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The Mediterranean diet revisited-towards resolving the (French) paradox
Abstract
The Mediterranean diet traditionally refers to diets typical of the olive‐growing regions of the Mediterranean, but has a number of important constituents in addition to olive oil. These include: a large consumption of salads and legumes, and also wheat, olives, grapes, other fruits and their derivative products, including alcohol.1 As noted by Trichopoulou and Lagiou,1 total fat consumption may be high, at around 40% of total energy, as in Greece, or moderate, at around 30% of total energy, as in Italy. In Italy, the diet is characterized by pasta consumption, whereas in Spain fish consumption is particularly high. Ferro‐Luzzi and Sette2 and de Lorgeril3 also comment on the difficulty of adequately defining a Mediterranean diet. According to Trichopoulou,1 moderate alcohol consumption is an essential component, but moderate is not defined quantitatively. Ancel Keys, pioneer of the Seven Countries Study, had a hand in promoting the idea of a Mediterranean diet in his cookery book, written with his wife, ‘How to eat and stay well, the Mediterranean way’.
The French paradox is a reference to the observation that a high consumption of animal fats is paradoxically coexistent with one of the lowest incidence of ischaemic heart disease in Europe.4 But others5 have noted that France is not alone and that other southern European countries show this effect. Data from Ancel Keys' epic Seven Countries Study, the planning of which started in 1947, showed that, although edible fat intake in grams per day in Italy and parts of Yugoslavia were quite low, in Crete, where heart disease mortality was very low, intake was second only to Finland's, but was characterized by a high olive oil and a low saturated fat intake.6
The Greeks have the highest olive oil consumption: a staggering 20 kg/person/year,7 whereas …
... In this current framework, the scientific community has recognised that the Mediterranean diet (MD) has great effects on longevity, advanced cognitive impairment as well as lower incidence of chronic health problems such as cardiovascular disease, diabetes, stroke and cancer. This diet is characterised by consuming of vegetables, fruits and legumes, small amounts of dairy products (principally cheese and yogurt), low quantity of seafood and poultry, legume, olive oil as dressing and above all moderate amount of wine (Yarnell and Evans 2000;Martínez-González et al., 2019). In fact, according to several studies (Dang et al., 1998;Rotondo et al., 2001;Annunziata et al., 2016;Snopek et al., 2018), moderate intake of alcohol, in particular red wine, reduces the incidence of heart disease and increases longevity. ...
... Wine and its nutritive properties have been recognised for thousands of years as being beneficial thanks to the synergic mixture of some biochemical components with antioxidants anti-inflammatory proprieties such as polyphenols (e.g. bioflavonoids), tocopherols, phytosterols, anthocyanin (that contributes red wine their dark colour) (Yarnell and Evans 2000;Martínez-González et al., 2019). ...
The Human Development Index (HDI) is a statistic composite index composed of life expectancy, education, and per capita income indicators. Currently, wine consumption is increasingly becoming significant both for reducing several diseases and for improving well-being and quality of life. The aim of this paper is to investigate spatial and temporal characteristics of wine consumption in 45 countries belonging to the World Health Organization (WHO) European Region and its relationship with the HDI. We use a balanced panel data by WHO database (2005-2015). Random effects panel data model was selected over the fixed effects model based on the Hausman test in order to assess the effect of HDI, European Union (EU) membership and geographical areas on wine consumption. Results highlight that wine consumption decreases as HDI increases. We noted higher values of wine consumption in EU countries and a positive gradient from West to East in the area considered. These findings highlight the presence of a new consumer profile seeking quality and healthy consumption and whose awareness increases coinciding with a rise in the degree of country development. National and international policies can address issues of consumption style and persuade consumers to have a new eating cultural approach towards buying quality and healthy food. © 2020, NAIK Research Institute of Agricultural Economics. All rights reserved.
... It should be noted that resveratrol alone is unlikely to be the only contributor to the "French paradox". Many dietary and social factors may also contribute including a "Mediterranean" diet high in fruits, vegetables, and whole grains along with dietary intake of omega-3 fatty acids from olive oil, fish, and nuts [23,24]. It has been estimated that the concentration of resveratrol in wine ranges from as little as 0.2 mg/L to up to 10.6 mg/L, depending largely on grape type and environment [25]. ...
... These doses have been observed to exert pharmacological activity previously[8,25,170]. After dosing, a series of blood samples (0.5 ml) was collected at 0, 1, 15, 30 min, then1, 2,4,6,12,24,48,72,96, and 120 h. The cannula was flushed with 0.5 ml of normal saline after each sample collection. ...
... It also includes elevated consumption of fruit, legumes and vegetables, and for some variants, fish consumption. 13 In epidemiological studies, adherence to Mediterranean diet has been assessed by several a priori dietary scores. The most common Mediterranean-style dietary scores are the Mediterranean Diet Score, the modified Mediterranean Diet Score, the American Mediterranean Diet Score and the Literature-based Adherence score to the Mediterranean Diet (MEDI-LITE) 14 that differed by the presence or absence of olive oil, the definition of the components and the system for point allocation. ...
Background:
Mediterranean diet has been consistently negatively associated with cardiovascular diseases (CVD) but the superiority compared to official nutritional guidelines has not been tested yet. Our objective was to prospectively investigate the association between several nutritional scores and incidence of cardiovascular diseases.
Methods and findings:
A total of 94,113 participants from the NutriNet-Santé cohort were followed between 2009 and 2018. The participants have completed at least three 24 h dietary records during the first two-years of follow-up to compute nutritional scores reflecting adherence to the Mediterranean diet (MEDI-LITE), American dietary guidelines (AHEI-2010) and French dietary guidelines (mPNNS-GS). Sex-specific quartiles (Q) of scores were computed. Multivariable Cox proportional hazards models were used to estimate the associations between scores and incidence of CVD, documented using Hazard Ratio (HR) and 95% confidence intervals (95%CI). Thus, 1399 incident CVD events occurred during the follow-up (mean follow-up = 5.4 years). Comparing Q4 versus Q1 quartile, HR for the MEDI-LITE and AHEI-2010 were 0.79 (95% CI: 0.67-0.93, P-trend = .004) and 0.75 (95% CI: 0.63-0.89, P-trend = .002) respectively. These associations remained similar when removing early cases of CVD, when analyses were restricted to participants with >6 dietary records and when considering transient ischemic attacks. In this last case, association between CVD' risk and mPNNS-GS become significant.
Conclusions:
A better nutritional quality of diet is overall associated with lower risk of CVD. The future version of the PNNS-GS, based on the updated version of the French dietary guidelines, should strengthen the CVD protective effect of French recommendations.
... Beispiele für externe Faktoren sind Krankheitenund die individuelle Lebensweise [32,33]. Erfreulicherweise gibt es für das sekundäre Altern heute zahlrei-Abb. 1 [54][55][56][57][58][59][60][61][62]. ...
Effektive Anti-Aging-Wirkstoffe können nur dann entwickeltwerden, wenn der Alterungsprozess vollständig verstanden ist. Da dies bis heute noch nicht vollständig der Fall ist, sind derzeit nur solche Wirkstoffe verfügbar, die in bereits verstandene Teilbereiche des Alterungsprozesses eingreifen können. Der Beitrag umreißt die wesentlichen heute bekannten Anti-Aging-Strategien und erläutert, basierend darauf, neue und innovative Konzepte für die Entwicklung von Anti-Aging-Dermokosmetika.
... Im Prinzip kann man viele Erfolge der heutigen Ernährungsempfehlungen, sei es die Okinawa-Diät oder die mediterrane oder asiatische Küche, auch auf eine langfristige Kalorienrestriktion zurückführen, die auch im Tiermodell signifikante Anti-Aging-Effekte bestätigt [41][42][43][44][45][46][47][48][49][50][51][52][53]. Auch das sogenannte "French-Paradoxon" (das heißt, dass beobachtet wurde, dass Franzosen im Allgemeinen weniger Herz-Kreislauf-Probleme haben als andere Europäer, obwohl deren Ernährung -bis auf den Rotwein zum Essen -denen der anderen Europäer ähnelt) lässt sich mit einer Kalorienrestriktion vergleichen, denn das Resveratrol im Rotwein regt den Körper zu den gleichen Reparaturmechanismen an, wie es unter einer Kalorienrestriktion der Fall ist [54][55][56][57][58][59][60][61][62]. ...
Effektive Anti-Aging-Wirkstoffe können nur dann entwickelt werden, wenn der Alterungsprozess vollständig verstanden ist. Da dies bis heute noch nicht vollständig der Fall ist, sind derzeit nur solche Wirkstoffe verfügbar, die in bereits verstandene Teilbereiche des Alterungsprozesses eingreifen können. Der Beitrag umreißt die wesentlichen heute bekannten Anti-Aging-Strategien und erläutert neue Konzepte für die Entwicklung von Anti-Aging-Dermokosmetika.
... Subsequent studies of diet and cardiovascular heart disease (CHD), have since evaluated the effects of numerous dietary nutrients and dietary patterns on CHD risk (Mente et al., 2009). The Seven Countries European Study (Yarnell and Evans, 2000) investigated the distribution of CVD mortality in Europe and found this diagnosis three times higher in some places than in others. This particular study dealt with the interaction of classic CVD risk factors with the dietary habits as well as with their combined effects on the occurrence of CVD, including mortality. ...
It has often been suggested that cardiovascular mortality and their geographical heterogeneity are associated with nutrients intake patterns and also lipid profile. The large Spanish study Dieta y Riesgo de Enfermedades Cardiovasculares en España (DRECE) investigated this theory from 1991 to 2010. Out of the 4,783 Spanish individuals making up the DRECE cohort, 220 subjects (148 men and 72 women) died (4.62%) during the course of the study. The mean age of patients who died from cardiovascular causes (32 in all) was 61.08 years 95% CI (57.47-64.69) and 70.91% of them were males. The consumption of nutrients and the lipid profile by geographical area, studied by geospatial models, showed that the east and southern area of the country had the highest fat intake coupled to a high rate of unhealthy lipid profile. It was concluded that the spatial geographical analysis showed a relationship between high fat intake, unhealthy lipid profile and cardiovascular mortality in the different geographical areas, with a high variability within the country.
... Beispiele für externe Faktoren sind Krankheitenund die individuelle Lebensweise [32,33]. Erfreulicherweise gibt es für das sekundäre Altern heute zahlrei-Abb. 1 [54][55][56][57][58][59][60][61][62]. ...
Effektive Anti-Aging-Wirkstoffe können nur dann entwickelt werden, wenn der Alterungsprozess vollständig verstanden ist. Da dies bis heute noch nicht vollständig der Fall ist, sind derzeit nur solche Wirkstoffe verfügbar, die in bereits verstandene Teilbereiche des Alterungsprozesses eingreifen können. Der Beitrag umreißt die wesentlichen heute bekannten Anti-Aging-Strategien und erläutert, basierend darauf, neue und innovative Konzepte für die Entwicklung von Anti-Aging-Dermokosmetika.
... Pour vérifier l'originalité de l'expression, nous avons interrogé Google, d'où il ressort que « le paradoxe israélien » est une énigme alimentaire bien connue ! Le régime israélien-juif est défini comme « méditerranéen », faible en calories, en quantité totale de matières grasses et en graisses saturées, il comporte un niveau élevé d'acides gras hypolipidémiques (c'est-à-dire faible en viandes et en graisses animales, riche en graisses végétales, en fruits et en légumes), et est réputé réduire l'incidence des cardiopathies ischémiques [Yarnell et Evans, 2000]. Pourtant, contrairement aux autres consommateurs de ce régime -les Grecs, les Espagnols, les Français et, en l'occurrence, les Palestiniens -, seuls les Israéliens juifs souffrent de taux élevés d'insuffisances coronariennes associées à la présence de graisses [Dubnov et al. 2004 ;De Lorgeril et al. 2002]. ...
... The snail's meat has low calorie and fat content and high amounts of minerals, essential aminoacids and polyunsaturated fatty acids [2,3,4]. Recent research ranked snail meat as one of the positive factors of Mediterranean diet [5]. Various aspects of its biology, ecology and ecogenetics have been studied, as this species is the principal subject for snail farming (heliciculture) in Greece [6,7]. ...
Body weight, shell’s diameter, shell’s’ thickness, shell’s mechanical strength and chemical composition of the hypostracum of reared and wild snails (Cornu aspersum) were analyzed. Wild adult individuals were collected from Crete (Greece) and compared with adult individual snails reared under laboratory conditions. Α standard layer diet supplemented with 20% calcium was used as snails’ diet. An EDS (Energy Dispersive Spectrometry) method was used for the analysis of the hypostracum. The EDS analysis was made by the use of a scanning electron microscope. Calcium, oxygen, carbon and silicon were the chemical elements that they were detected at the C. aspersum hypostracum. No statistical difference was recorded between the chemical elements of the hypostracum of reared snails and of the wild ones. Both groups had similar body weight, shell mechanical strength and shell thickness.
... The snail's meat has low calorie and fat content and high amounts of minerals, essential aminoacids and polyunsaturated fatty acids [2,3,4]. Recent research ranked snail meat as one of the positive factors of Mediterranean diet [5]. Various aspects of its biology, ecology and ecogenetics have been studied, as this species is the principal subject for snail farming (heliciculture) in Greece [6,7]. ...
Muscular tissue collagen fibrils’ diameter and period of reared and wild snails (Cornu aspersum) were measured in order to investigate the role of nutrition on the collagen. Wild adult individuals were collected from Crete (Greece) and compared with adult individual snails reared under laboratory conditions fed a formulated diet. Transmission electron microscope and image analysis algorithms were used in the study. Statistically significant differences between the diameters of the collagen fibrils in the reared and the wild snails were found, and the D-period of the fibrils differed.
... D'une part, ce double accrochage a été frayé de l'extérieur par un phénomène de forte valorisation de l'intérêt diététique de l'alimentation méditerranéenne. Ce phénomène, largement construit par le monde biomédical (Hubert, 1998), peut là encore masquer les nuances et les controverses, liées notamment à la diversité des régimes alimentaires méditerranéens et à l'ignorance d'éventuels autres facteurs, comme le mode de vie (Yarnell et Evans, 2000). D'autre part, intrinsèquement, ce double accrochage est consolidé par la codification qu'il nous faudra décrire de cette allégation santé dans la démarche, appuyée sur l'implication des scientifiques. ...
Cet article étudie une démarche de qualification de produits alimentaires fondée sur une triple revendication relative au terroir, au respect de l’environnement, et enfin à l’atout préventif de ces produits en termes de santé, qui constitue l’originalité de cette marque collective. Cette introduction d’une allégation santé pose de nombreuses questions.Quelles tensions cela crée-t-il avec les autres revendications affichées? Comment construire durablement une valorisation qui s’appuie sur des connaissances largement instables, celles touchant aux liens entre alimentation et santé ? Comment valoriser un large éventail de produits, allant du vin aux fruits et légumes, mais aussi aux œufs, alors que l’atout santé est pour certains loin d’aller de soi ? Nous verrons comment ce dispositif parvient, grâce au rôle intermédiaire des techniciens qui l’animent, à faire coopérer des scientifiques que la question de la valorisation des produits agricoles ne concerne a priori pas et des agriculteurs que les aspects scientifiques ont peu de raison d’intéresser.
Background
The EAT-Lancet commission proposed, in 2019, a planetary, healthy and universal dietary. However, this diet has been rarely studied in relation to various health outcomes.
Objectives
We aimed to prospectively estimate the association between the EAT-Lancet diet and cancer and cardiovascular risk.
Design
The study was conducted among participants of the NutriNet-Santé cohort (2009–2021). The endpoints were the incident outcomes (cancer and cardiovascular diseases (CVD) and mortality from these diseases), combined and separately. Adherence to the EAT-Lancet diet was estimated using the EAT-Lancet Diet Index (ELD-I) modelled as quintiles (Q). Multivariable Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs), adjusted for potential confounders and moderators.
Results
A total of 62,382 subjects were included, 2,475 cases of cancer and 786 cases of cardiovascular occurred during a median follow-up of 8.1 years. The sample was 76% female, the mean age at inclusion was 51 years (Standard Deviation (SD) = 10.2 years). The ELD-I ranged from -162 to 332 points with a mean score of 45.4 points (SD = 25.6 points). In multivariable models, no significant association between the EAT-Lancet diet and the risk of cancer and CVD combined, and separately, was observed. Alcohol consumption was an effect modifier of the association. A significant association was observed among low drinkers (HR Q5 vs Q1 = 0.86, (95% CI 0.73, 1.02), p-trend = 0.02). A higher ELD-I was significantly associated with a lower risk of overall cancer only among females, (HR Q5 vs Q1 = 0.89, (95% CI 0.75, 1.05), p-trend = 0.03). Both associations were largely attenuated by body mass index.
Conclusion
Contrary to our hypothesis, our results documented significant associations between adherence to the EAT-Lancet diet and incidence of cancer only in some subgroups, and no association with CVD.
The Seven Countries Study suggested an association between serum cholesterol and cardiovascular disease (CVD). However, the association was not consistent across the various cohorts of participants in different countries; while it was very clear in US and Northern European cohorts, it was weak in Southern European and Japanese cohorts. Nevertheless, the study triggered research into cholesterol-lowering drug strategies, ultimately leading to the development of statins amongst others. Clinical evidence in support of statins is strong and the vast majority of the medical community advocate these drugs as highly effective first-line therapeutics in primary and secondary prevention of CVD. However, growing evidence of side-effects associated with statins in a significant proportion of patients suggests that these drugs are not a universal solution to CVD. There is a need, therefore, to revisit the evidence and to re-appraise the relative importance of cholesterol amongst many other lipids as potential modulators of atherogenesis. In this review, we assess the relative merits of statin therapy in CVD versus dietary interventions that impact on lipids other than cholesterol, including omega-3 fatty acids and polar lipid fractions of various foods (e.g. fish and olive oil). We conclude that careful design around the lipid components of dietary interventions presents a credible alternative in patients who are intolerant to statins or averse to taking such drugs.
Cardiovascular disease (CVD) is a major health problem worldwide and is a leading cause of morbidity and mortality in many countries, particularly in the United States (Roger et al. 2011). According to the statistical report from the American Heart Association, more than one-third of American adults (~82 million) have one or more types of CVD, including high blood pressure, coronary heart disease, heart failure, and stroke (Roger et al. 2011). Given the high prevalence of CVD, it is important to have effective ways to prevent and treat CVD.
Consumption of saturated fat is a risk factor whereas that of fruits and vegetables is considered as a prevention factor. A retrospective study, over a long period, of food consumption in France, enabled us to see that, for all that fat consumption increased, the composition of this fat was modified with the profit of unsaturated fatty acids. In addition, fruits and vegetables consumption increased too. French food consumption is in a European food consumption gradient, which is also found at the regional level. Nevertheless, the rather favourable evolution of French consumption is not as fast as that of its European neighbours.
The PRIME Study was begun in 1991 and recruited 10,600 men aged 50 to 59 years in the WHO MONICA Project centers of Belfast, Lille, Strasbourg and Toulouse. Although drinkers in France and Northern Ireland consumed almost identical amounts, the pattern of consumption was different. In Northern Ireland beer and spirits were the staple beverages, whereas in France it was predominantly red wine; in France, 90% of men drank at least one unit per week versus 61% in Northern Ireland. Frenchmen drank evenly throughout the week, whereas in Northern Ireland two thirds of the consumption took place on Friday and Saturday nights. In the 5-year follow up of PRIME in France, the usual cardiovascular protective effect of increasing consumption (up to 45 units per week) was shown and the level of significance for trend in consumption was highly significant (p = 0.006); in Northern Ireland, this pattern was less consistent and did not attain significance. It remains a matter of conjecture whether in Northern Ireland the beneficial effects of alcohol consumption were annulled by a pattern of drinking that increases blood pressure, a well-established risk factor for heart disease, or whether the protection in France resulted from the consumption of wine along with food.
Both epidemiological and experimental studies have revealed that intake of wine, particularly red wine, in moderation protects cardiovascular health; however, the experimental basis for such an action is not fully understood. Because all types of red wine contain varying amounts of alcohol and antioxidants, it is likely that the cardioprotective effect of red wine is due to both these constituents. In view of its direct action on the vascular smooth muscle cells, alcohol may produce coronary vasodilation in addition to attenuating oxidative stress by its action on the central nervous system. The antioxidant components of red wine may provide cardioprotection by their ability to reduce oxidative stress in the heart under different pathological conditions. Mild-to-moderate red wine consumption improves cardiac function in the ischemic myocardium through the protection of endothelial function, the expression of several cardioprotective oxidative stress-inducible proteins, as well as the activation of adenosine receptors and nitrous oxide synthase mechanisms.
The cutaneous hemangiomas of infancy or infantile hemangiomas are the most common benign tumor of childhood. They were formerly known as strawberry hemangiomas in reason of its typical appearance although uncommon morphologic variations can be found. Usually hemangiomas are harmless growths that are the result of proliferation of endothelial cells during early childhood. Involution of the lesion occurs at 12-18 months and can last up to 7 years. Occasionally, infantile hemangiomas suffer dramatic overgrowth causing esthetical damages, as well compromises to vital structures that requires prompt intervention. Propranolol, a beta-adrenergic receptor antagonist that was invented by Sir James Black in 1960s, appears to be an effective treatment for infantile hemangiomas and should now be used as a first-line treatment in hemangiomas when intervention is required. Keloids (that resembles crab claws) and hypertrophic scars are fibrous tissue outgrowths that result from a derailment in the normal wound-healing process. Systemic or intralesional propranolol may play a role in the amelioration of keloids and hypertrophic scars due to their potential to induce vasoconstriction of over proliferating tissues, triggering apoptosis of endothelial cells and also to their effect as modulator of inflammatory process during wound healing. In adding the propranolol to the melting pot of abnormal (or supra-normal) wound healing, we hypothesized that we can battle keloids with propranolol.
Sir,
Despite a high level of risk factors such as elevated serum cholesterol level, diabetes, hypertension and a high intake of saturated fat, French males display the lowest mortality rate from coronary heart disease and cardiovascular diseases in Western industrialized nations (36% lower than the USA and 39% lower than the UK).1 It has been suggested that regular consumption of red wine may explain this phenomenon, which has been dubbed the ‘French paradox’,2 i.e. the coexistence of a high‐fat diet and a low incidence of coronary artery disease. Of course, as was pointed out by Yarnell and Evans in their …
Sir,
There is no question that there is a low incidence of coronary heart disease among people who live close to the Mediterranean, and obviously eating is an essential part of living. Unfortunately, there is within society at large and scientific medicine also, a tendency to jump to the conclusion that an association inevitably involves causation. For a number of years, we have therefore had a strong view expressed and indeed an assumption made that coronary heart disease is basically dietary, and that …
We studied medicinal and food plant species, recording an extraordinary number of species and uses in Castilla-La Mancha, Murcia and Valencia in Spain. Focusing on two demographically distinct regions - Castilla-La Mancha and Lower Segura Valley. A high proportion of the flora (20 to 30 %) is known for its medicinal properties, and, interestingly, a high number of medicinal-food plants (5 to 7 %) is recorded. The concept of "Local Food" involves the whole repertory of species that characterises the local diet (incl. local cultivars and non-cultivated gathered food plants). The number of food plant species varies between 15 and 25 % of the vascular flora, and for the gathered food plants (GFP) this decreases to a 3 to 8 %. Those GFP that are also used for medicinal purposes are only 2 to 4 % of the total vascular flora. The relevant plant families are very similar in relative numbers along the different areas: Compositae, Rosaceae and Umbelliferae, followed of Boraginaceae, Liliaceae, Cruciferae, and Caryophyllaceae. Chenopodiaceae, Polygonaceae and Gramineae are less uniformly represented or in lesser numbers. The high species diversity does not imply a general dietary relevance of this particular plant family. For instance Caryophyllaceae with a relatively low number of species comprises the "collejas" (Silene vulgaris) that have shown to be the more widely consumed species. Information regarding 145 species has been recorded. Among the Gathered Food Plant Species 81 are used in medicine, in double proportion than the cultivated food plants. 61 are orally administered, in the same form as food.
Blood lipid profile of French men and women obtained from the general population is not well known. Furthermore, the association between these lipids, as a function of other potential risk factors for cardiovascular disease, and sociodemographic factors such as age, educational level, and region of residence is not well studied in large samples in Europe.
Data on French healthy volunteers, aged between 40 and 65 years for men (n = 5141) and 35 and 65 years for women (n = 7876) were obtained from the "Supplementation en Vitamines et Mineraux Antioxydants" (SU.VI.MAX) study, a primary prevention trial. Baseline blood samples were collected in 1994-1995 and analyzed for cholesterol, triglyceride, apolipoproteins (apo)-B and -A1. The results were analyzed separately for men and women as a function of age, educational level, and area of residence.
Overall, blood lipid levels for men and women did not differ significantly from those reported in other Western industrialized countries. Except for triglyceride in men, all blood lipids were statistically different among ages. In women, cholesterol, apo-A1, and apo-B showed a significant decrease with educational level. Statistical differences were found in both genders between blood lipids and lipoproteins among regions of residence.
Even if differences between region of residence were found in blood lipid levels, this cannot explain the North-East to South gradient in the prevalence of cardiovascular disease in France nor differences between France and other industrialized Western countries.
We investigated the association of a polymorphism within the promoter of TauNuF-alpha locus at the position -308 on the likelihood of having acute coronary syndromes (ACS) in Greek adults.
We studied demographic, lifestyle, and clinical information in 237 hospitalized patients (185 males) with a first event of an ACS and 237 matched by age and sex (controls) without any clinical evidence of coronary heart disease. Genotyping was performed by PCR-RFLP analysis.
The genotype frequencies were in patients, 87% (n = 206), 12% (n = 29), and 1% (n = 2) for G/G, G/A, and A/A, and in controls, 96% (n = 227), 4% (n = 10), and 0% (n = 0) for G/G, G/A, and A/A, respectively (P = 0.04). After adjusting for age and sex, as well as various potential confounders, we observed that G/A or A/A genotypes were associated with 1.94-fold higher odds (95% CI 1.06 to 3.68) of ACS compared to G/G homozygotes. No gene to-gender or to-clinical syndrome interactions were observed. Further subgroup analysis showed that the distribution of TNF-alpha -308G>A polymorphism was associated with the presence of family history of CHD in patients, but not in controls. In particular, in G/A and A/A patients 17.2% reported family history of CHD, whereas in G/G patients, 34.5% reported family history (P = 0.036).
Our findings may state a hypothesis of an association between the -308G>A TNF-alpha polymorphism the development of ACS and the presence of family history of CHD, in Greece.
Interdialytic weight gain is an important prognostic factor in dialysis patients. Different eating patterns may affect interdialytic weight gain. The goal was to assess the effect of the Mediterranean type of diet on interdialytic weight gain of chronic hemodialysis patients.
This study had a cross-sectional design.
Four hospital-based satellite hemodialysis units in different cities in Turkey.
A total of 702 patients (279 women, 423 men; mean age, 47.8 +/- 15.5 years) were included in the study. They were grouped according to the hemodialysis centers: Alanya-Izmir (group 1, n = 194) and Ankara-Adana (group 2, n = 508).
Group 1 patients were consuming a Mediterranean type of diet, whereas group 2 patients had a diet rich in protein and carbohydrates. All of the patients were under the same dialysis and treatment protocols. The demographic data, the medications, interdialytic weight gains, and laboratory data such as serum albumin, C-reactive protein, hemoglobin, hematocrit, serum iron binding capacity, ferritin, and parathyroid hormone during the last 3 months for each patient were recorded.
The interdialytic weight gain differences between the groups were compared using the Student t-test and the Mann-Whitney U test.
When the two groups were compared according to age, sex, blood pressure, serum albumin, hematocrit, and parathyroid hormone levels, there was no statistically significant difference. Mean interdialytic weight gain for group 1 and group 2 was 2.47 +/- 0.94 kg and 3.08 +/- 0.94 kg, respectively (P < .001). When the two groups were compared according to their iron requirements, group 1 showed an increased requirement for doses of iron and erythropoietin (P < .001 and P < .001, respectively).
A Mediterranean-type diet, rich in seafood and vegetables, was associated with less interdialytic weight gain compared with a diet rich in protein and carbohydrates. Although all of our patients had the same diet education and treatment protocols, the geographic region and culture influenced their compliance to diet and their therapeutic outcomes.
Tumor necrosis factor-alpha (TNF-alpha) is a key cytokine in the inflammation process of atherosclerosis. Through its effects on lipid metabolism, insulin resistance and endothelial function, it might be involved in coronary heart disease (CHD). A biallelic polymorphism within the promoter of TNF-alpha locus at the position -308 has been reported to be associated with TNF production. We have studied the association of this polymorphism with CHD in a Mediterranean non-diabetic and type 2 diabetic population.
Three hundred and forty one CHD patients (106 with type 2 diabetes), 207 healthy matched control subjects and 135 type 2 diabetic patients without CHD were evaluated. A single nucleotide polymorphism at the promoter TNF-alpha (-308) was analyzed by RFLP-PCR.
TNF-alpha (-308) genotype and allele frequencies for A carriers were higher in CHD patients than those observed in the control group (32.3 vs. 23.2%, P=0.03; and 18.8 vs. 12.1%, P=0.0047; respectively) independently of other risk factors. Genotypic analysis revealed that CHD patients with type 2 DM displayed a greater prevalence of the -308 TNF-alpha A allele (40.6%) than controls (23.2%) or CHD patients without type 2 DM (28.5%) (P=0.0056). The odds ratio for CHD in type 2 diabetic patients in presence of -308 TNF-alpha A allele was 2.86 (CI 95%: 1.55-5.32). This difference was observed mainly in diabetic women for the A allele carriers (OR: 4.29; CI 95%: 1.6-11.76).
These results suggest that -308 TNF-alpha gene polymorphism may contribute to CHD risk in patients with type 2 diabetes and it could constitute an useful predictive marker for CHD in type 2 diabetic women.
The foods and nutrients discussed in this paper are components of dietary patterns that have been associated with lower cardiovascular disease risk. The focus of this review is on the effects of antioxidant foods on vascular health and discussion of their potential mechanisms of action. The foods reviewed include fruits and vegetables, red grapes and red wine, tea, cocoa/chocolate, and olive oil. The primary challenge in studying the cardioprotective components of a dietary pattern is in identifying mechanism(s) of action as well as the bioactive nutrients responsible. In selecting papers for this review, we focused on studies of whole foods and beverages that met the following criteria: 1) they are commonly consumed in typical diets, 2) they appear to have direct antioxidant effects, and 3) they have demonstrated effects on endothelial function in several human studies. The evidence presented herein suggests that dietary consumption of fruits and vegetables, red grapes and red wine, tea, chocolate, and olive oil may improve vascular reactivity, in part, by attenuating the adverse effects of oxidation on endothelial function. Additional research is needed to better understand the mechanism(s) by which antioxidant-rich foods and beverages favorably affect endothelial function and the extent to which this reflects direct antioxidant effects.
Olive oil is known as a valuable vegetable oil and, as such, used throughout the world. Scientific research
results confirm the beneficial effect of olive oil and Mediterranean diet on health, especially on the
health of people living in areas situated along the Mediterranean Sea.
Based on the literature review, it was found that the most valuable olive oil, the extra virgin oil, contains
many beneficial nutrients, such as: oleic acid, the one of fatty acids, as well as phenolic compounds,
b-sitosterol, a-tocopherol, and squalene that protect people against lifestyle diseases. The highest production
and consumption of olive oil is in the Mediterranean Basin countries. The Mediterranean diet is characterized
by a balanced composition of food products and includes, in the first instance, cereal products,
and, next, fruits, vegetables, and legumes. Olive oil is the main source of fat in this diet. Only a complete
diet combined with physical activity and with drinking plenty of water is able to keep the human body in
a proper state of health.
Deaths from ischaemic heart-disease in 18 developed countries are not strongly associated with health-service factors such as doctor and nurse density. There is a negative association with gross national product per capita and a positive but inconsistent association with saturated and monounsaturated fat intake. The principal finding is a strong and specific negative association between ischaemic heart-disease deaths and alcohol consumption. This is shown to be wholly attributable to wine consumption.
A specially prepared dog model of myocardial infarction was used to test the efficacy of the long-chain polyunsaturated fish oil omega 3 fatty acids eicosapentaenoic (20:5 n-3) and docosahexaenoic (22:6 n-3) acids to prevent ischemia-induced malignant cardiac arrhythmias. The dogs had sustained a prior experimental myocardial infarction from ligation of the left anterior descending coronary artery, and a hydraulic cuff was implanted around the left circumflex artery at that operation. After recovery from that procedure the animals were tested during a treadmill exercise test. With compression of the left circumflex artery sensitive animals will predictably develop ventricular fibrillation (VF). In such prepared dogs an emulsion of fish oil fatty acids was infused i.v. over a 50- to 60-min period just before the exercise-plus-ischemia test, and the effect on development of VF was recorded. The infusion was 100 ml of a 10% (vol/vol) emulsion of a fish oil concentrate containing 70% omega 3 fatty acids with free eicosapentaenoic acid and docosahexaenoic acid composing 33.9% and 25.0% of that total, respectively. Alternatively, some animals similarly received an emulsion containing 5 ml of the free fatty acid concentrate plus 5 ml of a triacylglyerol concentrate containing 65% omega 3 fatty acids with eicosapentaenoic acid and docosahexaenoic acid composing 34.0% and 23.6% of that total, respectively. In seven of eight animals the infusion of the fish oil emulsion completely prevented the acute occurrence of VF in the susceptible animals (P < 0.005). In five of five of these animals the subsequent exercise-plus-ischemia test after a similar infusion of an emulsion in which soy bean oil replaced the fish oil fatty acid concentrates resulted in prompt development of VF. Possible mechanisms for this protective effect of omega 3 fatty acids against exercise and ischemia-induced malignant arrhythmias are considered.
To assess the patterns of alcohol consumption in France and Northern Ireland.
Four cross-sectional studies.
Sample of 50-59 y old men living in France and Northern Ireland, consuming at least one unit of alcoholic beverage per week.
5363 subjects from France and 1367 from Northern Ireland.
None.
Consumption of wine was higher in France whereas consumption of beer and spirits was higher in Northern Ireland. Alcohol drinking was rather homogeneous throughout the week in France, whereas Fridays and Saturdays accounted for 60% of total alcohol consumption in Northern Ireland. In both countries, current smokers had a higher consumption of all types of alcoholic beverages than non-smokers. Similarly, obese and hypertensive subjects had a higher total alcohol consumption than non-obese or normotensive subjects, but the type of alcoholic beverages differed between countries. In Northern Ireland, subjects which reported some physical activity consumed significantly less alcoholic beverages than sedentary subjects, whereas no differences were found in France. Conversely, subjects with dyslipidemia consumed more alcoholic beverages than normolipidemic subjects in France, whereas no differences were found in Northern Ireland. In France, total alcohol, wine and beer consumption was negatively related to socioeconomic status and educational level. In Northern Ireland, total alcohol, beer and spirits consumption was negatively related whereas wine consumption was positively related to socioeconomic status and educational level.
Alcohol drinking patterns differ between France and Northern Ireland, and also according to cardiovascular risk factors, socioeconomic and educational levels.
Merck, Sharp & Dohme-Chibret (France), the NICHSA and the Department of Health and Social Service (Northern Ireland).
In most countries, high intake of saturated fat is positively related to high mortality from coronary heart disease (CHD). However, the situation in France is paradoxical in that there is high intake of saturated fat but low mortality from CHD. This paradox may be attributable in part to high wine consumption. Epidemiological studies indicate that consumption of alcohol at the level of intake in France (20-30 g per day) can reduce risk of CHD by at least 40%. Alcohol is believed to protect from CHD by preventing atherosclerosis through the action of high-density-lipoprotein cholesterol, but serum concentrations of this factor are no higher in France than in other countries. Re-examination of previous results suggests that, in the main, moderate alcohol intake does not prevent CHD through an effect on atherosclerosis, but rather through a haemostatic mechanism. Data from Caerphilly, Wales, show that platelet aggregation, which is related to CHD, is inhibited significantly by alcohol at levels of intake associated with reduced risk of CHD. Inhibition of platelet reactivity by wine (alcohol) may be one explanation for protection from CHD in France, since pilot studies have shown that platelet reactivity is lower in France than in Scotland.
To calculate the effect of changes in carbohydrate and fatty acid intake on serum lipid and lipoprotein levels, we reviewed 27 controlled trials published between 1970 and 1991 that met specific inclusion criteria. These studies yielded 65 data points, which were analyzed by multiple regression analysis using isocaloric exchanges of saturated (sat), monounsaturated (mono), and polyunsaturated (poly) fatty acids versus carbohydrates (carb) as the independent variables. For high density lipoprotein (HDL) we found the following equation: delta HDL cholesterol (mmol/l) = 0.012 x (carb----sat) + 0.009 x (carb----mono) + 0.007 x (carb---- poly) or, in milligrams per deciliter, 0.47 x (carb----sat) + 0.34 x (carb----mono) + 0.28 x (carb----poly). Expressions in parentheses denote the percentage of daily energy intake from carbohydrates that is replaced by saturated, cis-monounsaturated, or polyunsaturated fatty acids. All fatty acids elevated HDL cholesterol when substituted for carbohydrates, but the effect diminished with increasing unsaturation of the fatty acids. For low density lipoprotein (LDL) the equation was delta LDL cholesterol (mmol/l) = 0.033 x (carb----sat) - 0.006 x (carb----mono) - 0.014 x (carb----poly) or, in milligrams per deciliter, 1.28 x (carb----sat) - 0.24 x (carb----mono) - 0.55 x (carb---- poly). The coefficient for polyunsaturates was significantly different from zero, but that for monounsaturates was not. For triglycerides the equation was delta triglycerides (mmol/l) = -0.025 x (carb----sat) - 0.022 x (carb----mono) - 0.028 x (carb---- poly) or, in milligrams per deciliter, -2.22 x (carb----sat) - 1.99 x (carb----mono) - 2.47 x (carb----poly).(ABSTRACT TRUNCATED AT 250 WORDS)
This document is the methodological appendix to the paper titled "Estimating the contribution of changes in classical risk factors to trends in coronary-event rates across the WHO MONICA Project populations" published in Lancet, 2000;355:675-687.
It covers three topics:
- brief description of the regression analysis and the output statistics used in the paper;
- justification for the age-standardization used for calculating risk factor trends for the regression analysis; and
- derivation of the quality score which was used to weight the populations in the regression analysis.
There has been much interest regarding the components that contribute to the beneficial health effects of the Mediterranean diet. Recent findings suggest that polyphenolic compounds found in olive oil are endowed with several biologic activities that may contribute to the lower incidence of coronary heart disease in the Mediterranean area.
The objective of this study was to examine whether oils high in monounsaturated or polyunsaturated fats have a differential effect on serum lipid levels, using a meta-analytical approach. Fourteen studies (1983 through 1994) were identified that met six inclusion criteria, the primary criterion being that a study have at least two intervention diets that varied in monounsaturated and polyunsaturated fat content but were otherwise similar in total fat, saturated fat, fiber, and dietary cholesterol. Seven studies included a comparable high-saturated fat diet. Standardized effect sizes observed treatment difference in mean end-point lipid levels, divided by the pooled (SD) were calculated for individual studies, then individual effect sizes were pooled. The results indicated no significant differences in total, LDL, or HDL cholesterol levels when oils high in monounsaturated or polyunsaturated fats were compared directly. Triglyceride levels were modestly but consistently lower on the diets high in polyunsaturated fats (P = .05). Replacement of saturated fat with either monounsaturated or polyunsaturated fat led to significant decreases in total and LDL cholesterol (P < .001), and the pooled effect sizes were comparable for either type of unsaturate (effect sizes ranged from -0.64 to -0.68, ie, roughly a decrease of 0.65 mmol/L [25 mg/dL] relative to the high-saturated fat diets). Neither type of unsaturated fat significantly changed HDL cholesterol or triglyceride levels relative to the high-saturated fat diets. In conclusion, the evidence from this meta-analysis strongly indicates there is no significant difference in LDL or HDL cholesterol levels when oils high in either monounsaturated or polyunsaturated fats are exchanged in the diet. Any dietary recommendations for the use of one in preference to the other should be based on outcomes other than serum cholesterol levels.
The relation of alcohol intake to total mortality is J-shaped. Abstainers have modestly higher mortality than moderate drinkers but considerably lower [corrected] mortality than heavy drinkers. The higher mortality among abstainers cannot be explained by selection or the presence of other risk factors. Known biologic mechanisms support the conclusion that moderate drinking increases the lifespan. No major differences have been found between the effects of beer, wine or liquor. While drinking patterns and changes in these influence mortality over time, little is known about their significance. The lowest risk of death seems to be at the average intake level of one drink per day. However, due to several sources of error in the assessment of alcohol intake no precise limits of optimal or safe drinking can be recommended. Trials are needed to ascertain these limits. Drinkers should practice moderation and watch for any harmful effects of alcohol.
In a prospective, randomised single-blinded secondary prevention trial we compared the effect of a Mediterranean alpha-linolenic acid-rich diet to the usual post-infarct prudent diet. After a first myocardial infarction, patients were randomly assigned to the experimental (n = 302) or control group (n = 303). Patients were seen again 8 weeks after randomisation, and each year for 5 years. The experimental group consumed significantly less lipids, saturated fat, cholesterol, and linoleic acid but more oleic and alpha-linolenic acids confirmed by measurements in plasma. Serum lipids, blood pressure, and body mass index remained similar in the 2 groups. In the experimental group, plasma levels of albumin, vitamin E, and vitamin C were increased, and granulocyte count decreased. After a mean follow up of 27 months, there were 16 cardiac deaths in the control and 3 in the experimental group; 17 non-fatal myocardial infarction in the control and 5 in the experimental groups: a risk ratio for these two main endpoints combined of 0.27 (95% CI 0.12-0.59, p = 0.001) after adjustment for prognostic variables. Overall mortality was 20 in the control, 8 in the experimental group, an adjusted risk ratio of 0.30 (95% CI 0.11-0.82, p = 0.02). An alpha-linolenic acid-rich Mediterranean diet seems to be more efficient than presently used diets in the secondary prevention of coronary events and death.
The low rate of coronary heart disease (CHD) in France compared with other developed countries with comparable dietary intake has been called the French paradox. We explored this paradox by looking at alcohol, diet, and mortality data from 21 developed, relatively affluent countries in the years 1965, 1970, 1980, and 1988. We assessed wine, beer, and spirits intake separately. France had the highest wine intake and the highest total alcohol intake, and the second lowest CHD mortality rate. In univariate analyses, ethanol in wine was slightly more inversely correlated with CHD than total wine volume. In multivariate analyses, animal fat tended to be positively correlated, and fruit consumption inversely correlated, with CHD. Beer and spirits were only weakly inversely correlated with CHD. The strongest and most consistent correlation was the inverse association of wine ethanol with CHD. However, wine ethanol was unrelated to total mortality. We conclude that ethanol, particularly wine ethanol, is inversely related to CHD but not to longevity in populations. Although light to moderate alcohol consumption may improve longevity, alcohol abuse--which sharply reduces longevity--is correlated with average alcohol consumption in populations. Thus, while the risk/benefit ratio varies for individuals, the use of alcohol for cardioprotective purposes should not be encouraged as a public health measure.
Flavonoids are polyphenolic antioxidants naturally present in vegetables, fruits, and beverages such as tea and wine. In vitro, flavonoids inhibit oxidation of low-density lipoprotein and reduce thrombotic tendency, but their effects on atherosclerotic complications in human beings are unknown. We measured the content in various foods of the flavonoids quercetin, kaempferol, myricetin, apigenin, and luteolin. We then assessed the flavonoid intake of 805 men aged 65-84 years in 1985 by a cross-check dietary history; the men were then followed up for 5 years. Mean baseline flavonoid intake was 25.9 mg daily. The major sources of intake were tea (61%), onions (13%), and apples (10%). Between 1985 and 1990, 43 men died of coronary heart disease. Fatal or non-fatal myocardial infarction occurred in 38 of 693 men with no history of myocardial infarction at baseline. Flavonoid intake (analysed in tertiles) was significantly inversely associated with mortality from coronary heart disease (p for trend = 0.015) and showed an inverse relation with incidence of myocardial infarction, which was of borderline significance (p for trend = 0.08). The relative risk of coronary heart disease mortality in the highest versus the lowest tertile of flavonoid intake was 0.42 (95% CI 0.20-0.88). After adjustment for age, body-mass index, smoking, serum total and high-density-lipoprotein cholesterol, blood pressure, physical activity, coffee consumption, and intake of energy, vitamin C, vitamin E, beta-carotene, and dietary fibre, the risk was still significant (0.32 [0.15-0.71]). Intakes of tea, onions, and apples were also inversely related to coronary heart disease mortality, but these associations were weaker. Flavonoids in regularly consumed foods may reduce the risk of death from coronary heart disease in elderly men.
In France the low rates of death due to ischemic heart disease have been attributed to the high consumption of alcohol. However, the question remains: are the higher death rates for causes associated with alcohol consumption an explanation?
Diseases were defined according to the International Classification of Diseases, revision 9. World Health Organization data on country- and age-specific death rates were used.
Official causes-of-death statistics for men 40-74 years of age show that in 1990 French men under 50 years old had low death rates from ischemic heart disease but a relatively high all-cause mortality rate, in contrast to low rates for men 60 to 74 years of age. Among French men aged 40-44 years in 1960, 34% had died before reaching the age of 70-74 years. In comparison, 37% in the United States and 36% in England and Wales, had died by this age, with 4.5%, 14.1%, and 15.2% of deaths, respectively, due to ischemic heart disease. If all of the men who died early of causes associated with alcohol had died of ischemic heart disease, there would still be a lower rate in France (21%) than in the United States (26%) or in England and Wales (25%).
Thus, although some of the chronic heavy drinkers in France die early of causes associated with excessive alcohol consumption, this is not the only reason for the low ischemic heart disease death rates.
The French paradox relates to the paradoxical association of a diet high in saturated fat and cholesterol with low coronary heart disease mortality and is contrary to the 'lipid hypothesis'. France and other regions with low heart disease mortality have a high consumption of fruit and vegetables. Epidemiologic studies show fruit and vegetable consumption is inversely related to coronary heart disease mortality, but recent intervention studies do not support the theory that protection is due to antioxidant vitamins. Fruit and vegetables, however, are rich sources of folate. Folate lowers plasma homocysteine levels. Even mild to moderate elevation in plasma homocysteine level is a strong risk factor for arteriosclerosis of the coronary, cerebral, and peripheral arteries. This should explain not only the French paradox but also why known risk factors may explain as little as 25% of the risk for coronary heart disease.
The term Mediterranean diet refers to dietary patterns found in olive-growing areas of the Mediterranean region and described in the 1960s and beyond. There are several variants of the Mediterranean diet, but some common components can be identified: high monounsaturated/saturated fat ratio; ethanol consumption at moderate levels and mainly in the form of wine; high consumption of vegetables, fruits, legumes, and grains; moderate consumption of milk and dairy products, mostly in the form of cheese; and low consumption of meat and meat products. Growing evidence demonstrates that the Mediterranean diet is beneficial to health; the evidence is stronger for coronary heart disease, but it also applies to some forms of cancer. Results from recent investigations provide a strong biomedical foundation for the beneficial effects of the Mediterranean diet.
The WHO MONICA (monitoring trends and determinants in cardiovascular disease) Project monitored, from the early 1980s, trends over 10 years in coronary heart disease (CHD) across 37 populations in 21 countries. We aimed to validate trends in mortality, partitioning responsibility between changing coronary-event rates and changing survival.
Registers identified non-fatal definite myocardial infarction and definite, possible, or unclassifiable coronary deaths in men and women aged 35-64 years, followed up for 28 days in or out of hospital. We calculated rates from population denominators to estimate trends in age-standardised rates and case fatality (percentage of 28-day fatalities=[100-survival percentage]).
During 371 population-years, 166,000 events were registered. Official CHD mortality rates, based on death certification, fell (annual changes: men -4.0% [range -10.8 to 3.2]; women -4.0% [-12.7 to 3.0]). By MONICA criteria, CHD mortality rates were higher, but fell less (-2.7% [-8.0 to 4.2] and -2.1% [-8.5 to 4.1]). Changes in non-fatal rates were smaller (-2.1%, [-6.9 to 2.8] and -0.8% [-9.8 to 6.8]). MONICA coronary-event rates (fatal and non-fatal combined) fell more (-2.1% [-6.5 to 2.8] and -1.4% [-6.7 to 2.8]) than case fatality (-0.6% [-4.2 to 3.1] and -0.8% [-4.8 to 2.9]). Contribution to changing CHD mortality varied, but in populations in which mortality decreased, coronary-event rates contributed two thirds and case fatality one third.
Over the decade studied, the 37 populations in the WHO MONICA Project showed substantial contributions from changes in survival, but the major determinant of decline in CHD mortality is whatever drives changing coronary-event rates.
Mortality from ischaemic heart disease in France is about a quarter of that in Britain, but the major risk factors are similar. Undercertification of ischaemic heart disease in France could account for about 20% of the difference. The high consumption of alcohol in France, and of red wine in particular, explains little of the difference. We propose that the difference is due to the time lag between increases in consumption of animal fat and serum cholesterol concentrations and the resulting increase in mortality from heart disease similar to the recognised time lag between smoking and lung cancer. Consumption of animal fat and serum cholesterol concentrations increased only recently in France but did so decades ago in Britain. Evidence supports this explanation: mortality from heart disease across countries, including France, correlates strongly with levels of animal fat consumption and serum cholesterol in the past (30 years ago) but only weakly to recent levels. Based on past levels, mortality data for France are not discrepant.
There is substantial evidence that several variants of the Mediterranean diet reduce the incidence of coronary heart disease (CHD) and perhaps other chronic conditions. Recently, the final results of the Lyon Diet Heart Study, a randomized secondary prevention trial, indicated that the Mediterranean diet substantially reduces the rate of recurrence after a first myocardial infarction. Data from this study also suggest that the Mediterranean diet protects against CHD through mechanisms that are independent of traditional CHD risk factors. We postulate that the antioxidant properties of several plant foods in the Mediterranean diet may be critical mediators of the beneficial effects of this diet.
The revolution in coronary care in the mid-1980s to mid-1990s corresponded with monitoring of coronary heart disease (CHD) in 31 populations of the WHO MONICA Project. We studied the impact of this revolution on coronary endpoints.
Case fatality, coronary-event rates, and CHD mortality were monitored in men and women aged 35-64 years in two separate 3-4-year periods. In each period, we recorded percentage use of eight treatments: coronary-artery reperfusion before, thrombolytics during, and beta-blockers, antiplatelet drugs, and angiotensin-converting-enzyme (ACE) inhibitors before and during non-fatal myocardial infarction. Values were averaged to produce treatment scores. We correlated changes across populations, and regressed changes in coronary endpoints on changes in treatment scores.
Treatment changes correlated positively with each other but inversely with change in coronary endpoints. By regression, for the common average treatment change of 20, case fatality fell by 19% (95% CI 12-26) in men and 16% (5-27) in women; coronary-event rates fell by 25% (16-35) and 23% (7-39); and CHD mortality rates fell by 42% (31-53) and 34% (17-50). The regression model explained an estimated 61% and 41% of variance for men and women in trends for case fatality, 52% and 30% for coronary-event rates, and 72% and 56% for CHD mortality.
Changes in coronary care and secondary prevention were strongly linked with declining coronary endpoints. Scores and benefits followed a geographical east-to-west gradient. The apparent effects of the treatment might be exaggerated by other changes in economically successful populations, so their specificity needs further assessment.
From the mid-1980s to mid-1990s, the WHO MONICA Project monitored coronary events and classic risk factors for coronary heart disease (CHD) in 38 populations from 21 countries. We assessed the extent to which changes in these risk factors explain the variation in the trends in coronary-event rates across the populations.
In men and women aged 35-64 years, non-fatal myocardial infarction and coronary deaths were registered continuously to assess trends in rates of coronary events. We carried out population surveys to estimate trends in risk factors. Trends in event rates were regressed on trends in risk score and in individual risk factors.
Smoking rates decreased in most male populations but trends were mixed in women; mean blood pressures and cholesterol concentrations decreased, bodymass index increased, and overall risk scores and coronary-event rates decreased. The model of trends in 10-year coronary-event rates against risk scores and single risk factors showed a poor fit, but this was improved with a 4-year time lag for coronary events. The explanatory power of the analyses was limited by imprecision of the estimates and homogeneity of trends in the study populations.
Changes in the classic risk factors seem to partly explain the variation in population trends in CHD. Residual variance is attributable to difficulties in measurement and analysis, including time lag, and to factors that were not included, such as medical interventions. The results support prevention policies based on the classic risk factors but suggest potential for prevention beyond these.
This Review covers the sources and the main effects on human health of well-known micronutrients such as minerals and vitamins and also of microconstituents contained in the Mediterranean diet. Vitamins were first identified because of deficiency diseases still present in certain parts of the world. Hydrosoluble vitamins, among them folic acid and vitamin C, also play a role in chronic degenerative diseases, not only the main cause of mortality in the Western world but also increasingly common in developing countries. Hydrosoluble vitamins are well represented in the Mediterranean diet, more so than vitamin A, a liposoluble vitamin obtained primarily from animal foods. Vitamin E is important for antioxidant and cellular functions. The Mediterranean diet is also rich in provitamins A, such as alpha- and beta-carotene and beta-cryptoxanthine. Microconstituents are non-nutritional compounds known to protect plants and more recently suspected to have a protective effect in humans. They play a role in the antioxidant defense of the organism, but their effect on various enzyme activities appears even more promising and is still under investigation. It is nevertheless difficult to isolate the effect of the numerous biofactors present in the Mediterranean diet from the foods themselves, especially because of the possible synergy between the various biofactors.
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