The Mediterranean Diet

"The doctor of the future will no longer treat the human frame with drugs but rather will cure and prevent disease with nutrition." - Thomas Edison

My classmates and I were first introduced to the Mediterranean diet during our second year of medical school. We were in one of our Endocrinology lectures, the study of medicine that pertains to hormones and endocrine glands. A large part of Endocrinology is diabetes management, so we were having a discussion about various types of diets and what kinds of effects, if any, they were found to have on people’s health. Not just weight loss, but overall health, meaning a decrease in rates of death or diseases, such as heart disease, diabetes, and cancer.

The Research

One of the articles we reviewed was published in the New England Journal of Medicine by Trichopoulou et al. (2003). The study examined adherence to the Mediterranean diet and followed over 22,000 Greek individuals, tracking any deaths, as well as deaths from coronary heart disease and cancer, over a 44-month period. Adherence was assessed based on a 9-point scale, which we will discuss later. What they found was that people who were more adherent to the Mediterranean diet had lower overall mortality, as well as lower rates of death due to coronary heart disease and cancer. Every two-point increase in the Mediterranean diet adherence score was associated with a 25% reduction in mortality risk due to coronary heart disease and cancer.

A follow-up study in the British Medical Journal by Trichopoulou, et al. (2005)  looked at adherence to a modified Mediterranean diet among the elderly, this time across ten European countries with over 500,000 individuals, demonstrating a continued association between adherence to the Mediterranean diet and lower overall mortality with a reduction of 7% across all countries with each two-point increase in adherence score. The main difference between the two studies was that the initial study gave a point for adherence for consumption of predominantly monounsatured fats, due to the high amount of olive oil consumed in the Mediterranean, whereas the larger study across ten nations defined adherence to fat consumption as one predominantly unsaturated fats, given that the unsaturated fats of choice in the non-Mediterranean countries were more predominantly polyunsaturated fats. Regardless, this showed that even a modified Mediterranean diet was associated with a reduction in mortality.

A study by Mitrou, et al. (2007) in Journal of the American Medical Association (JAMA) extended this study to the U.S. population, examining adherence among nearly 400,000  elderly individuals across six states. This study demonstrated again that higher adherence to a diet consistent with the Mediterranean diet was associated with decreased overall mortality and decreased mortality due to cardiovascular disease and cancer both in men and women, with each 1-point increase associated with a 5% reduction in mortality.

The Mediterranean Diet

So, what do we mean when we say “adherence to the Mediterranean diet” and how does that translate into our daily lives? No, it does not mean that you should limit yourself to Greek cuisine. That seems to be a common misconception when people first hear about the Mediterranean diet, but it is more about adhering to nine general guidelines, so this means you can still enjoy some of your favorites across a variety of cuisines by making a few modifications or selecting ingredients wisely.

Adherence in these studies were measured on a 9-point scale, ranging from 0 to 9. A score of 0 corresponded to no adherence, whereas a score of 9 was completely adherent to the diet. The points could be thought of in four main categories: 1) five points representing an increase in beneficial components (vegetables, legumes, fruits and nuts, whole grains, and fish), 2) two points representing a decrease in presumed detrimental components (meat/poultry and dairy), 3) selecting healthy fats, and 4) moderate alcohol consumption. Let’s dig into these further.

1. Increase Vegetables

Mom’s have been saying it for decades: eat your vegetables! Adherence to the Mediterranean diet requires you to eat 2-3 cups of vegetables per day. Examples of vegetables to add include dark leafy greens, carrots, squash, peppers, eggplant, cucumbers, and tomatoes. These can take any form and be eaten at any point during the day. Potatoes and other starchy vegetables do not count toward your daily vegetable intake. The goal here is 2-3 cups per day. If you think that a cup of carrots can make a great afternoon snack, you can see how easy it is to reach this daily goal. Since one bell pepper is about 1 cup, you can get half or a third of your daily vegetables by having a stuffed pepper for dinner.

Dr. Garavatti prepping peppers with one of our registered dietitians.

Photo credit: Min An

2. Increase Legumes

Beans! Beans! The magical fruit, the more you eat the more you…decrease your risk of death due to heart disease and cancer! Not sure that one will be quite as catchy, but increasing your legume consumption is another easy way to add a point to your Mediterranean diet score. Legumes, as we discussed in the section on proteins, are any seed encased in a pod. This means any kind of bean is a legume: green, white, black, pinto, garbanzo/chickpeas, kidney, navy, cannellini, lima, and any others you can think of. This also includes peas of any variety and lentils. Finally, though a bit of a misnomer, peanuts are actually legumes, so when you eat that PB&J you’re adding some legumes to your diet. This one is especially easy to achieve, as you only need to consume at least 2 cups per week.

3. Increase Fruits & Nuts

This is another one that can easily be worked into your day. Fruit and nuts can be a great afternoon snack. With fruit’s natural sweetness they can also be used to satisfy that sweet tooth. The proteins and healthy fats in nuts can also tackle that afternoon hunger between lunch and dinner. A quarter cup of nuts is about a palmful, which is doable, right? And before you start thinking that 1-1 1/2 cups of fruit seems like a lot, I’ll let you know that one medium apple is about one cup when it is cored and sliced. So, turns out maybe an apple a day does keep the doctor away.

Photo credit: Madison Inouye

4. Increase Cereals/Whole Grains

When we talk about cereal here, we are not talking about Fruit Loops and Frosted Flakes. The word cereal is derived from the Roman god of agriculture and harvest, Ceres. So, when we are talking about cereals here, we mean in the sense of an edible grains. Ideally these should be a whole grain, as discussed in the carbohydrates section. Whole grains take many forms, including quinoa and amaranth, which as we’ve already discussed are complete proteins, since they provide all of the essential amino acids. You can also satisfy this part of the Mediterranean diet with whole wheat pasta, brown rice, oats, barley, and even corn or cornmeal. So, yes, you can still enjoy Taco Tuesday as long as they are made with corn tortillas. The recommendation here is 1 1/2 cups per day.

Photo credit: Pixabay

Photo credit: Caroline Attwood

5. Increase Fish/Seafood

Given that the Mediterranean diet is based on cuisines developed over many centuries in sea-faring towns, it only makes sense that the Mediterranean diet would include fish and seafood. It’s recommended to consumed 2-4 ounces per week. This could be as easy as having a piece of salmon for dinner one night out of the week. While the fattier fish, such as salmon, tuna, and anchovies, are preferred, this can also be satisfied by having shrimp other shellfish. Pick one meal each week to celebrate the sea with a piece of fish or some seafood and add that point to your score.

6. Healthy Fats/Oils

Ok, I’ll admit that there was a time in my life when my bacon fat drippings would get poured into a ramekin by the stovetop for later use. But now, I’m born again! Next to my stovetop is a bottle of canola or grapeseed oil, and not far from it is a bottle of olive oil. The goal with this part of the Mediterranean diet is to aim for more unsaturated fats than saturated fats. That means selecting plant-based oils such as canola, grapeseed, sesame, and olive oil, over animal-based fats. Avocados are another great source of unsaturated fats that can be added to salads or whipped up into a salad dressing to provide some of that creaminess. Steering away from saturated fats like those found in meats is also preferred. Opt for the leaner cuts of meat discussed in the section on proteins, trim chicken of skin and fat, and if you’re shopping for ground meats, choose those that are at least 90/10. Now, this isn’t to say that you have to completely avoid saturated fats, but be mindful of the proportions that you are using compared to unsaturated options. Butter is one thing that I definitely have a hard time giving up, but I’ve found that in many cases I can use a combination of butter with one of the healthier oils, which allows me to use less butter and still get that great flavor. Use nutrition labels to familiarize yourself with those ingredients that are higher in saturated fats and identify those that are lower in saturated fats.

Photo credit: Foodie Factor

Photo credit: Pixabay

7. Less Dairy

For dairy, the recommendation is to limit yourself to no more than one serving (8 ounces) per day. Try to opt for low-fat dairy and fermented, such as yogurt, cheese, kefir, cottage cheese, and ricotta cheese. Limiting dairy will also limit the amount of saturated fats you are consuming. Spreading out those 8 ounces throughout the day can help make sure you get that dairy fix without overdoing it. Also, be mindful of how much dairy is in certain food products that you might not even think about, like your morning latte.

Photo credit: Life of Pix

8. Less Meat

Here we are talking more about meats like beef, pork, poultry, and lamb. It is recommended to decrease your daily intake to less than 3-4 ounces. This is about the size of a deck of cards. If you’re concerned that this will limit your protein intake, then jump over to the section on proteins to review alternative plant-based sources of protein, such as quinoa, legumes, and whole grains.

Photo credit: Pixabay

Photo credit: Breakingpic

9. Moderate Alcohol

It turns out that a moderate amount of alcohol may be beneficial to your health. For the Mediterranean diet, it is recommended to have no more than one drink daily for females and no more than two drinks daily for males. Part of the recommendation also stipulates that this needs to be consumed with your meal. Initially, red wine was thought to be the only drink to add benefit, but now it’s believed that it’s actually the ethanol that provides the benefit here. It’s worth mentioning that we are talking about a “standard drink” here, which means 12 fluid ounces of beer, 5 fluid ounce of wine, and 1 1/2 fluid ounces of distilled spirits. For those that do not drink, it’s not recommended that you start simply to get this point. Additionally, people should still avoid binge drinking; unlike cell phone plans, unused drinks do not rollover.

Calculate Your Score

Now it’s your turn to calculate your score. Think about what your current dietary habits are like and check the boxes next to the aspects of the Mediterranean diet that you practice. Your Mediterranean diet score will then be shown at the bottom.

Ok, you’ve got a score now, but what does that mean? Well, the studies that have examined adherence to the diet typically divided people into three categories:

  • Score 6-9 – high adherence
  • Score 4-5 – moderate adherence
  • Score 0-3 – low adherence

So, you’re probably wondering what your score means for your risk, and unfortunately, it’s not that simple. So many factors play into heart disease, cancer, and deaths related to both. What I can tell you is that the studies have shown the greatest benefit to be in those whose scores are at least 6. So, if you are at a 4, that’s great; you’re already most of the way there. Select two areas that you can work on. Perhaps it’s using healthier fats or adding more fruits and nuts to your daily routine. Use your score to identify your strengths and use these to examine what you’ve done to achieve these. Then use your score to identify areas that need some improvement. Are you able to apply any of the techniques used to achieve adherence in other areas to any of the ones you haven’t achieved?

If you find yourself in the low adherence category, don’t feel bad! Before I took culinary medicine my score was 2. But I identified some areas to improve and have since increased my score to 4. I still have some work to do, but I’m not expecting to make changes overnight. Changing behaviors is a slow process. Our dietary habits didn’t develop overnight, many of them were cultivated over years, so it will take some time to change them. Be patient and, most importantly, find ways to make healthy food delicious.

Diet vs Dieting

Culinary Medicine

Sodium & the DASH Diet