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Implementing a Mediterranean-Style Diet Outside the Mediterranean Region

Abstract

Purpose of Review

Populations surrounding the Mediterranean basin have traditionally reaped health benefits from a Mediterranean diet (MedDiet), which may benefit Westernized countries plagued by chronic disease. But is it feasible to implement beyond the Mediterranean? To answer this question, we present evidence from randomized controlled trials that achieved high dietary compliance rates with subsequent physical and mental health benefits.

Recent Findings

In the 1960s, the Seven Countries Study identified dietary qualities of Mediterranean populations associated with healthy aging and longevity. The PREDIMED study confirmed reductions in CVD-related mortality with a MedDiet; a meta-analysis in over 4.7 million people showed reduced mortality, CVD-related mortality, and reduced risk of Parkinson’s and Alzheimer’s disease. Continually emerging research supports the MedDiet’s benefits for chronic diseases including metabolic syndrome, cancers, liver disease, type 2 diabetes, depression, and anxiety.

Summary

We summarize components of studies outside the Mediterranean that achieved high compliance to a Med-style diet: dietitian led, dietary education, goal setting, mindfulness; recipe books, meal plans, and food checklists; food hampers; regular contact between volunteers and staff through regular cooking classes; clinic visits; and recipes that are simple, palatable, and affordable. The next step is testing the MedDiet’s feasibility in the community. Potential obstacles include access to dietetic/health care professionals, high meat intake, pervasive processed foods, and fast food outlets. For Western countries to promote a Med-style diet, collective support from government, key stakeholders and policy makers, food industry, retailers, and health professionals is needed to ensure the healthiest choice is the easiest choice.

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Fig. 1

Abbreviations

CVD:

Cardiovascular disease

HbA1C:

Glycated hemoglobin

HELFIMED:

Healthy Eating for Life with a Mediterranean Diet

MedDiet:

Mediterranean diet

MedLey:

Mediterranean diet for cognitive and cardiovascular health in the elderly

NAFLD:

Non-alcoholic fatty liver disease

PREDIMED:

Prevención con Dieta Mediterránea

SMILES:

Supporting the Modification of Lifestyle Interventions in Lowered Emotional States

UNESCO:

United Nations Educational, Scientific and Cultural Organization

References

Papers of particular interest, published recently, have been highlighted as: •• Of major importance.

  1. Bomford A. The Greek island of old age BBC News: BBC News; 2013 [Available from: http://www.bbc.com/news/magazine-20898379.

  2. Keys A, Mienotti A, Karvonen MJ, Aravanis C, Blackburn H, Buzina R, et al. The diet and 15-year death rate in the seven countries study. Am J Epidemiol. 1986;124(6):903–15.

    Article  PubMed  CAS  Google Scholar 

  3. Davis C, Bryan J, Hodgson J, Murphy K. Definition of the Mediterranean diet: a literature review. Nutrients. 2015;7:9139–53.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  4. Samatas Y. History of olive oil Explore Crete Yannis Samatas; unknown [Available from: http://www.explorecrete.com/nature/olive-oil-history.html.

  5. Bach-Faig A, Berry EM, Lairon D, Reguant J, Trichopoulou A, Dernini S, et al. Mediterranean diet pyramid today. Science and cultural updates. Public Health Nutr. 2011;14(12A):2274–84.

    Article  PubMed  Google Scholar 

  6. Papamiltiadous ES, Roberts SK, Nicoll AJ, Ryan MC, Itsiopoulos C, Salim A, et al. A randomised controlled trial of a Mediterranean dietary intervention for adults with non alcoholic fatty liver disease (MEDINA): study protocol. BMC Gastroenterol. 2016;16:14.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  7. Ryan MC, Itsiopoulos C, Thodis T, Ward G, Trost N, Hofferberth S, et al. The Mediterranean diet improves hepatic steatosis and insulin sensitivity in individuals with non-alcoholic fatty liver disease. J Hepatol. 2013;59(1):138–43.

    Article  PubMed  CAS  Google Scholar 

  8. Sofi F, Cesari F, Abbate R, Gensini GF, Casini A. Adherence to Mediterranean diet and health status: meta-analysis. BMJ. 2008;337:a1344.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr. 2014;17(12):2769–82.

    Article  PubMed  Google Scholar 

  10. Toledo E, Salas-Salvado J, Donat-Vargas C, Buil-Cosiales P, Estruch R, Ros E, et al. Mediterranean diet and invasive breast cancer risk among women at high cardiovascular risk in the PREDIMED trial: a randomized clinical trial. JAMA Intern Med. 2015;175(11):1752–60.

    Article  PubMed  Google Scholar 

  11. Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado J, Ruiz-Gutierrez V, Covas MI, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med. 2006;145(1):1–11.

    Article  PubMed  Google Scholar 

  12. Jacka FN, O’Neil A, Opie R, Itsiopoulos C, Cotton S, Mohebbi M, et al. A randomised controlled trial of dietary improvement for adults with major depression (the “SMILES” trial). BMC Med. 2017;15(1):23.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Opie RS, O’Neil A, Jacka FN, Pizzinga J, Itsiopoulos C. A modified Mediterranean dietary intervention for adults with major depression: dietary protocol and feasibility data from the SMILES trial. Nutr Neurosci 2017;1–15.

  14. •• Parletta N, Zarnowiecki D, Cho J, Wilson A, Bogomolova S, Villani A, et al. A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and mental health in people with depression: a randomized controlled trial (HELFIMED). Nutr Neurosci. 2017;1–14. This paper showed successful adoption of a Med-style diet, which with fish oil improved mental health and depressive symptoms over 3 months in Australians with depression. Dietary changes were sustained over 6 months.

  15. Psaltopoulou T, Sergentanis TN, Panagiotakos DB, Sergentanis IN, Kosti R, Scarmeas N. Mediterranean diet, stroke, cognitive impairment, and depression: a meta-analysis. Ann Neurol. 2013;74(4):580–91.

    Article  PubMed  Google Scholar 

  16. Lee J, Pase M, Pipingas A, Raubenheimer J, Thurgood M, Villalon L, et al. Switching to a 10-day Mediterranean-style diet improves mood and cardiovascular function in a controlled crossover study. Nutrition. 2015;31(5):647–52.

    Article  PubMed  Google Scholar 

  17. Scarmeas N, Luchsinger JA, Schupf N, Brickman AM, Cosentino S, Tang MX, et al. Physical activity, diet, and risk of Alzheimer disease. JAMA : J Am Med Assoc. 2009;302(6):627–37.

    Article  CAS  Google Scholar 

  18. Valls-Pedret C, Sala-Vila A, Serra-Mir M, Corella D, de la Torre R, Martinez-Gonzalez MA, et al. Mediterranean diet and age-related cognitive decline: a randomized clinical trial. JAMA Intern Med. 2015;175(7):1094–103.

    Article  PubMed  Google Scholar 

  19. de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999;99(6):779–85.

    Article  PubMed  Google Scholar 

  20. Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol. 2011;57(11):1299–313.

    Article  PubMed  CAS  Google Scholar 

  21. Salas-Salvado J, Fernandez-Ballart J, Ros E, Martinez-Gonzalez MA, Fito M, Estruch R, et al. Effect of a Mediterranean diet supplemented with nuts on metabolic syndrome status: one-year results of the PREDIMED randomized trial. Arch Intern Med. 2008;168(22):2449–58.

    Article  PubMed  CAS  Google Scholar 

  22. Schwarzfuchs D, Golan R, Shai I. Four-year follow-up after two-year dietary interventions. N Engl J Med. 2012;367(14):1373–4.

    Article  PubMed  CAS  Google Scholar 

  23. Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008;359(3):229–41.

    Article  PubMed  CAS  Google Scholar 

  24. •• Davis CR, Hodgson JM, Woodman R, Bryan J, Wilson C, Murphy KJ. A Mediterranean diet lowers blood pressure and improves endothelial function: results from the MedLey randomized intervention trial. Am J Clin Nutr. 2017. This paper highlights that high adherence to a MedDiet over 6 month can reduce cardiovascular risk including blood pressure and improve flow mediation dilatation in an Australian population.

  25. Hodge AM, English DR, Itsiopoulos C, O’Dea K, Giles GG. Does a Mediterranean diet reduce the mortality risk associated with diabetes: evidence from the Melbourne Collaborative Cohort Study. Nutr Metab Cardiovasc Dis. 2011;21(9):733–9.

    Article  PubMed  CAS  Google Scholar 

  26. Rienks J, Dobson AJ, Mishra GD. Mediterranean dietary pattern and prevalence and incidence of depressive symptoms in mid-aged women: results from a large community-based prospective study. Eur J Clin Nutr. 2013;67(1):75–82.

    Article  PubMed  CAS  Google Scholar 

  27. Gu Y, Luchsinger JA, Stern Y, Scarmeas N. Mediterranean diet, inflammatory and metabolic biomarkers, and risk of Alzheimer’s disease. J Alzheimer's Dis : JAD. 2010;22(2):483–92.

    Article  CAS  Google Scholar 

  28. Scarmeas N, Stern Y, Mayeux R, Luchsinger JA. Mediterranean diet, Alzheimer disease, and vascular mediation. Arch Neurol. 2006;63(12):1709–17.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Scarmeas N, Stern Y, Tang MX, Mayeux R, Luchsinger JA. Mediterranean diet and risk for Alzheimer’s disease. Ann Neurol. 2006;59(6):912–21.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Itsiopoulos C, Brazionis L, Kaimakamis M, Cameron M, Best JD, O’Dea K, et al. Can the Mediterranean diet lower HbA1c in type 2 diabetes? Results from a randomized cross-over study. Nutr Metab Cardiovasc Dis. 2011;21(9):740–7.

    Article  PubMed  CAS  Google Scholar 

  31. Knight A, Bryan J, Wilson C, Hodgson J, Murphy K. A randomised controlled intervention trial evaluating the efficacy of a Mediterranean dietary pattern on cognitive function and psychological wellbeing in healthy older adults: the MedLey study. BMC Geriatr. 2015;15:55.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Knight A, Bryan J, Wilson C, Hodgson JM, Davis CR, Murphy KJ. The Mediterranean diet and cognitive function among healthy older adults in a 6-month randomised controlled trial: the MedLey study. Nutrients. 2016;8(9).

  33. Davis C, Hodgson J, Bryan J, Garg M, Woodman R, Murphy K. Older Australians can achieve high adherence to the Mediterranean diet during a 6 month randomised intervention; Results Medley Study Nutrients 2017;9(6).

  34. Davis CR, Bryan J, Hodgson JM, Woodman R, Murphy KJ. A Mediterranean diet reduces F2-isoprostanes and triglycerides among older Australian men and women after 6 months. J Nutr. 2017;147(7):1348–55.

    Article  PubMed  CAS  Google Scholar 

  35. Hardman RJ, Kennedy G, Macpherson H, Scholey AB, Pipingas A. A randomised controlled trial investigating the effects of Mediterranean diet and aerobic exercise on cognition in cognitively healthy older people living independently within aged care facilities: the Lifestyle Intervention in Independent Living Aged Care (LIILAC) study protocol [ACTRN12614001133628]. Nutr J. 2015;14:53.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  36. Wade AT, Davis CR, Dyer KA, Hodgson JM, Woodman RJ, Keage HA, et al. A Mediterranean diet to improve cardiovascular and cognitive health: protocol for a randomised controlled intervention study. Nutrients. 2017;9(2).

  37. Wade AT, Davis CR, Dyer KA, Hodgson JM, Woodman RJ, Keage HAD, et al. Including pork in the Mediterranean diet for an Australian population: protocol for a randomised controlled trial assessing cardiovascular risk and cognitive function. Nutr J. 2017;16(1):84.

    Article  PubMed  PubMed Central  Google Scholar 

  38. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at https://health.gov/dietaryguidelines/2015/guidelines/.

  39. O’Neil A, Berk M, Itsiopoulos C, Castle D, Opie R, Pizzinga J, et al. A randomised, controlled trial of a dietary intervention for adults with major depression (the “SMILES” trial): study protocol. BMC Psychiatry. 2013;13. https://doi.org/10.1186/1471-244X-13-114):114.

  40. Zarnowiecki D, Cho J, Wilson AM, Bogomolova S, Villani A, Itsiopoulos C, et al. A 6-month randomised controlled trial investigating effects of Mediterranean-style diet and fish oil supplementation on dietary behaviour change, mental and cardiometabolic health and health-related quality of life in adults with depression (HELFIMED): Study protocol. BMC Nutrition. 2016;2:52. https://doi.org/10.1186/s40795-016-0095-1.

    Article  Google Scholar 

  41. Bogomolova S, Zarnowiecki D, Wilson A, Fielder A, Procter N, Itsiopoulos C, et al. Dietary intervention for people with mental illness in South Australia. Health Promotion International. 2016. https://doi.org/10.1093/heapro/daw055.

  42. Davis C, Bryan J, Wilson C, Hodgson J, Dhillon V, Murphy K. A randomised controlled intervention trial evaluating the efficacy of an Australianised Mediterranean diet compared to the habitual Australian diet on cognitive function, psychological wellbeing and cardiovascular health in healthy older adults (MedLey study): protocol paper. BMC Nutrition. 2015;1:35.

    Article  Google Scholar 

  43. Itsiopoulos C. The Mediterranean diet: Pan Macmillan Australia; 2015.

  44. Organisation for Economic Co-operation and Development. Agricultural output – Meat Consumption. 2016.

  45. •• Davis CR, Hodgson J, Bryan J, Woodman RJ, Murphy K. Older Australians can achieve high adherence to the Mediterranean diet during a 6 month intervention; Results from the Medley study. 2017. This paper highlights how high adherence was achieved with the MedLey study. The paper makes reference to the protocol published elsewhere.

  46. Australian Bureau of Statistics. Australian health survey: consumption of food groups from the Australian Dietary Guidelines. ACT, Australia; 2016.

  47. Kafatos A, Verhagen H, Moschandreas J, Apostolaki I, Van Westerop JJ. Mediterranean diet of Crete: foods and nutrient content. J Am Diet Assoc. 2000;100(12):1487–93.

    Article  PubMed  CAS  Google Scholar 

  48. Trichopoulou A, Vasilopoulou E, Georga K, Soukara S, Dilis V. Traditional foods: why and how to sustain them. Trends Food Sci Technol. 2006;17(9):498–504.

    Article  CAS  Google Scholar 

  49. European Food Safety Authority SOoDRVfcEJ, 2015. 13(5): p. 1–82.

  50. Australian Institute of Health and Welfare EtpooiACp-.

  51. Svedbom A, Hernlund E, Ivergard M, Compston J, Cooper C, Stenmark J, et al. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos. 2013;8:137.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  52. Australian Bureau of Statistics. 6401.0 Consumer Price Index, Australia Table 11. CPI: group, sub-group and expenditure class, index numbers by capital city. Canberra: ABS, 2012. Updated 24 April 2012 [viewed 25 April 2012]. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/allprimarymainfeatures/938DA570A34A8EDACA2568A900139350?opendocument Accessed 15 March 2018.

  53. Obesity 2015 Executive summary. Lancet 2015; published 18 Feb.

  54. Ball L, Desbrow B, Leveritt M. An exploration of individuals’ preferences for nutrition care from Australian primary care health professionals. Aust J Prim Health. 2013;20(1):113–20.

    Article  Google Scholar 

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Acknowledgements

The authors would like to acknowledge the investigators, staff, and students involved in the planning, delivery, and publication of HELFIMED—especially Dorota Zarnowiecki and Jihyun Cho—and MedLey, in particular Kathryn Dyer and Dr. Courtney Davis and PhD student Alexandra Wade for the planning and delivery of subsequent Mediterranean Dietary trials in Adelaide.

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Authors and Affiliations

Authors

Corresponding author

Correspondence to Karen J. Murphy.

Ethics declarations

Conflict of Interest

Karen J Murphy and Natalie Parletta declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Nutrition

Sample of popular HELFIMED recipes replacing meat with legumes

Sample of popular HELFIMED recipes replacing meat with legumes

Chilli Beans

This simple, versatile Mexican-inspired dish has a tasty combination of flavours and textures with the cool creaminess of the avocado combined with the rich spiciness of the beans. Serve with rice or quinoa for extra boost of protein and nutrients. Also a delicious and nutritious topping for nachos, burritos or tacos.

Ingredients

  • 1-2 tblsp extra virgin olive oil

  • 1 red onion

  • 2-4 cloves garlic

  • 2-3 fresh chillies or ~1 tsp powdered chilli to taste

  • 2 heaped tsp sweet paprika

  • 1 tsp salt

  • 1 can crushed tomatoes

  • 1 can red kidney beans

  • Grated mozzarella cheese

  • Use all or any combination of the following vegetables

  • Celery

  • Carrot

  • Eggplant

  • Red capsicum

  • Zucchini

  • Sweet potato

Method

  1. 1.

    Finely chop all vegetables (except avocado)

  2. 2.

    Lightly heat olive oil in a saucepan then add onion, celery, carrot and eggplant

  3. 3.

    Cook until onion is clear; add garlic, fresh or dried chilli and paprika; cook for a few minutes, stirring occasionally

  4. 4.

    Add cans of tomatoes and kidney beans with remaining vegetables plus half a can of water and salt

  5. 5.

    Cook until simmering, stirring occasionally; lower heat and put the lid on

  6. 6.

    Cut avocado into slices

  7. 7.

    When the vegetables are soft, serve the chilli beans with grated cheese and avocado on top – can be eaten alone or with rice/quinoa, burritos, nachos or tacos.

Lentil Nut Burgers

These tasty meat-free burgers are high in protein and can be eaten with salad and home-made chips or on a bread roll with salad and sauce. Great for picnics and barbeques. Omit the breadcrumbs for a gluten-free version.

Ingredients

  • 1 can lentils

  • 1 potato

  • 1 small sweet potato

  • Handful of mushrooms, finely chopped or processed

  • 1 cup chopped parsley

  • 1 onion, finely chopped

  • 2 cloves garlic, finely chopped

  • ½-1 cup ground mixed nuts (e.g. almonds, walnuts, cashews)

  • 1 egg

  • Salt and pepper

  • Chilli powder or cayenne pepper (optional)

  • 1 tblsp soy sauce or tamari

  • Breadcrumbs for coating

  • Extra virgin olive oil for cooking

Method

  1. 1.

    Peel and dice the potato and sweet potato, boil in salted water and cook until just soft enough to mash (not too soft); mash and allow to cool.

  2. 2.

    Finely chop onion, garlic, parsley and mushroom.

  3. 3.

    Mix all ingredients apart from breadcrumbs and olive oil. Adjust ground nuts as needed for consistency firm enough to form patties.

  4. 4.

    Shake some breadcrumbs onto a plate, make patties from the lentil mixture and roll in the breadcrumbs to cover. (If desired, the burgers can be frozen in batches for other meals at this point).

  5. 5.

    Lightly heat olive oil in a frying pan and cook patties on both sides until golden brown.

Shepherd’s Pie with Lentils

A tasty, nutritious alternative to Shepherd’s Pie. This dish was especially popular with a person who didn’t previously like lentils – she started cooking it on a regular basis!

Ingredients

  • 1 cup lentils and 4 cups water or stock (or 2 cans lentils)

  • 1 onion, chopped

  • 4 cloves garlic, chopped

  • 1 large carrot, diced

  • 1 large or two medium zucchini, diced

  • 1 stalk celery, diced

  • 1-2 cups mushrooms, chopped

  • 2-3 bay leaves

  • 1 tsp sea salt and black pepper

  • 2 tblsp parsley, chopped

  • 6 potatoes, chopped

  • 2 cloves garlic, chopped

  • ½ cup milk

  • Extra virgin olive oil

  • Grated mozzarella cheese (optional)

Method

  1. 1.

    If using whole lentils, place lentils and water or stock in a saucepan with bay leaves; bring to boil then simmer.

  2. 2.

    Lightly heat olive oil in saucepan, add chopped onions, carrot and celery and sauté until onions start to become clear and vegies soften.

  3. 3.

    Add chopped garlic, zucchini and mushrooms and cook until zucchini starts to soften.

  4. 4.

    Add lentils to the vegetables with cooking water (or canned lentils and bay leaves), with salt, pepper and parsley, and continue to cook until lentils are soft.

  5. 5.

    Meanwhile, boil some water, peel and chop potatoes. Cook in salted boiling water until soft and drain water out. (Pre-heat oven now to 180 degrees.)

  6. 6.

    Mash or blend cooked potatoes with salt, pepper, milk and a drizzle of olive oil.

  7. 7.

    Pour cooked lentil mixture into a casserole dish and gently spread the mashed potato over the top. If using grated cheese, sprinkle over the top. Bake until cheese melts and starts to brown (or top is golden if not using cheese); serve with a green salad.

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Murphy, K.J., Parletta, N. Implementing a Mediterranean-Style Diet Outside the Mediterranean Region. Curr Atheroscler Rep 20, 28 (2018). https://doi.org/10.1007/s11883-018-0732-z

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  • DOI: https://doi.org/10.1007/s11883-018-0732-z

Keywords

  • Mediterranean diet
  • MedDiet
  • MedLey
  • HELFIMED
  • Blue zones