Mediterranean Diet- A Gift of God

Trichopoulou Antonia, MD

WHO Collaborating Centre for Nutrition

Department of Epidemiology
Medical School, University of Athens

International Conference on Mediterranean Diet and Health

December 11-12, 2007
New Delhi
 Outline

• What is the Mediterranean diet

• Mediterranean diet and health

 The MD can be thought of as having 9 characteristics:

• high olive oil consumption

• high consumption of legumes

• high consumption of cereals

• high consumption of fruits

• high consumption of vegetables

• moderate consumption of dairy products, mostly as cheese and yogurt

• moderate to high consumption of fish

• low consumption of meat and meat products

• moderate wine consumption, if it is accepted by religion and social norms

 Mediterranean diet and Health:
Epidemiological Evidence

• Ecological studies

• Case-control studies

• Prospective cohort studies

• Randomized intervention studies

 Life expectancy / Disease Rates in U.S., Greece
and Japan, in 1960’s
U.S. Greece Japan
Life expectancy at
(M) 27 31 27
age 45 in years
(F) 33 34 32
Coronary Heart 33
(M) 189 34
Disease
(F) 54 14 21
Cerebrovascular
(M) 30 26 102
Diseases
(F) 24 23 57
Breast Cancer (F) 22 8 4
Stomach Cancer (M) 6 10 48
(F) 3 6 26
Colon, Rectal Cancer (M) 11 3 5
(F) 10 3 5
Total Cancer (M) 102 83 98
(F) 87 61 77
Source:W. Willett, Science 1994
EPIC participating countries
European Prospective Investigation into
Cancer and Nutrition (EPIC)

22 centres in 10 European Countries

Approximately 500.000 Europeans

participate in the EPIC project

Coordinating Center
International Agency for Research on Cancer (IARC)
Word Health Organization
EPIC GREECE
 Many studies have evaluated the
association between single foods, food
groups, or nutrients and
chronic diseases

Last 10 years: focus on the

identification of a dietary pattern that
maximizes longevity
 Dietary patterns have the ability to:

integrate complex or subtle interactive effects

or many dietary exposures
 Adherence to a Μediterranean diet and survival in a Greek population

per 2-unit increase in Mediterranean diet score

A higher degree of adherence to the Mediterranean diet was associated with
a significant reduction in :

total mortality
adjusted mortality ratio 0.75

coronary heart disease

adjusted mortality ratio 0.67

cancer
adjusted mortality ratio 0.76
Trichopoulou et al. NEJM 2003
Rather than single foods or nutrients,
a global health dietary pattern could
exert protective effect

The combination of different types of

food with healthy characteristics
might be necessary to express their
protective potential
The role of diet on the longevity of elderly Europeans

QLK6-CT-2001-00241

100 000 elderly Europeans

> 60 years at enrolment

from 9 European countries, participants of EPIC

Modified Mediterranean diet and survival: EPIC-Elderly cohort

Results

per 2-unit increase in Mediterranean diet score

A higher degree of adherence to the Mediterranean diet was associated with

8% reduction in overall mortality:

But the reduction was considerably higher in Mediterranean countries like

Spain and Greece

Trichopoulou et al. BMJ 2005

 Mediterranean Diet, Lifestyle Factors, and 10-year mortality in Elderly
Europen Men and Women

Among individuals aged 70 to 90 years,

adherence to a Mediterranean diet and

healthful lifestyle is associated with a more than

50% lower rate of all- cause and cause-specific

mortality

Knoops et al. JAMA, 2004

Effect of a Mediterranean –style diet on endothelial dysfunction and
markers of vascular inflammation in the metabolic Syndrome” a
randomized trial markers

A Mediterranean-style diet might be effective

in reducing

the prevalence of the metabolic syndrome

and its associated cardiovascular risk

Esposito et al. JAMA 2004

Mediterranean diet and survival of coronary patients: EPIC-Greece cohort

Results

a 2-unit increase in Mediterranean diet score

was associated with

27 % reduction in overall mortality

among individuals diagnosed

as having coronary heart disease

Trichopoulou et al. Arch Intern Med 2005

Mediterranean diet and survival of coronary patients: EPIC-Greece cohort

Results (continued)

The reduced mortality amounted to 31%

when only cardiac deaths were considered

as the relevant outcome

Trichopoulou et al. Arch Intern Med 2005

 Modified Mediterranean diet and survival: EPIC-Elderly cohort

Conclusion

Greater adherence to the traditional Mediterranean diet

is associated with a significant

reduction in mortality among individuals diagnosed as

having coronary heart disease

Trichopoulou et al. Arch Intern Med 2005

Modified Mediterranean diet and survival after myocardial
infarction: the EPIC-Elderly study

2671 EPIC participants

from nine countries
60 years or older

had prevalent myocardial infarction but no stroke

or cancer at enrollment

Trichopoulou A. et al. Eur J Epidem 2007

Modified Mediterranean diet and survival after myocardial
infarction: the EPIC-Elderly study

Increased adherence to modified Mediterranean diet

by two units

was associated with

18% lower overall mortality rate

Trichopoulou A. et al. Eur J Epidem 2007

Effects of a Mediterranean-style diet on cardiovascular risk factors:
a randomized trial

Compared with a low-fat diet

Mediterranean diets supplemented with

olive oil or nuts have beneficial effects on
cardiovascular risk factors

Estruch et al. Ann Intern Med, 2006

Olive oil, Mediterranean diet and arterial blood pressure: the Greek EPIC cohort

An increase of olive oil consumption

by one standard deviation was associated with

significant reduction

of both systolic and diastolic blood pressure

by almost 1mm Hg and 0.5 mm Hg

across 20 343 individuals

Psaltopoulou et al. 2004 AJCN

Mediterranean diet in relation to body mass index and waist-to-hip
ratio: the Greek EPIC Study

There is no association

between

Mediterranean diet

and

BMI or W/H ratio

Trichopoulou et al. Am J Clin Nutr 2005

Mediterranean diet and obesity in a Spanish population

The data indicated that

the traditional Mediterranean dietary pattern

may be inversely associated with BMI

Schroder, J Nutr 2004

Olive oil and the Mediterranean diet: beyond the rhetoric

> 13,5 % of total calories from olive oil

< 6,8 % of total calories from olive oil

Consumers of larger quantities of olive oil have

low saturated fat intake,

high consumption of vegetables and legumes

and
more adequate vitamin intake

Serra-Mayem L. 2003 Eur J Clin Nutr

 Minor constituents of olive oil
Hydrocarbons
Non-glyceride esters
Tocopherols
Carotenoids
Aliphatic alcohols
4-methyl sterols
Sterols
Hydroxy-and dihydroxy-terpenic alcohols
Phospholipids
Phenolic compounds (50-800 mg/Kg)
Chlorophyls
Glycolipids
Aldehydes
Ketons
Esters
The effect of polyphenols in olive oil on heart disease risk factors: a
randomized trial.

Olive oil is more than a monounsaturated

fat

Its phenolic content can also provide

benefits for plasma lipid levels and
oxidative damage

Covas et al Ann Intern Med. 2006

 Ongoing research aims to elucidate
the role of dietary antioxidants in disease prevention

The main approach was based on the hypothesis

that the chronic disorders common in many societies
are related
to cumulative oxidative damage to DNA, proteins and
lipids in body tissues
Olive oil and red wine antioxidant polyphenols inhibit endothelial
activation: antiatherogenic properties of Mediterranean diet
phytochemicals.

Antiatherogenic properties of Mediterranean diet

phytochemicals

Olive oil and red wine antioxidant polyphenols

inhibit endothelial activation

Carluccio et al Arterioscler Thromb Vasc Biol. 2003

Effect of a traditional Mediterranean diet on lipoprotein oxidation:
A randomized, controlled trial

Individuals at high cardiovascular risk

who improved their diet

toward a Traditional Mediterranean Diet

pattern

showed significant reductions in cellular

lipid levels and LDL oxidation

Fito et al. Arch Intern Med, 2007

The traditional Mediterranean diet is
associated with longer survival

This could be partly attributed to

Mediterranean traditional foods, which
this diet implies
 Inorganic constituents
10000

Mediterranean menu
1000
EC daily recommendations
log(daily intake, mg)

100

10

K Fe Na Ca Mg Zn Cu Mn

1. Commission of the European Communities. Food-Science Techniques: Reports of the Scientific Committee
for Food (Thirty-first series), Office for Official Publications of the European Communities, Luxembourg,1993,pp 1-248
Contributors to the main flavonoids
categories intake for Greece & The
Netherlands

The Netherlands 1

Tea beverages
Onions
Apples

Greece
Apples 1. Hertog, Hollman, Katan, Kromhout “Intake of
potentially anticarcinogenic flavonoids and their
Parsley determinants in adults in The Netherlands”, Nutr
Cancer 1993;20(1):21-9
Onions
Olives
Spring onions
Red wine
Spinach
 CONCLUSIONS

The investigated traditional Mediterranean menu :

‰meets current dietary recommendations – balanced diet

‰high flavonoid content- obtained from wide range of foods

Trichopoulou et al. 2005 Diet diversification and health promotion. Forum Nutr.Basel, Karger,
Vasilopoulou et al. 2005 Curr.Med.Chem-Immun, Endoc.& Metab.Agents,
 Med Diet Healthy alternative approach

• Not sharply different from other recommended diets

• Two elements distinguish it from other prudent diets

1. It stresses the pattern rather than individual components

and
2. Provides no restriction on lipid intake so long as they are not
saturated and are preferably in the form of olive oil
 Conclusion

Mediterranean diet corresponds so well

to the ideal diet, as currently understood
by the scientific community that can be
thought of as a gift of the God to the
people of the Mediterranean basin.
 Conclusion
Results from large-scale observational
studies indicate that diets freely chosen
by the general population can approach
the Mediterranean-diet optimum
provided that the nutritional milieu and
the food culture are conducive to the
adoption of a Mediterranean diet
"Let food be thy medicine
and
medicine be thy food"

Hippocrates
THANK YOU FOR YOUR ATTENTION