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Mediterranean Diet – an overview

  • August 09, 2020
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Mediterranean diet composed by olive oil, fruits, vegetables, whole grains, nuts, legumes, small amounts of diary (cheese and yogurt) and fish has proven effect in preventing diabetes (Sofer et al., 2015).

From: Encyclopedia of Endocrine Diseases (Second Edition), 2019

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A. Trichopoulou, E. Vasilopoulou, in Encyclopedia of Food and Health, 2016


The traditional Mediterranean diet (MD) is the diet prevailing until the early 1960s in the olive tree-growing areas of the Mediterranean basin. Until then and in spite of frequent violent disruptions, daily life and dietary habits in the Mediterranean region remained largely unchanged, and populations still applied simple and time-honored nutritional approaches. In the 1960s, however, the food industrial revolution, which was gradually expanding in Europe after the Second World War, finally reached the Southern European countries causing a serious disruption in the traditional dietary pattern of the Mediterranean populations.

The traditional MD is the heritage of millennia of exchanges of people, cultures, and foods of the countries around the Mediterranean basin. The succession of different dominant population groups introduced and/or contributed to the diffusion of different crops and foods. Some plants, like the olive tree, wheat, and the grapevine, have apparently been in this area since antiquity. Other plants, however, such as orange and lemon trees, as well as tomatoes, eggplants, corn, rice, and potatoes, were imported at different time periods. All of these, however, have found their way into the MD, which reflects a balanced ecosystem supported by the benevolent climate of this region.

The MD implies a common dietary pattern in Mediterranean countries; however, there are differences in the dietary patterns of the Mediterranean populations due to regional, cultural, and religious factors. However, in all of them, olive oil occupies a central position. It is therefore legitimate to consider these diets as variants of a single entity, the MD, which refers to dietary patterns found in olive-growing areas of the Mediterranean region until the 1960s. The traditional MD is characterized by high consumption of olive oil, vegetables, legumes, fruits, and unrefined cereals; regular but moderate wine intake, mostly during meals unless prohibited for religious purposes; moderate to high consumption of fish; low consumption of meat; and low to moderate intake of dairy products.

The word diet derives from the ancient Greek word ‘diaita,’ which implies equilibrium and lifestyle. Therefore, the traditional MD is more than just a diet; it is a whole lifestyle pattern with physical activity playing an integral role. This healthy lifestyle is also the consequence of the availability of local agricultural products, related to the geographic and climatic Mediterranean environment. A life-affirming aspect of the Mediterranean food culture is the central role of conviviality: the pleasure of sharing food with others and of celebrating communal culinary traditions and life at large. A notable point is wine consumption, which, except when prohibited on religious grounds, has been consumed in moderation in Mediterranean countries, almost always during meals and as a rule in the company of friends – the ancient Greek word ‘symposium’ means drinking in company, but with a connotation of intellectual interchange.

The MD was acknowledged by UNESCO in 2010 as an intangible cultural heritage with the following description:

The Mediterranean diet constitutes a set of skills, knowledge, practices and traditions ranging from the landscape to the table, including the crops, harvesting, fishing, conservation, processing, preparation and, particularly, consumption of food. The Mediterranean diet is characterized by a nutritional model that has remained constant over time and space, consisting mainly of olive oil, cereals, fresh or dried fruit and vegetables, a moderate amount of fish, dairy and meat, and many condiments and spices, all accompanied by wine or infusions, always respecting beliefs of each community. However, the Mediterranean diet encompasses more than just food. It promotes social interaction, since communal meals are the cornerstone of social customs and festive events.

The traditional MD reflects as much the benign climate and the flora of the area, as the culture and the hardship of the people who were mostly responsible for the formulation of this diet.

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Elena Azzini, Giuseppe Maiani, in The Mediterranean Diet, 2015


Scientists have focused their attention on the traditional Mediterranean diet (MD), designated an Intangible Cultural Heritage by UNESCO, for its proven health benefits. The overall objective of this chapter is to reexamine the role of the MD in human nutrition, particularly its effect on human antioxidant nutritional status. We emphasize the attention on plant-origin foods rich in vitamins, minerals, dietary fiber, and phytonutrients that contribute to general well-being, satiety, and the maintenance of a balanced diet. A solid scientific background seems to support the MD as an optimal dietary pattern for healthy eating and the prevention of a wide spectrum of disease including cardiovascular disease [1,2]. neurodegenerative [3–5] and inflammatory disease [6], metabolic disorders [7,8], and cancer [9].

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Keith Grimaldi PhD, Antonio Paoli MD, BSc, in The Mediterranean Diet, 2015


The Mediterranean diet is recognized as one of the most healthy in the world, and variations of it seem to be the most successful nutritional regimens for reducing cardiovascular risk factors. But what is the Mediterranean diet? Is it the same for everyone? The answer to the first question is exhaustively treated by other contributors to this book. To answer the second question, this chapter looks at recent nutrigenomic research applied to the Mediterranean diet. It is divided into three sections: (1) nutrigenetics, the use of the Mediterranean diet to neutralize potentially negative effects of some common genetic variants; (2) nutrigenetics, individual differences in the response to the Mediterranean diet; and (3) nutrigenomics, the effects of the Mediterranean diet on gene expression.

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Mark C.C. Cheah, … George B.B. Goh, in Bioactive Food as Dietary Interventions for Diabetes (Second Edition), 2019

8 Mediterranean Diet

MD is characterized by a low consumption of red meat and full fat diaries with an increased consumption of fish poultry, fruits, vegetables, non-refined cereals legumes, and potatoes.87 The diet is low in SFA and rich in omega-3 PUFA, MUFA, with olive oil as the main contributor of MUFA. Olive oil is typically used in food preparation and also for consumption. Low-to-moderate amounts of wine may be taken with meals. The MD however, lacks a clear, universally accepted definition. While it reflects the traditional eating habits practiced by populations indigenous to the areas bordering the Mediterranean sea, the exact composition of the MD is heterogeneous with a high degree of geographic variability.88 In epidemiological studies, the MD Score, proposed by Tricopoulou et al.87, 89 is commonly used to define adherence to the traditional MD. The score allocates a value of 0 or 1 in each of nine components: [(i) vegetables, (ii) legumes, (iii) fruit and nuts, (iv) cereal, (v) fish, (vi) the beneficial ratio of MUFA to SFA, (vii) all meats, (viii) dairy products, and (ix) alcohol] according to sex-specific median cut-offs.

In NAFLD patients, adherence to the MD was associated with a lower intrahepatic TG content, likelihood of high-grade steatosis/NASH and degree of IR.90–94 Several studies have evaluated MD as a possible dietary intervention in patients in NAFLD/NASH (Table 3). Exploring different diets in obese patients with DM, Fraser et al.29 demonstrated that MD was independently associated with the lowest ALT levels at both 6 and 12 months when compared with the other diets. Bozzetto et al.95 in a 8 week randomized trial comprising 45 patients with type 2 DM studied the effects of a high-CHO/high-fiber/low-GI diet vs a high MUFA diet with and without a physical activity program; 29% hepatic fat reduction was noted in the high MUFA diet, when compared with only 4% reduction in the low GI diet. Consistent findings of beneficial effects of MD on hepatic fat, weight, insulin sensitivity, and other metabolic parameters were also reported by Ryan et al.96 and Abenavoli et al.97

Table 3. Studies evaluating the effects of Mediterranean diet and NAFLD/metabolic syndrome

Author (year) Study design Patient population Intervention/evaluation Summary of results
Aller et al.90 Cross-sectional study

82 patients with NAFLD/NASH

Associations between adherence to MD and liver histological characteristics

Adherence to MD was associated with a lower likelihood of having steatohepatitis 0.43 (CI: 95%: 0.29–0.64) and steatosis 0.42 (CI: 95%: 0.26–0.70)

Kontogianni et al.91 Cross-sectional study

73 patients with NAFLD

Associations between adherence to MD and patient biochemical profile, histology

Patients with nonalcoholic steatohepatitis (NASH) exhibited lower adherence to MD (29.3 ± 3.2 vs 34.1 ± 4.4, P = 0.004)

Adherence to MD was associated with a lower likelihood of having steatohepatitis (odds ratio: 0.64, 95% confidence interval: 0.45–0.92)

Chan et al.92 Cross-sectional study

797 healthy volunteers in population health screening

N = 220 with NAFLD

Associations between DQ-I and MDS with NAFLD prevalence (as determined by MRS)

DQ-I but not MDS was associated with the prevalence of NAFLD

Nonadherence as assessed by DQ-I was associated with the likelihood of having NAFLD (OR: 1.24 (95% CI: 1.06–1.45), P = .009)

Baratta et al.93 Cross-sectional study

584 patients with metabolic risk factors

Association between adherence to MD and NAFLD (as diagnosed by ultrasound)

Adherence to MD (high adherence vs low adherence) was negatively associated with NAFLD (OR: 0.093 (95% CI: 0.011–0.792), P = 0.030)

Fraser et al.29 Quasi-randomized study

259 Obese patients with diabetes

12-month study

Randomized to three isocaloric diets:


American Diabetes Association (2003) (n = 64)

50%–55% CHO, 30% Fat, 20% Protein


Low GI (n = 73)

50%–55% Low GI CHO, 30% fat, 20% protein


Modified Mediterranean (n = 64)

35% low GI CHO, 45% fat (high MUFA), 15%–20% protein

Endpoint: reduction in ALT levels

Lowest mean ALT levels in the modified MD, followed by the low GI diet

Effect persisted despite correction for waist to hip ratio, BMI, homeostasis or TG

Bozzetto et al.95 2 × 2 Randomized parallel-group design

45 patients with type 2 DM

8-week study of isocaloric high-CHO/high-fiber/low-GI diet vs a high MUFA diet with and without a physical activity program

Liver fat as assessed by MRS

Hepatic fat content was decreased in by a greater degree MUFA (− 29%) and MUFA + Exercise (–25%) groups than in CHO/fiber (–4%) and CHO/ fiber + Exercise groups (–6%).

Ryan et al.96 Randomized, cross-over trial

12 nondiabetic patients with biopsy proven NAFLD

6 week dietary intervention comparing MD vs a control diet (low fat, high CHO) with a 6 week washout in-between

Biochemistry, Insulin sensitivity and hepatic fat content were compared

No difference in mean weight loss between both groups

Significant relative reduction in hepatic fat by MRS in MD vs control (39 ± 4% vs 7 ± 3%, P = 0.012)

Improvements in insulin sensitivity in MD vs control

Abenavoli et al.97 Randomized, control trial

50 overweight patients, BMI> 25 kg/m2 with NAFLD

Randomized into:


Low calorie MD (1400–1600 kcal/day: 50–60% CHO, 15%–20% protein, MUFA, PUFA < 30%, SFA < 10%, fiber 25–30 g/day)


Low calorie MD with Antioxidants


No treatment

Anthropometric parameters, biochemistry, hepatic fat content (FL Index) and liver stiffness were compared

Significant reductions in weight, BMI, waist circumference, fasting glucose, serum insulin, triglycerides, fatty liver index, and liver stiffness as assessed by transient elastrography favoring MD groups vs control

CHO, carbohydrates; DQ-I, Diet Quality Index-International; FL Index, Fatty Liver index (ultrasound assessment of steatosis); LSM, liver stiffness measurement; MD, Mediterranean diet; MDS, Mediterranean diet score; MRS, magnetic resonance spectroscopy; MUFA, monounsaturated fatty acids; PUFA, polyunsaturated fatty acids; SFA, saturated fatty acids; T2DM, type 2 diabetes mellitus; TE, transient elastography; VLDL, very low density lipoproteins.

Given the numerous benefits that the MD has toward the various components of the MS and associated complications (stroke, cardiovascular disease) that extend beyond the benefits of weight loss, MD has been one of the diets endorsed by the AHD/American College of Cardiology.98 With respect to NAFLD, the MD has also been endorsed by EASL-EASD-EASO in their 2016 guidelines as the diet of choice for patients with NAFLD.20

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Dimitra Karageorgou MSc, … Antonis Zampelas PhD, in The Mediterranean Diet, 2015


The Mediterranean diet has been repeatedly associated with protective effects on health status and, in particular, οn the development of chronic diseases. The purpose of this chapter is to provide an up-to-date review of evidence from prospective cohort studies and randomized controlled trials regarding the effect of Mediterranean diet on cardiovascular disease. The outcomes of interest are fatal and nonfatal total cardiovascular disease, coronary heart disease, and stroke. Results from prospective studies show that the Mediterranean diet is associated with lower risk of total cardiovascular and coronary heart disease, but the findings for stroke are contradictory. Randomized controlled trials studying either disease outcome are overall very limited in number; thus, although existing evidence suggests a protective effect of the Mediterranean diet on cardiovascular disease incidence, a causal relationship cannot be concluded with certainty. However, clinical trials of potential intermediate cardiovascular factors show that the Mediterranean diet has a beneficial effect on them.

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Maria Annunziata Carluccio PhD, … Raffaele De Caterina MD, PhD, in The Mediterranean Diet, 2015


The Mediterranean diet (MD) has become a cornerstone for the prevention of chronic disease. The MD is a plant-based diet particularly rich in phytochemicals named polyphenols. A high consumption of polyphenols has been suggested to have beneficial effects on human health. Although a single food or extract cannot replace the combination of natural phytonutrients in the MD, olives and olive oil offer unique and powerful health-promoting components. Olive oil polyphenols, similar to other MD polyphenols, exhibit multiple protective effects (inhibition of oxidative stress, reduction of oxidized low-density lipoproteins and other cardiovascular risk factors, and inhibition of inflammation) that occur through the regulation of genes involved in atherosclerosis, inflammation, and oxidative stress. The healthy properties of olive oil polyphenols further explain olive oil as a functional food and the MD as the best wholesome diet to counteract chronic and degenerative disease, not only in Mediterranean lands but also globally.

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Yardena Arnoni MSc, Elliot M. Berry MD, FRCP, in The Mediterranean Diet, 2015


The Mediterranean diet is reviewed in the context of history and culture. The health benefits of the Mediterranean diet are scientifically recognized. The ancient Mediterranean diet focuses on the seven biblical species—wheat, barley, grapes, figs, pomegranates, olives, and date honey—together with other indigenous foods from the Middle East that radiated out of the cradle of civilization in Mesopotamia. In addition to food, lifestyle modification of the original Mediterranean tradition involves physical activity and communal meals. The Mediterranean diet is a convenient, lifestyle-friendly diet that, when fortified by its biblical attributes, may enhance health benefits and be more enjoyable and hence sustainable. Adoption of such a lifestyle may help combat the obesogenic environment and decrease the risks of the noncommunicable diseases of modern life.

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Claire T. McEvoy RD, PhD, Jayne V. Woodside PhD, in Glucose Intake and Utilization in Pre-Diabetes and Diabetes, 2015


The Med diet has been proposed as a healthy eating model for disease prevention. Strong and consistent observational evidence supports this assertion for both CVD and T2DM prevention. However, clinical trial evidence demonstrating a causal effect was lacking until recently. Findings from the primary prevention PREDIMED large-scale RCT confirm the protective effect of a Med diet for prevention of CVD (particularly stroke) and possibly T2DM. Furthermore, several possible mechanisms of action have been elucidated from this trial and other intervention studies, which indicate a beneficial effect of a Med diet on established risk factors for CVD and possibly other positive health effects on vascular and metabolic pathways, which can influence the rate of progression of atherosclerosis and/or development of T2DM.

However, further well-designed trials are needed to confirm the effectiveness of a Med diet for CVD and T2DM prevention. To date, the strongest supporting evidence base is derived from studies involving Mediterranean populations. Further studies should involve other populations who habitually consume a different dietary pattern than that of a traditional Med diet. Research is also required to determine how an increase in adherence to a Med diet can be optimally achieved in non-Mediterranean populations.

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M. Innes Asher BSc, MBChB, FRACP, … Eamon Ellwood DipTch, DipInfo Tech, in Kendig & Chernick’s Disorders of the Respiratory Tract in Children (Eighth Edition), 2012

Mediterranean Diet

The Mediterranean diet, on the other hand, has been suggested as a healthy dietary pattern that may reduce the risk of asthma. In ISAAC Phase Two, food selection according to the Mediterranean diet was associated with a lower prevalence of current wheeze and asthma ever.314 In fact, ISAAC data indicated lower asthma prevalence in Mediterranean countries with diet as a possible variable to explain this disparity.14 There is a consistent relationship between a Mediterranean diet and asthma symptoms,336,375,376 but not for current wheezing in all studies.377 Further investigation of this association and possible mechanisms would be of interest.

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Dragan Micic, Snezana Polovina, in Encyclopedia of Endocrine Diseases (Second Edition), 2019

Mediterranean Diet

Mediterranean diet composed by olive oil, fruits, vegetables, whole grains, nuts, legumes, small amounts of diary (cheese and yogurt) and fish has proven effect in preventing diabetes (Sofer et al., 2015). The same diet was not such effective in glycemic control in patients with diabetes. Possible explanation for unsatisfied glycemic control is greater fruit intake in Mediterranean diet that is recommendable for diabetic patients (Díez-Espino et al., 2011). The main difference between the Mediterranean and ADA diets is in monounsaturated (MUFAs) content. MUFAs has impact on insulin sensitivity, postprandial glucose level, and lipid profile (Esposito et al., 2010).

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