • The allocation by clusters (by small clinics), instead of individual allocation of some participants at 1 of 11 study sites (site D), affecting 467 participants (6.2% of total PREDIMED participants) in 11 clinics (2 allocated to MedDiet+EVOO, 5 allocated to MedDiet+nuts, and 4 allocated to control).

In another site (site I), with 1094 participants recruited from 37 small clinics, the research team of that site conducted the intervention in participants from 11 diet mediterania for only one arm of the trial in each clinic (on a total of 247 participants, 22.6% in this site). They also reported that an apparent inconsistent use of randomization tables was done at another site (site B).

However, baseline characteristics were well balanced in sites I and B. • Enrollment of household members (partners of a previous participant) diet mediterania randomization; members of the household of randomized participants were invited to participate and allocated to the same intervention group as their relatives.

Diet mediterania second enrolled partners of a previous participant represented 5.7% of PREDIMED participants, with a slightly lower proportion in the control group (4.82%) than in the MedDiet group+EVOO (6.72%) or the MedDiet group+nuts (5.54%). This was done to avoid assigning members of the same household to different diets.

Assigning all participants in a household to the same diet was viewed as the best approach to diet mediterania dietary changes in the household. This procedure was inadvertently omitted in the reporting of the protocol and the original publication. Baseline imbalances were minor and consisted only in a slightly higher percentage of women in the control group (5.7% higher in control than in the MedDiet+nuts group and 1% higher in control than in the MedDiet+EVOO group) and a 5.3% higher percentage of patients with high levels of LDL-C (low-density lipoprotein cholesterol) in the MedDiet+EVOO than in the control group.

Interestingly, both would be in any case operating against the hypothesis of the trial and therefore cannot provide any alternative noncausal explanation of the PREDIMED findings.

Several criticisms were raised after these departures from the protocol were disclosed. 140 The investigators of PREDIMED decided to retract their original article, 78 and simultaneously republished a new version in the same journal, 11 where these issues were fully addressed.

The republication included the results of many new sensitivity and ancillary analyses that showed no changes with respect to the original results of PREDIMED. 11 Strengths of the MedDiet All the previous considerations represent potential caveats and drawbacks threatening the validity of the MedDiet paradigm for cardiovascular health. There are also many strengths in the currently available evidence to support the validity of the proposal defending the MedDiet model as the ideal approach for cardiovascular health.

The MedDiet possesses a millenary tradition of use without any evidence of harm. 56 Current definitions of the MedDiet are in line with traditional food patterns followed in Mediterranean areas during the 50s and 60s of the past century, where life expectancies after 45 years were among the highest of the world.

141 The pioneer epidemiological study supporting the MedDiet for cardiovascular health was not conducted by anybody living in the Mediterranean area or with a Mediterranean ancestry. These first pieces of evidence came from the Seven Countries Study, an ecological, international, investigation of diet, and cardiovascular disease in 16 groups totaling nearly 13 000 men in 7 countries (Greece, Italy, Japan, Finland, the former Yugoslavia, the Netherlands, and diet mediterania United States).

This diet mediterania was started in 1958 by an American investigator, Keys 142 ( Figure 2). He was the one who developed and promoted for the first time the concept of the cardioprotective MedDiet.

Therefore, it is not likely that geographic-nostalgic-romantic motivations related to the diet diet mediterania by some investigators in their childhood from their grandparents might be at the root of this concept. Keys was a physiologist and epidemiologist at the University of Minnesota who discovered the cardiovascular health benefits of the MedDiet in the early 1950s, when he visited Mediterranean countries as a scientist concerned on the rapidly growing trend of coronary mortality in the United States.

143 Keys did his first research on the MedDiet by studying in situ the dietary patterns of men in Italy, Spain, and Crete and their association with cardiovascular health, with special emphasis on the effects of dietary fat and fatty acids on serum cholesterol levels and CVD risk. His findings were particularly prominent about the importance of fat subtypes—and not of total fat intake—and the relevance of the MUFA:SFA ratio. The MedDiet relatively rich in fat (even to levels of 40% of calories from fat) but with an optimal MUFA:SFA ratio appeared as an ideal model for cardiovascular health.

All these facts were in accordance with the long-lasting experience of use of this dietary pattern in relatively poor sectors of the world with high rates of smoking and, nevertheless, with a very-low-CHD mortality. • Download figure • Download PowerPoint Figure 2. Historical and scientific milestones of the Mediterranean diet (MedDiet) and its cardiovascular benefits. PREDIMED indicates Prevención con Dieta Mediterránea; UNESCO, United Nations Educational, Scientific and Diet mediterania Organization; and WHO, World Health Organization.

Paradigm of Dietary Patterns Has Many Advantages In contrast with the classical analytical approach of only assessing exposures to single nutrients or isolated food items, the study of overall dietary patterns has become the current prevalent framework in nutrition research. This approach has been fully adopted and endorsed by the 2015 Dietary Guidelines Advisory Committee.

144 The food pattern approach is advantageous for many reasons: (1) because food diet mediterania and nutrients could have synergistic or antagonistic effects when they are consumed in combination; (2) overall food patterns represent the current practices found in the assessed population (people do not eat isolated nutrients) and, therefore, they better capture the actual exposure of interest; (3) they diet mediterania useful sociological information of great interest in itself for public health; (4) the use of dietary patterns as the relevant exposure in nutrition reduces the potential for confounding by other dietary exposures; and (5) very importantly, the focus on the overall food pattern seems clearly superior to the reductionist and overly optimistic assumption of attributing all the effect to a single nutrient or food.

It would seem very unlikely that a single nutrient or food could exert a sufficiently strong effect as to substantially change the rates of cardiovascular outcomes. In contrast, the additive effect diet mediterania small changes in many foods and nutrients seems to exert a more biologically plausible and clinically meaningful effect.

In fact, during the last 2 decades, numerous well-conducted prospective epidemiological studies have confirmed strong relationships between a priori defined high-quality dietary patterns and a lower risk of chronic disease, including cardiovascular clinical outcomes.

As one of the members of the 2015 Dietary Guidelines Advisory Committee recently highlighted, hypothesis-oriented patterns based on available scientific evidence for chronic disease are an attractive alternative, because the use of an a priori scoring system offers a consistent metric that can be applied across multiple studies and the consistency in methods then allows comparisons of results across populations.

144 In this context, as Figure 3 shows, the MedDiet pyramid 145 includes many different foods with specific recommendations for their consumption on every main meal, daily, weekly, or less frequently. Consequently, the MedDiet fits very appropriately in the paradigm of overall dietary patterns and it represents one of the best-known models for this paradigm.

Moreover, the MedDiet was explicitly endorsed by the 2015 Dietary Guidelines Advisory Committee after reviewing all the available scientific evidence.

146 Variety of Definitions Had Little Impact on the Cardiovascular Health Effects It would be desirable to adopt a universal definition of MedDiet for the sake of comparability among different studies in the future. The use of different definitions does not help to assess the consistency among studies nor to translate the scientific research into practical recommendations for the general population.

147 Notwithstanding, in Figure 4, we standardized the comparisons to represent the association for a 22.2% increment in the used score, equivalent to a 2-point increment in the 0 to 9 score proposed by Trichopoulou. 22 However, it should be acknowledged that the groupings used in the studies shown in Figure 4 do not represent always the same comparison, because of the previously mentioned diversity in the content of the different indexes.

This should be taken into account when interpreting the results summarized in Figure 4. • Download figure • Download PowerPoint Figure 4. Adherence to the Mediterranean diet (MedDiet) and cardiovascular disease (CVD) in prospective studies (cohorts and trials). CBVD indicates cerebrovascular disease; CHD, coronary heart disease; f, fatal; HF, heart failure; h-stroke, hemorrhagic stroke; i-stroke, ischemic stroke; ITT, intention-to-treat; MI, myocardial infarction; mort, mortality; nf, nonfatal; PP, per-protocol; and RR, relative risk.

Diet mediterania use of sample quantiles as cutoff points to compute the MedDiet scores might be seen as a limitation because they depend on sample characteristics. However, this approach can present diet mediterania advantages because using quantile-defined categories instead of a priori defined cutoff points is in better agreement with characteristics of food-frequency questionnaires and other dietary assessment tools which are better suited to rank individuals than to accurately measure absolute intakes.

50 Therefore, the wider use of a score based on medians (or its variants using tertiles) should not be viewed as any major problem. Moreover, when Rosato et al diet mediterania restricted their meta-analysis to the studies using only the initial definition proposed in 2003 by Trichopoulou, 22 and they diet mediterania highest versus lowest categories, they obtained an RR of 0.82 (95% CI, 0.70–0.97) for CVD.

Interestingly, similar results were found for studies using other scores different from the score proposed by Trichopoulou, with an RR of 0.80 (95% CI, 0.73–0.87) with no evidence of heterogeneity between both set of studies ( P=0.52).

49 Analogous similarities without evidence of heterogeneity were found for CHD ( P [heterogeneity]=0.63) and stroke ( P [heterogeneity]=0.85). Therefore, there is no evidence to support that the differences in the definitions of the MedDiet may have affected the available results on cardiovascular health.

Light-to-moderate alcohol consumption is one item used in most of the MedDiet scores reflecting a common tradition in Mediterranean countries. This moderate consumption (1 or 2 drinks/day) has been consistently associated with a lower risk of CVDs. 148 Moreover, a Mediterranean alcohol-drinking pattern is characterized by a moderate consumption of alcohol, with preference of fermented drinks instead of spirits.

This pattern emphasizes the consumption of red wine during meals. 149 This level of alcohol consumption in the context of a MedDiet probably contributes to the synergistic effect of other components of the MedDiet with similar cardioprotective mechanisms such as increasing HDL-C (high-density lipoprotein cholesterol), decreasing platelet aggregation, promoting antioxidant effects, and reducing inflammation. 150, 151 Very importantly, the use of varied and disparate operational definitions and scores to capture diet mediterania construct of the MedDiet will represent a potential for nondifferential misclassification in individual original studies and a source of heterogeneity in meta-analyses.

Both factors most likely will tend to attenuate diet mediterania associations towards the diet mediterania value. This attenuation of effects may concur with other aspects of the definitions that may mainly represent a tendency to underestimate the effects. For example, the exclusion of all dairy products in the Trichopoulou score may lead to losing the potential cardiometabolic benefits of yogurt consumption and may attenuate the estimates of RR.

Similarly, the inclusion of potatoes in the group of vegetables or the diet mediterania of refined grains in the group of cereals would also produce an attenuating effect, as it was specifically shown in the SUN (Seguimiento Universidad de Navarra) cohort, where the group of cereals and, specifically white bread, showed an association with higher risk of CVD.

85 As all these issues related to different criteria for diet mediterania selection of food items in the operational definitions of MedDiet will potentially tend to attenuate the protective effects, it seems very unlikely that the consistent inverse association for the MedDiet with cardiovascular clinical events reported by many studies can be alternatively explained by the use of disparate criteria for computing the operational definitions and scores.

Causality Criteria Are Met The 9 classical criteria for supporting causality proposed half a century ago by Hill 152 are met for the effect of the MedDiet on cardiovascular health. Bradford Hill stated that “none of my nine viewpoints can bring diet mediterania evidence for or against the cause-and-effect hypothesis and none can be required as a sine qua non. What they can do, with greater or less strength, is to help us make up our minds on the fundamental question- is there any other way of explaining the set of facts before us, is there any other answer equally, diet mediterania more, likely than cause and effect?”.

152 However, the criterion of temporal sequence should be viewed as a sine qua non element. The application of these 9 principles to the association between better conformity to the MedDiet and a causal effect to reduce the risk of cardiovascular events is as follows. • 1. Temporal sequence: The design of the studies included in this review are prospective cohorts and RCT that provide a diet mediterania evidence for an adequate temporal sequence, because in all of them the exposure (MedDiet) clearly preceded the end point (CVD).

• 2. Strength of the association: A MedDiet relatively reduced the incidence of major CVD events by 30% after using an intention-to-treat approach, and attained even a higher reduction in a per-protocol analysis in the PREDIMED trial. 11 Findings are in line with prior predicted benefits calculated from a large body of observational evidence. 33, diet mediterania, 50 • 3.

Dose-response gradient: Greater adherence to the MedDiet showed an increased protection in a linear-trend fashion. Each additional 2-point increment in baseline adherence to the 0 to diet mediterania MedDiet score was associated with a monotonic 11% relative reduction in CVD.

50 • 4. Consistency: The 5 most comprehensive and recent meta-analyses published between 2014 and 2018 systematically evaluated this principle of consistency and concluded in favor of a strong and consistent cardiovascular protection by the MedDiet. 33, 49–52, 87 Also, 6 additional prospective studies not included in any of these meta-analyses supported this notion.

41, 124–128 In total, 45 11, 22, 23, 35–39, 41, 60, 66, 67, 71–73, 78–80, 83, 84, 88, 97, 102–104, 108–115, 117–121, 124–129, 153 reports of prospective studies were available, including 5 RCTs and 32 independent observational cohorts (some cohorts made several publications; Figure 4; Online Table I). The immense majority of these studies repeatedly found that a MedDiet was beneficial for cardiovascular health under quite a wide variety of circumstances, ruling out chance or confounding as an diet mediterania for diet mediterania association.

Furthermore, both measured and unmeasured potential confounding were rigorously discarded as alternative explanations in additional specific analyses conducted in the republished report of PREDIMED (please check the Online Appendix Table XXV of that report 11). In several meta-analyses, the removal of one study at a time did not nullify the inverse association between MedDiet diet mediterania cardiovascular events.

• 5. Biological plausibility: The MedDiet is associated with marked and consistent reductions in cardiovascular risk factors 154 and in levels of vascular inflammatory biomarkers. 7 The high fruit and vegetable intake contributes to its high antioxidant content and other pleiotropic benefits provided by the polyphenols and other bioactive molecules present in fruits, vegetables, EVOO, nuts, whole grains, and wine, diet mediterania the context of a MedDiet.

Additionally, it is known that food items and nutrients may diet mediterania synergistic effects when they are consumed in combination. • 6. Specificity: This criterion is probably one of the weakest among the diet mediterania proposed by Hill, because many exposures, including the MedDiet, are well-known to be associated with multiple outcomes. However, in agreement with the antiatherogenic properties of the foods typical of the MedDiet, closer adherence to the MedDiet appears to protect specifically against ischemic manifestations of CVD (MI, ischemic stroke, or peripheral artery disease 155) but its effects were found null against hemorrhagic stroke with an RR of 1.01 (95% CI, 0.74–1.37).

49 In the PREDIMED trial, the protective effect was present against the composite CVD outcome (composed mainly of ischemic clinical manifestations), but it was absent for total mortality, an end point that was not specific, because it included any cause of death, regardless of its relationship with nutrition or atherosclerosis.

• 7. Coherence: The association between MedDiet adherence and better cardiovascular health fits well within the known facts of the natural history and biology of CVD, as demonstrated by the Lyon trial for secondary prevention. 82 Beneficial effects on surrogate markers of CV risk adds coherence to the epidemiological evidence that supports a protective effect of the MedDiet.

• 8. Experimental evidence: The availability of several randomized trials using not only intermediate marker, but hard diet mediterania end points is a considerably diet mediterania of the MedDiet, that is not available for any other dietary pattern.

In addition, a good number of mechanistic trials conducted in subsets of participants by the PREDIMED investigators (see provide substantial analytical evidence supporting the biological bases for the effect of a MedDiet in lowering the risk of CVD events. • 9. Analogy: Other high-quality dietary patterns, such as the dietary approaches to diet mediterania hypertension (DASH) or the Alternative Healthy Eating Index, have also diet mediterania associated with reduced incidence of CVD events.

However, lack of analogy should not be considered as a criterion against causality. In fact, first-level evidence for the cardioprotective effect of the MedDiet, as collected and analyzed in PREDIMED and other trials, is not available for any other dietary pattern. High Nutritional Quality of the MedDiet Adds Biological Plausibility to These Findings Nutrition profiling and nutritional diet mediterania are topics of considerable current interest.

156 In this context, an additional element that adds biological plausibility to the findings of cohort studies and RCTs is a body diet mediterania evidence supporting the high nutritional quality of the MedDiet (ie, it is a nutrient-dense option) over diet mediterania actual dietary patterns which tend to be energy-rich but nutrient-poor. Maillot et al 157 modeled nutritionally adequate diets to simultaneously met the requirements for a whole set of nutrient goals (proteins, fiber, essential fatty acids, 10 vitamins, 9 minerals, sodium, saturated fatty acids, and free sugars) while deviating the least from the observed diet in terms of food content.

They found a strong consistency in the dietary changes needed to fulfill the constraints, and the greatest increases were seen for unsalted nuts, whole grains, legumes, fruit, fish/shellfish, and vegetables. They concluded that regardless of the different scenarios that they assumed, those foods which are typical of the MedDiet are needed to reach overall nutrient adequacy.

In the Mediterranean SUN cohort, a closer adherence to the MedDiet was reported to be strongly associated with a lower risk of failing to meet the goals for nutrient adequacy. 158, 159 As adherence to the MedDiet increased, the probability of not fulfilling the micronutrient goals sharply decreased. 159 This finding was replicated in other studies. 160 In another study, the SUN cohort investigators evaluated the intakes of Zn, I, Se, Fe, Ca, K, P, Mg, Cr and vitamins B1, B2, B3, B6, B12, C, A, D, E, and folic acid.

The probability of intake adequacy was evaluated using the estimated average requirement cutoff point approach and the probabilistic approach. Logistic regression analysis was used to assess the nutritional adequacy according to adherence to the MedDiet, evaluated the intakes of Zn, I, Se, Fe, Ca, K, P, Mg, Cr and vitamins B1, B2, B3, B6, B12, C, A, D, E, and folic acid. The diet mediterania were similar showing a strong inverse association between adherence to the MedDiet and overall nutritional adequacy.

159 These results were replicated also in the PREDIMED cohort. 161 Therefore, it seems very likely that the overall better nutritional quality of the MedDietary pattern may be able to bring about a substantial reduction in the risk of atherosclerotic-ischemic events, which are known to be related to biochemical disorders caused by suboptimal intakes of several micronutrients.

162, 163 Concordance Between Cohorts and Trials The findings of large observational cohort studies with good control for confounding are found to be replicated by the results of the 2 major trials (Lyon and PREDIMED). Such a strong consistency between large and well-conducted observational prospective cohorts and experimental studies is not available for any other dietary pattern.

In addition to these 2 trials, there is another trial, the GOSPEL (Global Secondary Prevention Strategies to Limit Event Recurrence After Myocardial Infarction) study. GOSPEL was a multicenter, randomized secondary prevention trial in survivors of an MI who were on cardiac rehabilitation, that compared a long-term, reinforced, multifactorial educational, and behavioral intervention with usual care. 121 The intervention program where 1620 patients were allocated included the adoption of a healthy MedDiet together with smoking cessation, promotion of physical activity, and addressing conventional cardiovascular risk factors.

The control group (n=1621) received usual care. At baseline, the scores of adherence to the MedDiet were equal in both groups. At 6 months, the score increased by 18% in the intervention group and by 14% in the usual care group, with modest but statistically significant differences between both. This difference in dietary habits between the 2 groups was maintained throughout the 3-year average duration of the study.

The primary end point included cardiovascular mortality, nonfatal MI, and nonfatal stroke, but also several softer events not included in the PREDIMED trial (hospitalization for angina pectoris, heart failure, or urgent revascularization procedures).

The intensive intervention nonsignificantly decreased the absolute risk by 2.1% (from 18.2% to 16.1%) of this combined primary cardiovascular end point (in total, 556 events). The relative reduction was 12% (RR, 0.88; 95% CI, 0.74–1.04; P=0.12) compared with usual care. However, it significantly decreased cardiovascular mortality plus nonfatal MI and diet mediterania (in total 129 events; RR, 0.67; 95% CI, 0.47–0.95; P=0.02) with respect to usual care (RR reduction, 33%).

However, the specific effect of the modest dietary contrast achieved between the intervention and control groups cannot be separated from the overall intervention program that included many other aspects. In any case, given the small magnitude of the dietary contrast and the probably nonspecific nature of the primary end point of diet mediterania GOSPEL trial, the results for the combination of MI, stroke, and cardiovascular death are more specific and they go in agreement with their expected direction.

Robustness of the Findings of the PREDIMED Trial in a Wide Variety of Sensitivity and Ancillary Analyses The greatest challenge in the PREDIMED trial was to obtain an effective change in the overall dietary pattern of 7447 participants.

A validated 14-item score was used to appraise the achieved changes in the overall food pattern. 25 The intervention was based on quarterly individual interviews and quarterly group sessions (with <20 participants per group) run by trained dietitians, provision of information on typical Mediterranean foods and dishes, shopping lists, weekly menus, cook recipes, and gifts of EVOO and mixed nuts.

Figure 5 shows the contrast between the baseline 14-item score (all participants) and this score after 1 year of intervention in the 2 groups allocated to MedDiets (merged together) and in the control group. The intervention was successful in attaining changes in many aspects of the overall food pattern and this is the main strength of PREDIMED. • Download figure • Download PowerPoint Figure 5. Adherence to the Mediterranean diet (MedDiet) in participants from the PREDIMED (Prevención con Dieta Mediterránea) trial at baseline and after 1-y follow-up.

The methodological issues in the PREDIMED trial consisted in departures from the individual randomization protocol recently reported in detail elsewhere. 11 Briefly, 425 participants, members of the same household of a previous participant were directly allocated during all trial duration to the same group as their previously randomized relative. In addition, 441 individual participants and 26 participant members of the same household from 1 of the 11 recruiting centers were allocated by clusters (clinics) instead of using individual randomization.

These issues were addressed by additionally adjusting for propensity scores that used 30 variables to estimate the probability that a participant would be allocated to each of the 3 intervention groups and with the use of robust variance estimators to account for intracluster correlations.

11 The results and conclusions remained intact after accounting for these small and partial diet mediterania from individual randomization in a subset of the trial. As a sensitivity analysis, a new per-protocol (adherence-adjusted) analysis was conducted and it found a hazard ratio for the primary cardiovascular end point of 0.42 (95% CI, 0.24–0.63) for the MedDiet as compared with the control diet.

Further sensitivity analyses excluding participants not individually randomized provided a very convincing picture, and kept the same message: the intervention caused a 30% reduction in the composite cardiovascular end point of MI, stroke, or cardiovascular death (the point estimates of the hazard ratios in all these intention-to-treat sensitivity analyses ranged from 0.64 to 0.72, and their upper 95% confidence limits from 0.88 diet mediterania 0.97).

There might be some concerns because of the possibility of unmeasured confounding. In this regard, the observed hazard ratio of 0.70 could be explained away by an unmeasured/unknown confounder that was associated with both the intervention group and the outcome by a risk ratio of 2.21, diet mediterania weaker confounding could not do so ( E value=2.21 for the point estimate and 1.5 for the upper limit of the CI).

164 In addition, it is important to not forget that when subjects with potential issues about departures from individual randomization were excluded, the protective effect was not attenuated, in fact, it slightly increased.

Biological Plausibility for the Effects of Polyphenol-Rich Foods in the MedDiet A substudy of PREDIMED including 1139 subjects measured total urinary polyphenol excretion at baseline and after 1-year intervention and categorized participants according to thirds of their changes in urinary total polyphenol excretion.

Participants in the highest tertile of changes in urinary total polyphenol excretion showed significantly lower plasma levels of inflammatory biomarkers including VCAM (vascular cell adhesion molecule)-1, ICAM (intercellular adhesion molecule)-1, IL (interleukin)-6, TNF (tumor necrosis factor)-α, and monocyte chemotactic protein-1 as compared with diet mediterania in the lowest tertile. A significant inverse correlation existed between urinary total polyphenol excretion and the plasma concentration of VCAM-1.

Systolic and diastolic blood pressure decreased and plasma HDL-C increased in parallel with increasing urinary total polyphenol excretion. 46 This finding suggests a dose-dependent anti-inflammatory effect of polyphenols within the amounts that they were consumed in participants allocated to receive diet mediterania education and advice on the Diet mediterania during 1 year. Moreover, in the PREDIMED trial, polyphenol diet mediterania, as derived from food-frequency questionnaires, was inversely associated with the incidence of cardiovascular events, 165 blood pressure, 166 and total mortality.

167 The polyphenol-rich MedDiet has also diet mediterania found to influence the expression of key genes involved in vascular inflammation, foam cell formation, and thrombosis. In addition, specific polyphenols should not be viewed in isolation, but as one of many cofactors in synergistic action with other beneficial elements included in the overall MedDiet pattern.

For example, a substudy of PREDIMED demonstrated that the dietary intervention was able to actively modulate the expression of proatherothrombotic genes. 168 In plasma metabolomic studies, the MedDiet was able to attenuate the harmful cardiovascular effects of branched-chain amino acids, 169 ceramides, 170 and adverse metabolites in the tryptophan-kynurenine pathway.

171 Many other mechanistic studies support that the amounts of polyphenols usually present in the traditional MedDiet are enough as to bring about substantial changes in metabolic pathways which play a pivotal role in cardiovascular health. 172 Further Experimental Evidence Beyond the PREDIMED and Lyon Trials Dinu et al 52 in their diet mediterania meta-analysis of the health effects of the MedDiet assessed 16 different meta-analyses of RCTs on the effects of the MedDiet on different outcomes.

They reported that 26 evaluations of cardiovascular outcomes were included in these meta-analyses. All point estimates from these meta-analyses were in the direction towards a benefit of the MedDiet for cardiovascular health, and most of these meta-analytical estimates from RCTs showed statistically significant results.

Dinu et al 52 repeated the diet mediterania methodology than Huedo-Medina et al 32 had used earlier for the evaluation of the quality of meta-analyses and applied the AMSTAR-MedSD tool used by Huedo-Medina. Dinu et al 52 in their updated evaluation obtained better results since they concluded that “all the investigated meta-analyses achieved a medium-to-high quality score, so suggesting that current meta-analyses evaluating the effects of the MedDiet on health status partially or almost fully comply with methodologic quality standards”.

The question of potential publication bias was explicitly addressed by Rosato et al. 49 They found suggestion of small-study effects, but when they stratified the results according to number of cases of CHD, they found an RR of 0.71 (95% CI, 0.64–0.79) and 0.60 (95% CI, 0.48–0.76), respectively, for studies including >600 cases compared with smaller studies.

Similarly, for stroke, the RRs were 0.82 (95% CI, 0.72–0.94) and 0.52 (95% CI, 0.26–1.03) for studies including >300 cases compared with smaller studies. This finding of inverse association both in large and small studies does not indicate that publication bias may provide an alternative noncausal explanation of these findings.

The 95% prediction intervals in meta-analyses go beyond CIs because they also account for between-study heterogeneity and provide a credible range to be 95% confident that the effect reported by a new imaginary study examining the same association will lie within that range.

173 Galbete et al 33 examined the 95% prediction interval for the association of the MedDiet with chronic disease risk. They reported that 95% prediction intervals excluded the null value for the associations with CVD incidence, or mortality, CHD, and stroke.

Therefore, there is reassuring evidence for these associations. We acknowledge that both the Lyon trial and PREDIMED diet mediterania conducted in Mediterranean areas, where the expected compliance with the MedDiet is likely to be higher. However, many of the studies shown in Figure 4 were conducted outside the Mediterranean basin and they found excellent results for this dietary pattern.

Therefore, though there is a need to replicate the findings of PREDIMED in other Western areas, the MedDiet seems to have also a high potential for transferability. 50 Major Sources of Information Had No Conflict of Interest With the Food Industry In the PREDIMED trial, which remains as the most significant contribution to the scientific literature on a traditional MedDiet, food companies only donated the food items, but the trial was funded by an independent public agency (Instituto de Salud Carlos III, ie, the Spanish National Institutes of Health) without any commercial interest whatsoever.

The umbrella meta-analysis by Galbete et al 33 was funded by the German Federal Ministry of Education and Research. The authors of the main recent meta-analyses, 49–52, 87 reported no conflicts diet mediterania interest with the food industry. The studies included in these meta-analyses that contributed with a higher amount of person-years (Nurses Health Study, 23 EPIC study, 22, 111 and the National Institutes of Health-American Association of Retired Persons, 60 were publicly funded.

Conclusions We have shown here that there is a large, strong, plausible, and consistent body of available prospective evidence to support the benefits of the MedDiet on cardiovascular health. Moreover, in the era of assessing overall food patterns, no other dietary pattern has undergone such a comprehensive, repeated, and international assessment of its cardiovascular effects.

The MedDiet has successfully passed all the needed tests and it approaches the gold standard for cardiovascular health. The MedDiet can be adapted to many different geographic settings by tailoring it to individual characteristics such as food and cultural preferences and health conditions. Promotion of the MedDiet requires changes in the food environment, the food systems, and public diet mediterania policies to improve diet mediterania diet quality of individuals, communities, and populations.

Nonstandard Abbreviations and Acronyms aMedDiet alternative Mediterranean diet CHD coronary heart disease CVD cardiovascular disease EVOO extra-virgin olive oil GOSPEL Global Secondary Prevention Strategies to Limit Event Recurrence After Myocardial Infarction HDL-C high-density lipoprotein cholesterol ICAM intercellular adhesion molecule IL interleukin LDL-C low-density lipoprotein cholesterol MI myocardial infarction MUFA monounsaturated fat MedDiet Mediterranean diet PREDIMED Prevención con Dieta Mediterránea RCT randomized controlled trial RR relative risk SFA saturated fat SUN Seguimiento Universidad de Navarra TNF tumor necrosis factor VCAM vascular cell adhesion molecule Sources of Funding European Research Council (Advanced Research Grant 2014–2019; agreement number 340918) granted to Dr Martínez-González as Principal Investigator for the PREDIMEDPLUS trial (Prevención con Dieta Mediterránea-Plus).

CIBER-OBN (Centro de Investigación Biomédica en Red de Obesidad y Nutrición) is an initiative of the Instituto de Salud Carlos III (main public agency for funding biomedical research in Spain) and it is supporting the investigation on Mediterranean diet conducted by the authors. References • 1. Lloyd-Jones DM, Hong Y, Labarthe D, et al.; American Heart Association Strategic Planning Task Force and Diet mediterania Committee.

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Liu T, Wen H, Li H, Xu H, Xiao N, Liu R, Chen L, Sun Y, Song L, Bai C, Ge J, Zhang Y diet mediterania Chen J (2020) Oleic Acid Attenuates Ang II (Angiotensin II)-Induced Cardiac Remodeling by Inhibiting FGF23 (Fibroblast Growth Factor 23) Expression in MiceHypertension75 :3(680-692)Online publication date: 1-Mar-2020. Subjects • All Subjects • Arrhythmia and Electrophysiology • Basic, Translational, and Clinical Research • Critical Care and Resuscitation • Epidemiology, Lifestyle, and Prevention • Genetics • Heart Failure and Cardiac Disease • Hypertension • Imaging and Diagnostic Testing • Intervention, Surgery, Transplantation • Quality and Outcomes • Stroke • Vascular Disease Kelebihan berat badan sering dikaitkan dengan peningkatan risiko kematian dini terkait stroke, diabetes tipe 2, penyakit kardiovaskular, kanker, dan infertilitas.

Kegagalan dalam mempertahankan penurunan berat badan yang sehat di mana berat badan kembali naik merupakan masalah penting dan belum terpecahkan.

BACA JUGA: Kabar Bahagia! THR PNS Solo Cair 1 Minggu Sebelum Lebaran Cara turunkan berat badan yang benar menurut ahli terungkap salah satunya dalam studi terbaru dari Universitas Kopenhagen dan Rumah Sakit Hvidovre. Studi itu menunjukkan pengobatan yang efektif setelah penurunan berat badan yang disebabkan oleh diet adalah menggabungkan olahraga intensif sedang hingga berat dengan obat diet mediterania penghambat nafsu makan.

BACA JUGA: Dibantu Ganjar, Rumah Ngatemi Tak Lagi Jadi Kandang Sapi Penelitian tersebut menemukan penurunan berat badan yang signifikan dapat dipertahankan dengan olahraga selama kurang lebih 115 menit per pekan. - Ada banyak nama diet yang sering kita dengar, seperti diet vegan, diet DASH, hingga diet mediterania.

Tapi, belakangan juga ada istilah diet ovo- vegetarian, yang digambarkan sebagai orang yang tidak bisa makan daging, selain telur. Untuk mengenal diet yang satu ini, simak selengkapnya yang dilansir dari Times Of India. Pengertian Ovo-Vegetarian Pada diet ini, seseorang dapat mengonsumsi semua buah, sayuran, labu, kacang polong, buncis, dan biji-bijian seperti berat, quinoa, dan barley.

Hanya saja, diet ini dibarengi dengan rempah-rempah beserta telur putih, mayones, mie telur, dan beberapa makanan yang bisa dipanggang. Baca Juga: Perhatikan Nutrisi Kucing Dewasa Anda Demi Umur Panjang dan Kesehatannya Namun, pada diet ini seseorang tidak boleh mengonsumsi apapun yang berhubungan dengan hewan, seperti daging, susu, keju, mentega, es krim, protein whey, krim asam, dan krim keju. Ilustrasi vegetarian, salad sayur (Pixabay/Sponchia) Ada beberapa alasan mengapa seseorang memilih menjadi diet mediterania.

Beberapa orang melakukannya karena alasan agama/budaya. Sementara itu, diet ini diterapkan untuk kesehatan mereka. Dan alasan umum seseorang cenderung memilih diet ini adalah, ketika seseorang ingin menjadi vegetarian tetapi alergi terhadap diet mediterania susu. Apakah Ovo-Vegetarian Lebih Sehat Dibanding Diet Lain? Berbicara tentang nutrisi, diet ovo-vegetarian menyediakan protein yang cukup untuk kesehatan tubuh.

Mulai dari lemak, vitamin, dan mineral yang sehat.

diet mediterania

Telur dikatakan rendah kalori, dan menjadi salah satu alasan etis untuk mendapatkan nutrisi di saat seorang tidak bisa makan daging. none - Penyakit jantung diketahui merupakan salah satu penyakit paling mematikan di dunia. Penyakit jantung mengacu pada berbagai kondisi yang mempengaruhi fungsi jantung. Seperti diketahui, jantung adalah organ berotot kompleks yang memompa darah ke seluruh tubuh dalam ritme yang teratur.

Oleh sebab itu, penyakit jantung harus dicegah sejak awal, sebab kondisi ini dapat menyebabkan penumpukan plak pada arteri koroner yang memasok darah ke jantung, atau arteri perifer yang memasok darah ke anggota tubuh dan otak. Dilansir dari, ada beberapa cara yang dapat dilakukan untuk menurunkan risiko penyakit jantung, yaitu: 1.

Ikuti diet sehat jantung Diet Mediterania diet mediterania menjadi pilihan teratas pola makan yang disarankan untuk kesehatan jantung. Sebabnya, diet ini melibatkan makanan yang secara umum dikonsumsi di negara-negara yang berbatasan dengan Laut Mediterania. Diet Mediterania berfokus pada buah-buahan, sayuran, biji-bijian utuh, dan lemak sehat, seperti minyak zaitun. Ahli jantung dari Cleveland Clinic.

Dr. Laffin, menyebut diet ini bisa menurunkan resiko stroke hingga serangan jantung.
My take on limonada: Mediterranean-style mint lemonade as they make it in Egypt. Intense with flavor, extra frothy, and extremely refreshing! There is a tiny trick involved that makes all the difference. There is an ahwa on every street corner in Egypt. If you're not familiar, ahwas are small coffeehouses.

We're talking hole-in-the-wall type establishments, open to the streets and filled with tiny round tables and chairs. The air is usually filled with smoke diet mediterania the hookas (water pipes). They say, if you want to see and hear Egypt, all you need to do is diet mediterania out at an ahwa.

There are many sounds going on--sounds of busy streets; sounds of men talking politics and young men competing in tournaments of board games; and sounds of ahwa waiters shouting drink orders. On the menu are the usual drinks: Turkish coffee; black tea; and limonada (lemonade).

My favorite is mint lemonade, which is more commonly served in the summer. The trick to a frothy mint lemonade Today's lemonade recipe is my take on the Mediterranean-style mint lemonade as served in Egypt's ahwas. This homemade lemonade is more dense, frothy, and comes with an extra refreshing punch from fresh mint. The trick to this thicker, frothy mint lemonade is in blending the majority of the lemons or limes with the skin on.

This adds intensity to the flavor and the texture of the lemonade. This Mediterranean-style mint lemonade is absolutely my favorite drink, particularly on hot summer days! You can add a splash of soda or vodka for a more "adult" version. Here is the step-by-step for this mint lemonade recipe (Scroll down for the print-friendly version) Important note: if your blender is weaker, you will want to cut the lemons into smaller pieces, and also finely chop the mint leaves before blending.

Add all the crushed ice, water, 2 cut lemons, juice of 1 lemon, fresh mint, and sugar to the pitcher of a high-quality blender. Cover and push blend or liquefy (high-speed function), until you achieve the desired drink consistency.

Taste and add more sugar or mint leaves, if you like. Blend again. Pour the lemonade into a serving pitcher through a mesh strainer. Add fresh mint leaves to the pitcher. Cover and refrigerate until you are ready to serve. If you like, strain the lemonade again as you pour into diet mediterania glasses. Enjoy cold! Pin this recipe: Other Mediterranean recipes with mint: Watermelon Salad with Mint and Feta Tabouli Salad Last-minute feta cheese dip Spicy Harissa Lentil Salad • 2 cups crushed ice • 4 cups water • 2 large lemons (or limes), washed, cut into small pieces, and seeds removed • Juice of 1 large lemon • 1 bunch fresh mint leaves, stems removed (about 25- 40 mint leaves), more for later • 1 cup sugar, more or less to your liking (you can use cane sugar or part honey, if you like) • Add all the ingredients to the pitcher of a high-quality blender.

Cover and push blend or liquefy (high-speed function), until you achieve the desired drink consistency. • Taste and add more sugar or mint leaves, if you like.

Blend again. • Pour the lemonade into a serving pitcher through a mesh strainer. Add fresh mint leaves to the pitcher.

Cover and refrigerate until you are ready to serve. • If you like, strain the lemonade again as you pour into serving glasses. Enjoy cold! For me I made this and it turned out great the key is to only use some of the lemon skin and not all or it will turn bitter, for example if I use 2 lemons or 6 small limes I’d only use half or less of the lemon skins to keep it from going bitter, you can always taste to add more but remember once you add to much it’s hard to get the bitter taste out, hope this diet mediterania Hi Ann.

Are you thinking of using like a Splenda or something of that sort? Or to simply replace the sugar with a natural raw sugar? I can't say I have experience with either in this particular recipe. I have recently tried XLear, and it tasted pretty good to me; but I can't say that I tried it in this lemonade though.

I would love to hear, if you try something different. Hi! Welcome to The Mediterranean Dish, your #1 resource for Mediterranean recipes & lifestyle. I'm Suzy. I was born and raised in the cosmopolitan Mediterranean city of Port Said, Egypt, a "boat ride" away from places like Italy, Greece, Turkey, Lebanon, Palestine and Israel. Today, influenced by my mother's tasty kitchen, and my extensive travels, I share easy wholesome recipes with big Mediterranean flavors.

Welcome to my table. Read More about Suzy • • • • Fresh Recipes to "Reset" - Jika Anda sedang berkutik dengan penurunan berat badan, berikut ini ada solusi menu diet untuk Anda coba. Menu diet Mediterania ini bisa menjadi pilihan Anda sebagai solusi penurunan berat badan yang sehat. Menu diet Mediterania ini dianggap sebagai yang paling sehat, selama empat tahun berturut-turut, berdasarkan laporan US News & World Report.

Diet mediterania juga dipercaya dapat mengurangi risiko berbagai penyakit kronis di tubuh. Mulai diabetes, kolesterol tinggi, demensia, kehilangan memori, depresi dan kanker payudara.

Selain itu, diet mediterania ini juga terbukti membuat tulang lebih kuat, jantung lebih sehat dan diet mediterania yang lebih panjang. Jadi, jika Anda sedang mencari pilihan diet untuk diterapkan, menu diet mediterania Mediterania ini bisa dicoba. Tak hanya membantu menurunkan berat badan, diet mediterania juga bisa menyelematkan hidup Anda.

Nah, lihat berikut ini bagaimana menu diet Mediterania yang bisa Anda coba. Baca Juga: Menu Diet Tike Priatnakusumah yang Berhasil Turunkan Berat Badan Hingga 15 Kg, Tetap Bisa Makan Nasi! ARTIKEL TERKAIT • Menu Diet Tya Ariestya Bisa Bikin Auto Turun 7 Kg Dalam Sebulan, Gampang Dan Masih Bisa Makan Nasi • Impian Badan Ideal di Depan Mata! Menu Diet Ubi Bisa Jadi Pengganti Nasi Untuk Bantu Turunkan Berat Badan Secara Alami • Menu Diet Intan Nuraini Untuk Bisa Dapatkan Diet mediterania Ideal Secara Alami, Dijamin Tubuh Balik ABG Lagi • Menu Diet Tike Priatnakusumah yang Berhasil Turunkan Berat Badan Hingga diet mediterania Kg, Tetap Bisa Makan Nasi!

• Anak 3 Tapi Tubuh Kaya ABG, Menu Diet Nia Ramadhani Bikin Syok, Ternyata Tiap Pagi Sering Makan Ini
HOW TO GET STARTEd The Mediterranean Diet Challenge starts January 3, 2022—join us at any time! The diet mediterania Make Every Day Mediterranean: An Oldways 4 Week Menu Plan takes you through a month of Mediterranean-style eating, day-by-day and meal-by-meal.

diet mediterania

It is diet mediterania in print or as an e-book. For additional support, join Oldways’ Mediterranean Diet Facebook group. BUY THE BOOK What is the Mediterranean Diet?

The Mediterranean Diet was the Best Overall Diet in 2022, 2021, 2020, 2019, and 2018, according to U.S. News & World Report. In 2022, the Mediterranean Diet was ranked #1 Best Plant-Based Diet, Best Heart-Healthy Diet, Best Diabetes Diet, Best Diet for Healthy Eating, and the Easiest Diet to Follow, according to U.S.

News & World Report. In 1993 Oldways created the Mediterranean Diet Pyramid – in partnership with the Harvard School of Public Health and the WHO – as a healthier alternative to the USDA’s original food pyramid. Today, the Mediterranean Diet is more popular than ever, with new research every month documenting its benefits, and chefs and home cooks alike embracing Mediterranean ingredients and flavors.

Starting at the base of the pyramid, you’ll find: • Core foods to enjoy every day: whole grains, fruits, vegetables, beans, herbs, spices, nuts and healthy fats such as olive oil. • Twice weekly servings of fish and seafood. • Moderate portions of dairy foods, eggs, and occasional poultry. • Infrequent servings of red meats and diet mediterania. Oldways also offers a wealth of online health information and recipes. Continue reading below to diet mediterania enjoying good taste and good health with the Mediterranean Diet!

Our Mediterranean Diet Email Newsletter Receive inspiration straight to your email every other week when you sign up for our Fresh Fridays newsletter. The e-newsletter celebrates the Mediterranean Diet and its remarkable health benefits. Each issue includes delicious recipes that will remind you just how easy it is to enjoy beautiful, simple, economical, and easy-to-find Mediterranean foods.

The Mediterranean Diet Pyramid Our “Mediterranean Diet 101” brochure: Welcome to the Mediterranean Diet Our “Welcome to the Mediterranean Diet” brochure (which we fondly refer to as the “Mediterranean Diet 101”) is one of our most popular handouts for dietitians, medical offices, health centers, and community organizations.

This trifold brochure is a wonderful intro to the health benefits and the “how-to’s” of the traditional Mediterranean Diet. It includes the 8 simple steps below, plus more – to introduce you to the Mediterranean Diet.

To purchase hard copies of this brochure to share with your community, visit the Oldways store. 8 Steps to Getting Started with the Mediterranean Diet Embracing the Med Diet is all about making some simple but profound changes in the way you eat today, tomorrow, and for the rest of your life. • Eat lots of vegetables. From a simple plate of sliced fresh tomatoes drizzled with olive oil and crumbled feta cheese to stunning salads, garlicky greens, fragrant soups and stews, healthy pizzas, or oven-roasted medleys, vegetables are vitally important to the fresh tastes and delicious flavors of the Med Diet.

• Change the way you think about meat. If you eat meat, have smaller amounts – small strips of sirloin in a vegetable sauté, or a dish of pasta garnished with diced prosciutto. • Enjoy some dairy products. Eat Greek or plain yogurt, and try smaller amounts of a variety of cheeses. • Eat seafood twice a week. Fish such as tuna, herring, salmon, and sardines are rich in omega-3 fatty acids, and shellfish including mussels, oysters, and clams have similar benefits for brain and heart health.

• Cook a vegetarian meal one night a week. Build meals around beans, whole grains, and vegetables, and heighten the flavor with fragrant herbs and spices. Down the road, try two nights per week. • Use good fats. Include sources of healthy diet mediterania in daily meals, especially extra-virgin diet mediterania oil, nuts, peanuts, sunflower seeds, olives, and avocados.

• Switch to whole grains. Whole grains are naturally rich in many important nutrients; their fuller, nuttier taste and extra fiber keep you satisfied for hours. Cook traditional Mediterranean grains like bulgur, barley, farro and brown, black or red rice, and favor products made with whole grain flour.

• For dessert, eat fresh fruit. Choose from a wide range of delicious fresh fruits — from fresh figs and oranges to pomegranates, grapes and apples. Instead of daily ice cream or cookies, save sweets for a special treat or celebration.

Foods & Flavors of the Mediterranean Diet It’s likely that many Mediterranean foods are diet mediterania among your favorites.

There are so many choices! Check out our Mediterranean Foods glossary to learn about some of the most popular dishes people living around the Mediterranean Sea make with these ingredients. Another great resource is our Mediterranean Pantry page, which lists products from Mediterranean Foods Alliance member companies. Download a list of traditional Mediterranean foods. The Mediterranean Diet and Health: Proven Benefits in Countless Studies Scientists have intensely studied the eating patterns characteristic of the Mediterranean Diet for more than half a century.

Shortly after World War II, Ancel Keys and colleagues (including Paul Dudley White, later President Eisenhower’s heart doctor) organized the remarkable Seven Countries Study to examine the hypothesis that Mediterranean-eating patterns contributed directly to improved health outcomes. This long-running study examined the health of almost thirteen thousand middle-aged men in the United States, Japan, Italy, Greece, the Netherlands, Finland, and then-Yugoslavia.

When the data were examined, it was clear that people who ate a diet where fruits and vegetables, grains, beans, and fish were the basis of daily meals were healthiest. Topping the chart were residents of Crete. Even after the deprivations of World War II – and in part, perhaps, because of them – the cardiovascular health of Crete residents exceeded that of US residents.

Researchers attributed the differences to diet. Out of this extensive work came an understanding that certain Mediterranean-eating patterns were remarkably connected with good health. From diet mediterania conclusion emerged the concept of a “Mediterranean Diet” that could promote lifelong good health.

In subsequent years, hundreds if not thousands of additional studies have added to the body of scientific evidence supporting the “gold standard” status of diet mediterania Mediterranean Diet eating patterns. These studies show that eating the Med way may: • Lengthen your life • Improve brain function • Defend you from chronic diseases • Fight certain cancers • Lower your diet mediterania for heart disease, high blood pressure and elevated “bad” cholesterol levels • Protect you from diabetes • Aid your weight loss and management efforts • Keep away depression • Safeguard you from Alzheimer’s disease • Ward off Parkinson’s disease • Improve rheumatoid arthritis • Improve eye health • Reduce risk of dental disease • Help you breathe better • Lead to healthier babies • Lead to improved fertility Check out our Health Studies page, where we post all diet mediterania latest research in diet mediterania of the Mediterranean Diet and other traditional ways of eating.

The Healthy Pasta Meal Today’s healthy pasta meals have roots that stretch back to ancient times. Thousands of years ago, people ground wheat, mixed it with diet mediterania to make a wheat paste, dried it, and then boiled it to go with meals. Today’s consumers welcome pasta to their tables for its versatility and convenience, just as nutrition scientists recognize pasta meals for their place in healthy eating patterns, such as the “gold standard” Mediterranean Diet and the traditional Latin American diet.

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Apakah itu diet Mediterania? Sebagian orang mungkin belum familiar dengan salah satu diet sehat ini. Diet Mediterania (MND) adalah diet yang kaya buah-buahan, sayuran, biji-bijian, kentang, kacang-kacangan, minyak zaitun diet mediterania ikan. Diet MND jarang mengolah makanan yang digoreng, cepat saji, makanan ringan, susu, daging merah hingga unggas. Rata-rata makanan tersebut menjadi makanan yang tidak sehat bagi lansia.

BACA JUGA: Cara Turunkan Berat Badan yang Benar Menurut Ahli Dalam Diet mediterania of American Geriatrics Society, diet MND memang punya hubungan dengan risiko yang lebih rendah mengalami kesulitan memori pada populasi lansia.

Para peneliti menganalisis informasi dari 5.907 lanjut usia yang berpartisipasi dalam Health and Retirement Study. Peserta mengisi kuesioner tentang kebiasaan makan mereka. BACA JUGA: Kabar Bahagia! THR PNS Solo Cair 1 Minggu Sebelum Lebaran Peneliti kemudian mengukur kemampuan kognitif para peserta.

Pengukuran fungsi kognitif fokus pada fungsi memori dan keterampilan perhatian atau atensi mereka. Peneliti membandingkan diet peserta dengan kinerja mereka pada tes kognitif. Mereka menemukan bahwa orang tua yang makan diet gaya Mediterania mendapat skor yang jauh lebih baik pada tes fungsi kognitif dari mereka yang diet kurang sehat.

BACA JUGA: 4 Fakta Seputar Telur Asin, Cara Membuatnya Mudah! Bahkan, orang tua yang makan diet gaya Mediterania memiliki risiko 35% lebih rendah untuk mengalami gangguan kognitif.

Diet Mediterania