To present the Mediterranean diet (MD) pyramid: a lifestyle for today.

A new graphic representation has been conceived as a simplified main frame to be adapted to the different nutritional and socio-economic contexts of the Mediterranean region. This review gathers updated recommendations considering the lifestyle, dietary, sociocultural, environmental and health challenges that the current Mediterranean populations are facing.

Mediterranean region and its populations.

Many innovations have arisen since previous graphical representations of the MD. First, the concept of composition of the ‘main meals’ is introduced to reinforce the plant-based core of the dietary pattern. Second, frugality and moderation is emphasised because of the major public health challenge of obesity. Third, qualitative cultural and lifestyle elements are taken into account, such as conviviality, culinary activities, physical activity and adequate rest, along with proportion and frequency recommendations of food consumption. These innovations are made without omitting other items associated with the production, selection, processing and consumption of foods, such as seasonality, biodiversity, and traditional, local and eco-friendly products.

Adopting a healthy lifestyle and preserving cultural elements should be considered in order to acquire all the benefits from the MD and preserve this cultural heritage. Considering the acknowledgment of the MD as an Intangible Cultural Heritage of Humanity by UNESCO (2010), and taking into account its contribution to health and general well-being, we hope to contribute to a much better adherence to this healthy dietary pattern and its way of life with this new graphic representation.

To present the Mediterranean diet as an example of a sustainable diet, in which nutrition, biodiversity, local food production, culture and sustainability are strongly interconnected.

Review of notions and activities contributing towards the acknowledgement of the Mediterranean diet as a sustainable diet.

The Mediterranean region and its populations.

Mediterranean populations.

The acknowledgement of the Mediterranean diet as a sustainable diet needs the development of new cross-cutting intersectoral case studies to demonstrate further the synergies among nutrition, biodiversity and sustainability as expressed by the Mediterranean diet for the benefit of present and future generations.

To place the Mediterranean diet (MedDi) in the context of the cultural history of the Middle East and emphasise the health effects of some of the biblical seven species – wheat, barley, grapes, figs, pomegranates, olives and date honey.

Review of the literature concerning the benefits of these foods.

Middle East and Mediterranean Basin.

Mediterranean populations and clinical studies utilising the MedDi.

The MedDi has been associated with lower rates of CVD, and epidemiological evidence promotes the benefits of consuming fruit and vegetables. Recommended foods for optimal health include whole grain, fish, wine, pomegranates, figs, walnuts and extra virgin olive oil. The biblical traditional diet, including the seven species and additional Mediterranean fruits, has great health advantages, especially for CVD. In addition to the diet, lifestyle adaptation that involves increasing physical activity and organised meals, together with healthy food choices, is consistent with the traditional MedDi. The MedDi is a manageable, lifestyle-friendly diet that, when fortified with its biblical antecedent attributes, may prove to be even more enjoyable and considerably healthier in combating the obesogenic environment and in decreasing the risks of the non-communicable diseases of modern life than conventional, modern dietary recommendations. The biblical seven species, together with other indigenous foods from the Middle East, are now scientifically recognised as healthy foods, and further improve the many beneficial effects of the MedDi.

To consider historical aspects of nuts in relation to origin and distribution, attributed medicinal benefits, symbolism, legends and superstitions.

Review of historical aspects of nuts.

Mediterranean region.

The varieties reviewed include almonds, walnuts, hazelnuts, pine nuts and pistachios.

Like other foods, nuts have a wide variety of cultural connections to the areas where they grow and to the people who live there or eat them. History, symbolism and legends reveal the ancient tradition of nuts and how they are related to the lives of our ancestors. Archaeological excavations in eastern Turkey have uncovered the existence of a non-migratory society whose economy centred on harvesting nuts. This shows that nuts have been a staple in the human diet since the beginnings of history. Moreover, since ancient times nuts have been used for their medicinal properties. They also play a role in many old legends and traditions.

To determine the postprandial lipaemia response before and after intervention with healthy diets in the Medi-RIVAGE cohort of subjects with moderate risk factors of CVD.

One hundred and thirty-five adults (fifty-two men and eighty-three women) followed either a Mediterranean-type (MED) diet or a low-fat American Heart Association-type diet in a parallel design for 3 months. At entry and after 3 months, lipids, glucose and insulin were measured in the fasting samples; TAG and apolipoprotein B48 (ApoB48; a marker of intestinally derived chylomicrons) levels were measured in the fasting and postprandial samples after a standard test meal.

The MED diet only lowered (P < 0·028) fasting TAG and both diets reduced TAG and ApoB48 levels 5 h after the test meal. The overall 5 h postprandial ApoB48 response (area under curve (AUC)/incremental AUC) was lowered after both diets but this effect was more marked after the MED-diet intervention. Whatever the TAG level at entry, normo- and hyper TAG subjects showed a reduction in the postprandial ApoB48 levels after 3-month diets. BMI at entry did not impact the effect of diets given subjects with BMI < or >25 kg/m2 showed reduced postprandial ApoB48. Men and women displayed comparable postprandial changes after dietary challenges.

A MED diet appears efficient to improve postprandial lipaemia, a recently acknowledged CVD risk, in men and women at moderate cardiovascular risk.

To review the evidence on the association between fruit and vegetable (F&V) consumption and risk of chronic disease, and to assess trends in the prevalence of low F&V consumption.

Systematic review and cross-sectional analyses of a Mediterranean cohort.

The Seguimiento University of Navarra (SUN) project (Spanish dynamic cohort of graduates).

A systematic review of prospective studies aimed to assess the relationship between fruit and/or vegetables consumption and chronic disease incidence was conducted. We also assessed 18 457 university graduates (59·4 % women; mean age = 39 (sd 12) years) enrolled in a dynamic cohort with permanently open recruitment. Baseline data were collected between 1999 and 2010 using a validated 136-item FFQ. Four definitions for low F&V consumption were used (<400 g/d, <200 g/4184 kJ (1000 kcal) per d, ≤2 servings/d and ≤1 serving/d). Multivariate-adjusted cross-sectional associations between the prevalence of low F&V consumption and the year of recruitment were estimated.

The systematic review found that a high F&V consumption is inversely associated with CVD incidence and mortality. This association is not so clear for cancer. Inconsistent findings have been reported for diabetes. In all, 13 % of participants in the SUN cohort did not meet the goal of consuming at least 400 g/d of F&V and 2·1 % of them did not reach >1 serving/d. Between 1999 and 2010 the consumption of F&V significantly increased.

Even among health-conscious university graduates, low F&V consumption is fairly prevalent. Although the temporal trends suggest an improvement, preventive strategies addressed to increase F&V consumption are needed.

The promotion of healthy lifestyles is one of the major goals of governments and international agencies all over the world. Wholegrain cereals are rich in nutrients and many phytochemical compounds, with recognised benefits for health, including dietary fibre, a number of phenolic compounds, lignans, vitamins and minerals and other bioactive components. The aim of the present work is to review the fundamental studies that support the consumption of wholegrain cereals and bread to prevent chronic diseases.

Descriptive review considering human studies.

Subjects included in randomised intervention trials and cohort studies from different countries published up to 2010.

Several studies show consistently that subjects who ingest three or more portions of foods per day based on wholegrain cereals have a 20–30 % lower risk of CVD than subjects who ingest low quantities of cereals. This level of protection is not observed with the ingestion of refined cereals, these being even higher than with the intake of fruit and vegetables. Likewise, high intake of wholegrain cereals and their products, such as whole-wheat bread, is associated with a 20–30 % reduction in the risk of type 2 diabetes. Finally, protection against the risk of colorectal cancer and polyps, other cancers of the digestive tract, cancers related to hormones and pancreatic cancer has been associated with the regular consumption of wholegrain cereals and derived products.

The regular intake of wholegrain cereals can contribute to reduction of risk factors related to non-communicable chronic diseases.

The Mediterranean diet has been related to a lower risk of some chronic diseases, including cancer. We aim to gain insight into the effects of the main source of fat of this diet on breast cancer, the most common type of malignancy in women.

Data from sixteen experimental series analysing the effects of dietary lipids on mammary carcinogenesis in an animal model, in the context of the international literature on the Mediterranean diet, olive oil and breast cancer risk.

Experimental and human data on the effects of olive oil and Mediterranean diet on breast cancer.

An animal model of induced breast cancer and other human and experimental studies in the literature.

Diets rich in extra virgin olive oil (EVOO) exert a negative modulatory effect on experimental breast cancer to a weak promoting effect, much lower than that obtained with a high-corn oil diet. EVOO confers to the mammary adenocarcinomas a clinical behaviour and morphological features compatible with low tumour aggressiveness. This differential effect, in relation to other dietary lipids, may be related to a lower effect on body weight and sexual maturation. In addition, EVOO induced different molecular changes in tumours, such as in the composition of cell membranes, activity of signalling proteins and gene expression. All these modifications could induce lower proliferation, higher apoptosis and lower DNA damage. These results, together with the favourable effect of olive oil reported in the literature when it is consumed in moderate quantities, suggest a beneficial influence of EVOO on breast cancer risk.

Consumption of EVOO in moderate quantities and throughout the lifetime appears to be a healthy choice and may favourably influence breast cancer risk.

To summarise our present knowledge on the Mediterranean diet in secondary prevention of CHD.

Review of literature.

Adult coronary patients.

CHD patients at high risk of cardiac death.

The two main causes of death in these patients are sudden cardiac death (SCD) and chronic heart failure (CHF). The main mechanism underlying recurrent cardiac events is coronary thrombosis resulting from atherosclerotic plaque erosion or ulceration. The occurrence of thrombosis is usually associated with plaque weakness in relation to high lipid content of the lesion where cholesterol only represents a very small part compared with other lipids (i.e. fatty acids). Thus, the three main aims of the preventive strategy are to prevent coronary thrombosis, malignant ventricular arrhythmia and the development of left ventricular dysfunction (and CHF) and finally to minimise the risk of plaque erosion and ulceration. There is now a consensus about recommending the Mediterranean diet pattern for the secondary prevention of CHD because no other dietary pattern has been successfully tested so far in these patients. The most important aspect, in contrast with the pharmacological prevention of CHD (including cholesterol lowering), is that the Mediterranean diet results in a striking effect on survival.

The traditional Mediterranean diet is effective in reducing both coronary atherosclerosis/thrombosis and the risk of fatal complications such as SCD and heart failure.

To compare and evaluate the reliability of several indexes of adherence to the Mediterranean diet.

The ten indexes included in the analysis were: Mediterranean Diet Score (MDS), Mediterranean Score (MS), Dietary Score (DS), Mediterranean-Dietary Quality Index (Med-DQI), Mediterranean Dietary Pattern adherence index (MDP), Mediterranean Adequacy Index (MAI), Mediterranean Style Dietary Pattern Score (MSDPS), Mediterranean food pattern PREDIMED Study (MeDiet-PREDIMED), relative Mediterranean diet (rMED) and Cardioprotective Mediterranean diet index. Factor analysis using the correlations between indexes was applied. The correlation with factors and the reliability coefficient were calculated.

A total of 324 healthy undergraduates at the University of Barcelona, Spain, were surveyed.

The highest correlations were observed between MDP adherence index and MAI (0·82); MAI and MSDPS (0·80); and MDS and rMED (0·77). Factor analysis showed a hidden common factor that explained over 70 % of the variability (71·03 %). This factor is understood as ‘adherence to the Mediterranean diet’. The indexes that showed the highest correlation with this factor were Med-DQI (0·85), MDS (0·84), rMED (0·80) and MAI (0·80). These indexes showed acceptable performance in measuring the adherence to the Mediterranean diet. The components that correlated strongly with this factor were monounsaturated-to-saturated fatty acid ratio (MS ratio), fruit and vegetables. Furthermore, a second common factor was found explaining 18 % of the variability. This second factor is highly positive related to dairy products and lean meat, and negative related to MS ratio.

The indexes showed satisfactory performance in assessing adherence to the Mediterranean diet. However, in order to improve the reliability and concordance between the indexes, further studies are required to select the components, the number of components, and the scoring criteria of the indexes to improve their internal consistency.

To define the Mediterranean diet model inside a Mediterranean social and cultural food framework and from the perspective of a local model of consumption.

Reflexion and review of literature available in relation to the Mediterranean diet, locality and proximity.

Mediterranean region and its populations.

The Mediterranean local food system under the term Mediterranean diet encourages local production and local consumption. From this perspective, this model takes part of every local Mediterranean lifestyles and encourages sustainability.

From a local Mediterranean point of view and as a proximity model of consumption, Mediterranean food and diet can be a sustainable resource for the Mediterranean area.