For decades, the Mediterranean diet has been lauded as a pathway to better health, offering a tantalizing promise: indulge in delicious, fresh foods and stay well. This isn't merely overhyped nonsense; mounting evidence spanning over 50 years suggests that the Mediterranean diet can indeed improve health in numerous ways. The diet's fame is largely attributed to US physiologist Ancel Keys and his wife Margaret, a chemist turned nutritionist. In the 1940s, Ancel was among the first to posit that saturated fats, predominantly found in animal products, are a major culprit in heart disease due to their contribution to cholesterol buildup in the blood.
The Origins of the Mediterranean Diet
Building on this, the couple embarked on a global journey to study the dietary habits of people in different regions. This endeavor culminated in the Seven Countries Study, initiated in 1956, which compared diet and health across parts of the US, Japan, Finland, the Netherlands, Italy, Greece, and the former Yugoslavia. During their research, Ancel and Margaret observed a remarkable phenomenon in southern Italy: a surprisingly high number of centenarians. They became convinced that the local diet, rich in unsaturated fat, held the key to this longevity.
The pair became ardent advocates of this dietary pattern, eventually relocating to southern Italy to experience its benefits firsthand. Their long lives - Ancel passed away in 2004 at the age of 100, and Margaret followed two years later at 97 - seemed to further validate their message.
Defining the Mediterranean Diet
However, confusion soon arose regarding the precise components of the Mediterranean diet. It certainly doesn't involve excessive amounts of indulgent dishes like lasagne, moussaka, pizza, and kofta kebabs. One widely accepted definition is the Mediterranean Diet Score (MDS), developed in the 1990s by Antonia Trichopoulou at the National School of Public Health in Athens, Greece, with an updated version published in 2003. According to the MDS, a complete Mediterranean diet is characterized by a high intake of vegetables, legumes, fruits, nuts, cereals, and a moderately high consumption of fish. Martínez-González considers this the most commonly used definition.
Over the years, the standard definition has undergone revisions as researchers have refined their understanding of the optimal dietary composition for prolonged health. Richard Hoffman at the University of Hertfordshire in the UK notes that dairy is now considered neutral, and the recommended amount of alcohol has decreased.
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Documented Health Benefits
The best evidence for the Mediterranean diet's efficacy lies in its ability to combat cardiovascular disease, says Hoffman. There is also evidence that the diet reduces the risk of developing cardiovascular disease in the first place. A 2020 review by Cochrane, a UK charity that examines evidence on health issues, looked at 22 randomised controlled trials investigating this issue and found “moderate quality evidence” that the diet reduced cardiovascular risk factors. The benefits appear to extend beyond cardiovascular health. A 2020 review concluded that people who follow the diet are 20 per cent less likely to develop type 2 diabetes than those who don’t. While some of these purported benefits may disappear as more rigorous studies are conducted, Martínez-González is confident that the diet is still worth adopting. The Mediterranean diet is associated with improving blood sugar regulation, as well as a 19-23 percent reduced risk of future diabetes risk. The Mediterranean diet may contribute to a reduced risk of cancer, possibly due to a predominance of foods rich in antioxidants and fiber.
Moderate consumption of red wine is associated with lower blood pressure, higher levels of “good” HDL cholesterol, lower levels of “bad” LDL cholesterol, lower blood sugar, and lower levels of inflammation. For cardioprotective effects, international guidelines suggest limiting red wine to about 5 ounces (150 mL) a day.
Caveats and Considerations
However, one of the biggest investigations of this way of eating is the Moli-sani study, which follows over 20,000 people who were recruited in southern Italy between 2005 and 2010. In a 2018 update, researchers led by Marialaura Bonaccio at IRCCS NEUROMED, a neurological institute in Pozzilli, Italy, found what seemed, at first, like a straightforward confirmation of an existing finding. However, there was a twist. The benefits were only seen in highly educated people and those with high household incomes.
One possibility is that the details of what people eat really matter, says Bonaccio. The quality of the food, she suggests, may play a role. This would fit the data: people from lower-income households may have little choice but to buy and eat cheaper frozen or processed foods, which may not be as nutritious as fresh foods.
With that in mind, researchers are now focusing on how specific components of the Mediterranean diet may account for its health benefits. One ingredient in particular is emerging as key: extra-virgin olive oil. Olive oil producers press and grind fresh olives to release the oil, which is actually derived from the fruit, says Hoffman. This makes it unlike other oils that come from seeds and have to be extracted using chemicals and high temperatures. “The Mediterranean diet is far more effective if it includes extra-virgin olive oil,” says Hoffman. The oil is rich in the unsaturated fats that were championed decades ago by Margaret and Ancel Keys. But there is growing evidence that its health benefits are partly explained by additional components that are lost if it is further processed to produce “refined” olive oil. These include a host of plant chemicals, one notable kind being polyphenols. The June review concluded that polyphenols were probably responsible for extra-virgin olive oil’s benefits.
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It isn’t just the microbiome that might be implicated in the health benefits of extra-virgin olive oil. Personal genetics may play a role too, given evidence that specific nutrients in olive oil and other components of the Mediterranean diet may influence the activity of genes linked to things like inflammation.
Is the Mediterranean Diet for Everyone?
Some researchers aren’t convinced it is for everyone. They think that, as we have learned more about what is going on, it has become increasingly unclear whether the diet can be made to work beyond the Mediterranean itself. For instance, Bonaccio says we now know that each world region is characterised by distinctive features, like climate and microbes, that alter the local optimal diet. Michael Marshall's look at the Mediterranean diet made one key observation I wish he had expanded on. He described how one scientist said different regions of the world may have their own optimum diet. This is what longevity researcher Dan Buettner found in his study of so-called blue zones, where there are high levels of centenarians. From one side of the planet to the other, blue zone inhabitants share some striking similarities that can be adapted to suit anyone.
“You don’t need to be eating Mediterranean vegetables like peppers and aubergines,” says Hoffman. Some components, like extra-virgin olive oil, would appear non-negotiable, however: Hoffman stresses its importance. Martínez-González wants to see taxes introduced on ultra-processed fare like sodas and fast food, and for the revenues to be used to subsidise healthier options. The improvements to public health that better-quality diets should bring would cut the costs of medical care.
Beyond the Food: Lifestyle Factors
However, even for those who can afford to purchase high-quality foods, there is one potentially vital component of the diet that can’t be found on supermarket shelves. It is possible that some of the reported benefits of the diet aren’t due to the food itself, but to the associated lifestyle. Bonaccio points out that the Mediterranean villagers studied by Ancel and Margaret Keys - and later by Trichopoulou - didn’t just eat a specific diet, “they also had a specific way of living”. For instance, they resided in the countryside and their work was often outdoors and physical. Other studies show such factors make a difference: research published in March 2023 found that walking just an extra 500 steps a day reduces the risk of cardiovascular disease in older adults.
It is probably also significant that the Mediterranean villagers studied in the 20th century prepared their own food and often ate leisurely meals in social groups - which some research suggests boosts general happiness and life satisfaction, both of which are also linked to better health. Often, meals are eaten with family from multiple generations. Many of us are conditioned to quickly scarf down whatever’s in front of us. Getting all the benefits of a traditional Mediterranean diet isn’t just about what you eat. But live more like a traditional Mediterranean?
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Traditional Mediterraneans generally ate foods that were grown locally, and therefore were as fresh as possible. They may also harvest produce from their own garden.
Incorporating Mediterranean Principles into Your Life
Unless we can find the time to prepare our own meals and savour them with friends, we may never feel the full effects of the Mediterranean diet. But carve out those extra hours each day for such dining, while also remaining active, and it might be possible for all of us to experience the health benefits that so impressed Ancel and Margaret on their visits to southern Italy in the 1950s.
Here are some practical tips for incorporating Mediterranean principles into your life:
- Slow down: Chew carefully, paying attention to textures and flavors. Put your fork down between bites.
- Embrace intermittent workouts: These are 5- to 10-minute mini-workouts that clients can do throughout their day, without having to set aside 30 minutes or an hour for intentional exercise.
- Get curious about seasonal and local foods: The takeaway: Help clients get curious about the seasonal and local foods in their region.
- "Mediterranean-ize" your current dietary habits: Another approach? Have them look at their current dietary habits and get creative about “Mediterranean-izing” them. For example: If they have dessert every day, could they trade that for fruit four or five days a week? Or if that feels too hard, three days? Don’t worry if it seems too easy. Easy is good because it allows them to experience success. For example, sweets aren’t eaten regularly, but they’re not “forbidden” either.
The Mediterranean Diet as a Sustainable Approach
Because the Mediterranean diet wasn’t purposely created by a group of doctors, dieticians, or scientists, it doesn’t come with strict rules. This means that the diet is practical, flexible, and psychologically, kind of freeing. Most diets have some drawbacks, usually related to what they restrict. But there are other reasons why the Mediterranean diet may not be the “perfect” approach. If fresh food is either inaccessible or unaffordable, following a “true” Mediterranean diet may not be practical (or possible).
If you’re a coach, you may have clients who follow different diets-and that’s okay. One tool that can help: Our Best Diet Quiz. There are many other ways to eat-vegetarian, fully plant-based (a.k.a. You can also check out the “anything” diet in the Precision Nutrition Macro Calculator. It allows you to create a free nutrition plan that’s personalized for your body, eating preferences, and goals. You can help people build sustainable nutrition and lifestyle habits that will significantly improve their physical and mental health-while you make a great living doing what you love. If you’d like to learn more, consider the PN Level 1 Nutrition Coaching Certification.
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