Why I Recommend the Mediterranean Diet

I recommend the Mediterranean diet (MED) to my patients. Every unbiased, systematic review of the research on diet and heart disease in the last 8 years has concluded that it is the most likely dietary model to provide protection against coronary heart disease. One review concludes

Among the dietary exposures with strong evidence of causation from cohort studies, only a Mediterranean dietary pattern is related to CHD (coronary heart disease) in randomized trials.

The MED is the only comprehensive dietary approach that has been proven to reduce total death  and heart attacks in comparison to standard diets. There are two major randomized controlled trials (the only kind of study that proves the value of a dietary intervention) with this diet.

From Eric Roehm at www.nutritionheart.com

  The first, called the Lyon heart Study,  was in patients who had had heart attacks (secondary prevention) . As this graph demonstrates, those patients randomized to receive instruction on following the Mediterranean diet had a 60% lower death rate and a 70% lower heart attack rate. The second was published last year in the New England Journal of Medicine and was a primary prevention study: that is, participants had not had heart attacks. Participants were randomized to one of three diets: a MED supplemented with extra-virgin olive oil,  MED supplemented with mixed nuts or a control diet (advice to reduce dietary fat). Participants received quarterly individual and group educational sessions and either free provision of olive oil, mixed nuts or small nonfood gifts. The high extra virgin olive oil group ingested an average of 3.6 tablespoons/day (51 grams/day equal to 459 calories/day) of olive oil with 98% of it being extra virgin olive oil. The high nut group ate 8.2% of their total daily calories in the form of nuts, including an additional approximately one ounce packet of nuts (15g of walnuts, 7.5 g of almonds, and 7.5g of hazelnuts) provided by the study coordinators. 7447 persons were enrolled (ages 55 to 80 years) for an average 4.8 years. Those persons following the MED diet (either supplemented with olive oil or nuts) were 30% less likely to have  a major cardiovascular event (heart attack, stroke or death from cardiovascular causes.) There was a statistically significant reduction in stroke rate (≈39%) when considered as an isolated endpoint. We don’t know exactly what components of the MED are the most beneficial.  This trial suggests that olive oil and nuts are at least two of the key ingredient so it makes sense to increase your consumption of these foods. Other studies strongly support fish consumption and alcohol consumption as key components. As I’ve discussed (?ad nauseam) in other posts, full fat dairy and eggs, although banned by most “heart healthy diets”, have not been shown to increase heart disease risk.  Fermented dairy consumption, in particular, in the form of plain full-fat yogurt (not adulterated with sugar) and full-fat cheese is consistently associated with a lower risk of coronary heart disease. Plain full-fat yogurt and full-fat cheese (from goat milk) were consumed by the inhabitants of Crete, the Greek Island on which the original MED was based.
It has to be emphasized that within this pattern of eating you want to be consuming real foods, not processed products of the industrial food industry which have been manipulated to appear healthy due to being “low-fat” or “low cholesterol.”
This is a pattern of eating which is varied, interesting and sustainable.
It’s one that can last a lifetime. ,


8 thoughts on “Why I Recommend the Mediterranean Diet”

  1. Fascinating! This still presents an extremely challenging decision for people like myself, who have had very high cholesterol and now @62 very (very) high CAC readings – asymptomatic, healthy, thin. I want to go all-in on the mediterranean thing (rather than all-plant based) BUT — the eggs, cheese, pastas, etc look very “scary” to me in light of so many reports warning against dairy and red meats (even in moderation). It also seems very (very!) probable that everyone’s personal genetics is a key factor in determining what foods one’s system will be healthiest. Is there any way to at least “guess” which road is most likely to keep me alive?

    • Evidence for all plant-based diets benefiting patients like you is very very weak (I’ve discussed the major evidence bases-Esselstyn, ornish, Pritikin- on this site)
      Evidence for mediterarranean diet is stronger.
      Evidence that dairy fat would increase you risk of CV events is weak (for butter, milke) to nonexistent (for yogurt, cheese).
      We have no evidence to craft a different diet plan based on personal characteristics.
      If you are without risk factors, your strongest action to reduce CV events is to begin appropriate medical therapy
      Dr. p

  2. I am frusturated. I am thin, and exercised daily. I thought I had a good diet. I am a woman and had a heart attack at 55 and now have four stents. I am still stunned. My insulin is 9, my fasting sugar is 85, my a1c is 5.1. The only thing I had was high LDL. HDL was good triglycerides were excellent. I had high homocystein levels. CRP was low. The doctor is getting me some vitamin D and vitamin K. I was low on vitamin D. This blog has been helpful. I get 20 different diets from the hospital. I am cutting out all “healthy” whole grains. My stomach feels better off wheat. I eat meat, vegetables, legumes and a little bit of fruit. I hope this works. I really don’t want to die.

  3. One of the most important components of the ‘MED” diet is the one overlooked by the Diet-Warriors.. “LIFE-style”. Not only did these folk get the food ‘right’ , they LIVED as part of an ’emotionally supportive’ society.
    Indeed, this Good Friends Sharing Good Food & Wine in a caring group is the only explanation for the Rosetta effect. – An Italian village of that name who transplanted to the US. Not only did they embrace the Fine Cuisine of the day…. but lived and worked hard and dangerously (at work).
    Heart disease was unknown, and only invaded when – with passage of time – the young moving away, and family and ‘tribal’ networks dying out.
    This cardio-supportive aspect goes a long way to explaining the French Paradox… They have NO regard to ‘Modern’ dietary guidelines, they eat cheeses, butter on croissants… drink wine in abundance and smoke…….
    – French cigarettes. !

  4. One thing stands out to me. There are genetic differences likely in Mediterraneans people, which may well allow tolerance of animal-based fats. I am not Mediterranean but my family illustrates the genetics involved, one side living to their 90s and a diet laden with pork fat and dairy. The other side all! died in their mid 60s, max, from heart disease, similar diet.

  5. Hi, Dr. Pearson! I’ve just discovered your wonderful blog — great stuff, thank you!
    I’m a nutritionist based in Boulder, CO and specialize in the Mediterranean diet (www.modernmediterranean.com).
    Inspired by my own brush with cancer 15 years ago and 11 years spent living in south-western France, I have written a book called “Zest for Life: The Mediterranean Anti-Cancer Diet.” In it, I mention the Lyon study as it found similar reductions in cancer risk among the MED-eaters.
    In addition to the reasons you mention above, I believe there are a few other factors that make the MED diet so healthy: A large amount of plant foods (veg, fruit, legumes, nuts, seeds, spices, herbs) packed with anti-inflammatory and antioxidant compounds; diversity — increasingly understood to be much more important than individual “superfoods;” and conviviality :).
    One point I slightly disagree with you on is butter and dairy fat. Not because of the saturated fats in them, but because of the estrogens they contain due to modern farming methods; see this blog post: https://www.psychologytoday.com/blog/nourish/201303/time-take-milk-the-menu and this one https://www.psychologytoday.com/blog/how-we-do-it/201403/got-milk-got-unwanted-hormones. Alas, dairy, and the fat in it, aren’t what they were in our great-grandmothers’ time!
    I’d be happy to send you a complimentary copy of my book if you tell me where to mail it to. And feel free to check out my blog at Psychology Today: https://www.psychologytoday.com/blog/nourish (I haven’t posted anything for a while because I have been bogged down with a book project, but that’s nearly done, so I’ll be back to blogging soon.)
    Best regards,

    • I appreciate your comments.
      The concern with saturated fats and breast cancer has been raised with me previously.
      I’ll take a look at your posts and try to render an informed response.


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