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Health Benefits of the Mediterranean Diet: An Update of Research Over the Last 5 Years

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The Mediterranean Diet (MedDiet) has been reported to be protective against the occurrence of several diseases. Increasing evidence suggests that the MedDiet could counter diseases associated with chronic inflammation, including metabolic syndrome, atherosclerosis, cancer, diabetes, obesity, pulmonary diseases, and cognition disorders. Adoption of a MedDiet was associated with beneficial effects on the secretion of anti-inflammatory cytokines, antioxidant cellular and circulating biomarkers as well as with regulation of gene polymorphisms involved in the atherosclerotic process. The MedDiet has been considered for the prevention of cardiovascular and other chronic degenerative diseases focusing on the impact of a holistic dietary approach rather than on single nutrients. Epidemiological dietary scores measuring adherence to a MedDiet have been developed. This narrative review considers the results of up-to-date clinical studies (with a focus on the last 5 years) that evaluated the effectiveness of the MedDiet in reducing the prevalence of chronic and degenerative diseases.
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Name: Efthymios Surname:
Gotsis
Name: Panagiotis Surname:
Anagnostis
Name: Anargyros Surname:
Mariolis
Name: Athanasia Surname:
Vlachou
Name: Niki Surname:
Katsiki
Name: Asterios Surname:
Karagiannis
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Degrees: Efthymios Gotsis
MD,MSc, Panagiotis
Anagnostis MD, PhD,
Anargyros Mariolis MD, PhD,
Athanasia Vlachou, Niki
Katsiki MD MSc PhD,
Asterios Karagiannis MD
PhD Prof of Internal Medicine
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Correct ref 16: Freedland SJ, Aronson WJ. Words of wisdom.
Re: Weight loss with a low-carbohydrate, Mediterranean, or low-
fat diet. Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow
S, Greenberg I, Golan R, Fraser D, Bolotin A, Vardi H, Tangi-
Rozental O, Zuk-Ramot R, Sarusi B, Brickner D, Schwartz Z,
Sheiner E, Marko R, Katorza E, Thiery J, Fiedler GM, Blüher M,
Stumvoll M, Stampfer MJ. Dietary Intervention Randomized
Controlled Trial (DIRECT) Group. N Engl J Med
2008;359:229-41. Eur Urol. 2009;55(1):249-50.
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Article
Health Benefits of the Mediterranean
Diet: An Update of Research Over
the Last 5 Years
Efthymios Gotsis
1
, Panagiotis Anagnostis
1
, Anargyros Mariolis
2
,
Athanasia
AQ 1
Vlachou
1
, Niki Katsiki
1
, and Asterios Karagiannis
1
Abstract
The Mediterranean
AQ 2
Diet (MedDiet) has been reported to be protective against the occurrence of several diseases. Increasing
evidence suggests that the MedDiet could counter diseases associated with chronic inflammation, including metabolic syndrome,
atherosclerosis, cancer, diabetes, obesity, pulmonary diseases, and cognition disorders. Adoption of a MedDiet was associated
with beneficial effects on the secretion of anti-inflammatory cytokines, antioxidant cellular and circulating biomarkers as well as
with regulation of gene polymorphisms involved in the atherosclerotic process. The MedDiet has been considered for the pre-
vention of cardiovascular and other chronic degenerative diseases focusing on the impact of a holistic dietary approach rather
than on single nutrients. Epidemiological dietary scores measuring adherence to a MedDiet have been developed. This narrative
review considers the results of up-to-date clinical studies (with a focus on the last 5 years) that evaluated the effectiveness of the
MedDiet in reducing the prevalence of chronic and degenerative diseases.
Keywords
Mediterranean diet, inflammation, atherosclerosis, metabolic syndrome, carotid intima–media thickness, cardiovascular disease,
cancer
Introduction
The impact of nutrition on human health has been evaluated
by several case–control, prospective cohorts and randomized
clinical trials which provide evidence that diet may affect the
health status of a population.
1
Nowadays, the World Health
Organization as well as all the major scientific associations
recognize that diet plays an important role in preventing
noncommunicable diseases.
2-4
Several studies evaluated the
associations between diets, foods or nutrients, and chronic dis-
eases, leading to general agreement about the effect of nutri-
tional factors on the etiology of common diseases, such as
cardiovascular disease (CVD), neoplastic diseases, and meta-
bolic syndrome (MetS).
5
Conversely, poor-quality diets may
favor the development of pathological health outcomes and
chronic diseases such as diabetes mellitus (DM), coronary artery
disease (CAD), cancer, and neurodegenerative disorders.
6,7
In order to explore the multiple associations between Med-
iterranean Diet (MedDiet) and chronic diseases, dietary scores
have been developed.
8
Furthermore, these scores are used to
evaluate food consumption trends and to develop public health
nutrition recommendations.
9
Unfortunately, despite the recog-
nition of the multiple benefits of the MedDiet, there has been a
gradual abandonment of this dietary pattern by the inhabitants
of the Mediterranean basin (especially among the young) in the
recent years.
10
In comparison with 45 years ago, population
adherence to MedDiet nowadays is diminished,
11
and this is
further enhanced by the observation that currently farmers from
Crete are likely to be at a higher risk of developing CVD com-
pared to earlier generations.
12
These findings were confirmed
recently in 12 Mediterranean Islands (the Mediterranean Island
Study), which showed that these populations gradually move
away from the protective traditional dietary pattern.
13
How-
ever, the MedDiet still remains a prevalent nutritional option
with multiple health profits.
The aim of this narrative review was to consider the cur-
rent evidence about the protective role of the MedDiet in
various chronic diseases and to elucidate potential underly-
ing mechanisms.
1
Second Propedeutic Department of Internal Medicine, Medical School, Aristotle
University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
2
Health Center, Areopoli, Greece
AQ 3
Corresponding Author:
Efthymios Gotsis, Second Propedeutic Department of Internal Medicine,
Medical School, Aristotle University of Thessaloniki, Hippokration Hospital,
Thessaloniki, 70 Leonidou Str, Sparta, 23100, Greece.
Email: thymiosgotsis@yahoo.gr
Angiology
1-15
ªThe Author(s) 2014
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DOI: 10.1177/0003319714532169
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The MedDiet: Elemental and Holistic Approach
For decades, several studies attempted to evaluate the signifi-
cance of single dietary components of the MedDiet on health
outcomes. However, several recent clinical trials of single-
nutrient supplementation, such as vitamins A, C, and E, failed
to show any benefit regarding primary CVD prevention.
14,15
People usually consume a complex of nutrients and do not gen-
erally focus on specific foods; this approach has several con-
founders and methodological limitations, as the components
of a diet may participate in multiple synergistic and antagonist
interactions.
16
Therefore, several epidemiological studies, dur-
ing the last 5 years, evaluated the adherence of a population to
the MedDiet pattern using diet indices based on a traditional
MedDiet reference pattern.
17
The MedDiet indices summarize
the diet by means of a single score that is affected by different
components, such as foods, food groups, or a combination of
foods and nutrients. Furthermore, dietary scores have been
used to explore the associations between the MedDiet, as an
integral entity, and health parameters such as life expectancy
or the incidence of obesity, CVD, and some types of cancers.
These indices are also useful tools to estimate food con-
sumption trends and to identify the factors involved, thus con-
tributing to the establishment of effective public health
nutrition recommendations.
18
In this context, a recent large
study reported that a greater adherence to MedDiet was associ-
ated with higher intake of total vegetal protein, polyunsaturated
fatty acids (PUFAs), mainly n-6 PUFAs, and lower intake of
total saturated fat.
19
Moreover, the PREvencion con DIeta
MEDiterranea (PREDIMED) trial, including 7305 participants,
aged 55 to 80 years, at high risk of CVD, showed that those
with little education, a larger waist to height ratio, or DM as
well as those who were less physically active, single, divorced,
separated, or smokers were less likely to adhere to the
MedDiet.
20
Therefore, the beneficial impact of MedDiet on
general health, despite differences in populations or research
practices, remains important.
Mediterranean Diet and Cancer
Ongoing findings from the European Prospective Study into
Cancer and Nutrition (EPIC) study (Greek cohort: n ¼23
349 men and women, not previously diagnosed with cancer,
CAD, or DM, with a mean follow-up time of 8.5 years) showed
that a greater adherence to a MedDiet was related to a signifi-
cant reduction in total mortality.
21,22
Alternate MedDiet
(aMED) score was recently shown to correlate inversely with
the risk of head and neck cancer.
23
Furthermore, data from the
Italian segment, including over 31 000 women, aged 36 to
64 years, who were followed up for 11.25 years, supported a
clear protective role of fruit and vegetable consumption in
breast cancer risk.
24
Another Italian study
25
reported that a
greater adherence to a MedDiet significantly improved CVD
risk as well as markers of oxidative stress and inflammation,
which are molecular pathways potentially involved in carcino-
genesis.
26,27
The entire EPIC study (142 605 men and 335 873
women) demonstrated that 4.7%of cancers among men and
2.4%among women might have been avoided if patients had
a greater adherence to the MedDiet pattern.
28
Animal studies of induced breast cancer have shown that
diets rich in extra virgin olive oil (such as the MedDiet) exert
a negative modulatory effect on tumors, particularly affecting
cell membranes composition, signaling proteins activity, and
gene expression. These influences may inhibit proliferation,
induce apoptosis, and minimize DNA damage, thus supporting
a potential benefit for olive oil on breast cancer risk.
29
Several dietary factors have been associated with the occur-
rence of cancers of the upper aerodigestive tract (UADT).
A recent case–control study in Greece showed that adherence
to the traditional MedDiet was related to a reduced risk of
UADT cancers.
30
This finding is in agreement with the lower
incidence of such cancers in Greece, despite the increased pre-
valence of smoking and drinking habits.
31
Similarly, prostatic
cancer risk was reduced in individuals following MedDiet
compared with those adopting a Western diet.
32
The increased
quantity and quality of phytochemicals that MedDiet contains
may contribute to these beneficial effects due to their antioxi-
dant and anti-inflammatory properties.
A dietetic approach to the anti-inflammatory action of food
lipids (PUFAs, monounsaturated fatty acids [MUFAs]
and saturated fatty acids [SFAs]) showed that dietary fatty acid
(FA) may affect FA availability to produce prostaglandins and
leukotrienes.
33
Intake of fat from a Greek-style MedDiet
(mostly MUFA from olive oil consumption) can be expected
to influence FA-metabolizing proteins, with an emphasis on the
metabolic pathways leading to the diminished formation of
proinflammatory eicosanoids.
34
Judging from the increasing
evidence for the anti-inflammatory effects of the MedDiet,
we can assume such a protective role in cancer pathophysiol-
ogy, but up to date, no direct correlation exists between diet,
or its components, and carcinogenic cell proliferation.
Mediterranean Diet and Neurodegenerative Diseases
A higher adherence to a MedDiet has been associated with
reduced cognitive decline.
35
Similarly, the foods, micro-, and
macronutrients that MedDiet contains have been separately
reported to protect against dementia and predementia syn-
dromes.
36
A recent meta-analysis examined the association
between adherence to a MedDiet and cognitive impairment, Par-
kinson disease, and depression.
37
Partial analyses showed that a
high adherence to the MedDiet significantly reduced the risk of
ischemic stroke, cognitive impairment, dementia, and Alzheimer
disease. A high adherence to the MedDiet also protected against
depression independent of age, but the benefits of moderate
adherence tended to diminish with advancing age.
37
These find-
ings for cognitive function were in agreement with the results of
the PREDIMED-NAVARRA randomized trial.
38
This may be of
special significance, given the ongoing aging of Western societ-
ies. Previous data also reported a lower risk of Alzheimer disease
following adherence to MedDiet as well as the Japanese diet.
39
A 9-year follow-up study in Tuscany, Italy (CHIANTI:
Invecchiare in CHIANTI), including 935 women and men, aged
2Angiology
65 years and older, showed that adherence to a Mediterranean-
style diet was related to a slower decline in mobility.
40
The
beneficial effect of this dietary pattern may be attributed to the
protective properties of 2 components of olive oil, that is, tyr-
osol (Tyr) and hydroxytyrosol (OH-Tyr), against b-amyloid
(Ab)-induced toxicity. Based on these findings, these 2 food
components of the MedDiet have been suggested as neuropro-
tective agents against Abtoxicity and may at least partly
explain the benefits of the MedDiet on prevention of Alzheimer
disease.
41
Several studies reported that adherence to a MedDiet
is associated with a reduction in the incidence of dementia, but
conflicting results exist.
42,43
Therefore, a clear correlation of
MedDiet with dementia and cognition mechanisms remains
to be established in future studies.
Mediterranean Diet and Respiratory Disease
A previous cross-sectional study including 174 asthmatics,
40 years of age, found that those with a high adherence to the
traditional MedDiet were more likely to achieve asthma control
as assessed by lung function, symptoms, and exhaled nitric
oxide. Higher fresh fruit intake reduced the risk of uncontrolled
disease, whereas higher ethanol intake increased this risk.
44
A recent meta-analysis supported the beneficial effect of adher-
ence to a MedDiet on asthma prevalence in children.
45
Further-
more, obese adults with moderate to severe obstructive sleep
apnea syndrome significantly decreased their apnea-hypopnea
index (AHI) after a 6-month consumption of a MedDiet.
46
There is evidence that a partial interaction exists between
adherence to MedDiet and adverse health consequences of
smoking.
47
Two cohort studies, INfancia y Medio Ambiente
(INMA; Spain) and a prospective mother–child cohort (Rhea
Study in Greece), showed that a higher MedDiet adherence
decreased the risk of a fetal growth-restricted infant delivery
in smoking mothers, an association that was not observed in
nonsmoking mothers.
48
Further research is needed to elucidate
the mechanisms through which nutritional components protect
the respiratory tract.
Mediterranean Diet and Kidney Disease
Improvements in kidney function were previously reported in
patients with chronic kidney disease (CKD) after adhering to
a MedDiet.
49
Epidemiological data from 3044 healthy men and
women showed that a greater adherence to MedDiet was inde-
pendently correlated with decreased urea and creatinine levels
and raised creatinine clearance rates.
50
In a report from the
PREDIMED study, 785 participants were randomly assigned
to 3 dietary approaches: a MedDiet supplemented with virgin
olive oil (MedDiet þolive oil), a MedDiet supplemented with
mixed nuts (MedDiet þnuts), and a control low-fat diet for
1 year.
51
All these approaches significantly improved kidney
function, with similar mean increases in estimated glomerular
filtration rate but unchanged urinary albumin–creatinine ratio
(ACR). The results do not support that MedDiet is more bene-
ficial than a low-fat diet with regard to renal function in such
patients at high CVD risk.
51
In contrast, in the 3 L (Leontio
Lyceum ALbuminuria) study,
52
a Greek cohort study on ado-
lescents, those who adhered to a MedDiet, had reduced levels
of albuminuria, independent of demographic and hemody-
namic cofactors compared with those who adhered less.
Furthermore, KIDMED score (an index that includes 16 com-
ponents and summarizes the principles of the MedDiet by an
arithmetic score ranging from 0 to 12) was inversely associ-
ated with ACR.
52
Obviously, more targeted research is
needed in order to clarify the relationship between MedDiet
and CKD.
Mediterranean Diet and Obesity
The Dietary Intervention Randomized Controlled Trial
(DIRECT), a 2-year randomized study including 322 moder-
ately obese patients, showed that good adherence to a MedDiet
resulted in a more favorable health status as reflected by
improved CVD risk factors, such as lipid profile, blood pres-
sure (BP), and glucose, especially in persons with diabetes and
compared with a low-carbohydrate diet.
53
Another interven-
tional study showed a significant association between interleu-
kin 6 (IL-6) gene-174G/C polymorphism, (C) being the minor
allele frequency and (G) the major, and nutritional pattern; CC
patients following the MedDiet enriched with virgin olive oil
had the greatest weight decrease compared with those on a
low-fat diet and with GG þGC polymorphisms.
54
Researchers from 10 European countries assessed the
cross-sectional association between adherence to a modified
MedDiet (rich in foods of vegetable origin and unsaturated
FAs) and obesity markers (ie, body mass index [BMI] and
waist circumference [WC]) in 497 308 individuals, aged 25
to 70 years.
55
Waist circumference was significantly lower
in men and women with a higher adherence to modified
MedDiet for a given BMI, the association being greater in
Northern European regions.
55
Similarly, a MedDiet score
(ie, REGICOR-Mediterranean diet score [R-MDS]) was
inversely correlated with WC increase in a Spanish popula-
tion.
56
Furthermore, recent studies concluded that adipokines
are involved in the regulation of BP, coagulation, food intake
and energy balance, insulin resistance, lipid and glucose
metabolism, angiogenesis, and vascular remodeling.
57
Among them, adiponectin exerts anti-atherogenic properties
by increasing FA oxidation, reducing circulating free FAs,
and improving insulin resistance.
58
Adiponectin gene variations
were also reported to affect body weight changes during a 3-year
follow-up period in patients with high CVD risk, leading to obe-
sity.
59
Interestingly, adherence to a Mediterranean-style diet was
able to reverse this negative effect compared to a low-fat diet.
59
Therefore, a healthy diet may protect against obesity (and
abdominal obesity) development, even in individuals with a high
CVD risk. Similar benefits were reported for children (aged 2-9
years) in 8 European countries in the Identification and pre-
vention of Dietary- and lifestyle-induced health EFfects In
Children and infantS (IDEFICS) study,
60
thus highlighting
the importance of the early adoption of a healthy dietary
pattern.
Gotsis et al 3
Table 1. Summary of the Literature About the Effects of MedDiet on Chronic Diseases and Their Risk Factors.
Authors/Year Type of Study Disease/Syndrome MedDiet-Proposed Protective Mechanism Active Component
AQ 10
Sherzai et al, 2012
7
Systematic review Stroke prevention MedDiet, DASH
Trichopoulou et al,
2009;
21
EPIC
(Greek segment)
Prospective cohort, 8.5 years Cancer Not defined Ethanol, fruits, vegetables, low
meat consumption, olive oil,
and legumes
Li et al, 2014
23
Prospective cohort, 11 years Head and neck cancer aMED
Masala et al, 2012;
24
EPIC (Italian
segment)
Prospective cohort, 11.5 years Breast cancer Leafy vegetables and fruits
Azzini et al, 2011
25
Observational CHD Higher levels of anti-inflammatory cytokines and
antioxidant markers
Holistic approach (score)
Escrich et al, 2011
29
In vitro Breast cancer Molecular changes, negative modulatory effects
in tumors
Virgin olive oil
Samoli et al, 2010
30
Case–control study Upper aerodigestive
cancer
Holistic approach (score 0-9)
Ferrı
´s-Tortajada et al,
2012
32
Literature review Prostatic cancer Phytochemicals with antioxidant
and anti-inflammatory
properties
Psaltopoulou et al,
2013
37
Meta-analysis Depression, stroke,
cognitive impairment,
Parkinson disease
MedDiet adherence
Milaneschi et al, 2011
40
Prospective cohort, 9 years Mobility decline MedDiet score
Barros et al, 2008
44
Cross-sectional Asthma Alternate MedDiet score, high
fruit intake, and low ethanol
consumption
Garcia-Marcos et al,
2013
45
Meta-analysis Children’s asthma Lower occurrence of the 3 respiratory outcomes
(current wheeze, current severe wheeze, and
asthma ever)
MedDiet
Papandreou et al,
2012
46
Randomized trial, 6 months OSAS Reduced AHI MedDiet combined with physical
activity
´az-Lo
´pez et al,
2012
51
Intervention, 1 year Kidney function Improves of GFR but no changes in ACR MedDiet
Razquin et al, 2010
54
Intervention, 3 years Body weight Reversal of -174G/C IL-6 gene variant-related effects
on body weight
MedDiet and virgin olive oil
Romaguera et al,
2009
55
Cross-sectional Waist circumference MedDiet
Funtikova et al, 2014
56
Prospective cohort, 10 years Waist circumference,
abdominal obesity
incidence
Lower abdominal fat gain R-MDS
Razquin et al, 2010
59
Intervention, 3 years Body weight Reversal of the adiponectin gene variant-related
effects on body weight
MedDiet enriched with virgin
olive oil or nuts
Tognon et al, 2014
60
(IDEFICS study)
Prospective cohort, 2 years Childhood obesity Inversely associated with childhood obesity fMDS
Kastorini CM et al,
2011
61
Meta-analysis Metabolic syndrome Lower mean levels of systolic and diastolic blood
pressure, glucose, lipid profile
MedDiet pattern
(continued)
4
Table 1. (continued)
Authors/Year Type of Study Disease/Syndrome MedDiet-Proposed Protective Mechanism Active Component
Esposito et al, 2010
62
Systematic review Glycemic control MedDiet
Esposito et al, 2009
63
Randomized trial, 4 years Glycemic control MedDiet
Lasa et al, 2014
64
Cross-sectional , multicenter
parallel trial
Glycemic control Increased values of adiponectin–leptin ratio,
adiponectin–HOMA-IR ratio, and decreased values
of waist circumference
MedDiet plus mixed nuts and
MedDiet plus olive oil
Itsiopoulos et al,
2011
65
Intervention Glycemic control MedDiet
Rossi et al, 2013 EPIC
(Greek segment)
66
Prospective cohort, 11.3 years Diabetes occurrence A higher MDS was inversely associated with diabetes
risk
MDS
Mosharraf et al, 2013
67
Prospective cohort study,
1 year
MACCE Improve long-term outcome including death/MACCE
in diabetic patients with CAD
Med-DQI
Karamanos et al,
2014
71
Observational study, 9 months Incidence of gestational
diabetes mellitus (GDM)
Lower incidence of GDM with better degree of
glucose tolerance, even without GDM
Mediterranean Diet Index (MDI)
Esposito et al, 2013
74
Systematic review Metabolic syndrome Beneficial role of adherence to the Mediterranean
dietary pattern regarding metabolic syndrome
presence and progression
MedDiet
Kesse-Guyot et al,
2013
75
Prospective study, 6 years Metabolic syndrome Beneficial role of MedDiet against components of
MetS or MetS incidence
MDS, an updated Mediterranean
score (MED), and MSDPS
Viscogliosi et al,
2013
76
Cross-sectional Metabolic syndrome
(NCEP III criteria)
– MedDiet
Richard et al, 2012
79
Intervention, 35 weeks Metabolic syndrome/body
weight
Reduction of inflammation markers without weight loss MedDiet
Defoort et al, 2011
80
(Medi-RIVAGE)
Intervention, 3 months Postprandial lipemia Diminishes TAGs and Apo B48 MedDiet
Salas-Salvado
´et al,
2014
83
Randomized trial; subgroup
analysis, 4.1 years
Incidence of type 2 DM
(new onset)
Reduced diabetes risk MedDiet enriched with olive oil
Sanchez-Tainta et al,
2008
88
Cross-sectional assessment in
a cohort study
CVD risk factors and their
clustering
Inverse relationship MedDiet
Nunez-Cordoba et al,
2009
90
SUN
Prospective cohort, 4.2 years CHD Lower mean levels of systolic and diastolic blood
pressure
Adherence to the MedDiet
Mente et al, 2009
92
Systematic review CHD Vegetables, nuts, MUFA, fruits
Fung et al, 2009
93
(Nurse’s Health
Study)
Prospective cohort, 20 years CHD Reduced rate, lower mortality from CHD MedDiet
Buckland G et al,
2009
94
Prospective cohort, 10.4 years CVD Lower incidence of CHD events MedDiet
Hoevenaar-Blom et al,
2012
95
Prospective cohort, 10-15 years CVD Lower incidence of CVD events MedDiet
Misirli et al, 2012
96
(EPIC Greek
segment)
Prospective cohort, 10.6 years CVD Decreased total mortality and CBVD incidence MedDiet score
Kastorini et al, 2011
97
Case/case–control CVD Protective on ischemic stroke development MedDiet score
Chrysohoou et al,
2012
98
Cross-sectional CHF Biventricular systolic and diastolic improvement
in patients with CHF
MedDiet Score
(continued)
5
Table 1. (continued)
Authors/Year Type of Study Disease/Syndrome MedDiet-Proposed Protective Mechanism Active Component
Corella et al, 2013
99
Randomized trial, 4.8 years CVD Regulates polymorphism of TCF7L2-rs7903146 MedDiet
Gardener et al,
2011
101
Prospective cohort, 9 years CVD events incidence Lower incidence of vascular events MedDiet
Sofi et al, 2008
102
Meta-analysis CVD, cancer, and
neurodegenerative
diseases
Inverse relationship MedDiet
Lopez-Garcia et al,
2014
104
Prospective Cohort, 5.8 years
(women) and 7.7 years (men)
CVD, cancer Decreased total mortality and stroke incidence aMED
Tognon et al, 2014
105
Prospective cohort, 11 years CVD incidence, MI Decreased total mortality and MI incidence MedDiet
Urpi-Sarda et al,
2012
108
(PREDIMED)
Intervention Atherosclerotic vascular
disease
Downregulates cellular and circulating biomarkers MedDiet enriched with virgin
olive oil and vegetables
Marı
´n et al, 2013
111
Cross-sectional/intervention Atherosclerotic vascular
disease
Downregulates endothelial cellular apoptosis MedDiet enriched with virgin
olive oil
Giordano et al,
2012
114
Review Chronic inflammation in
atherosclerosis
Scavenging and lowering free radicals, reactive oxygen
species (ROS)
Fruits and vegetables carotenoids
Dai et al, 2008
116
Case–control study Atherosclerotic vascular
disease
Decrease oxidative stress MedDiet components
Carluccio, et al
117
In vitro Atherosclerotic vascular
disease
Inhibit endothelial adhesion molecule expression Phytochemicals in olive oil and
red wine
Llorente-Corte
´setal,
2010
119
Intervention, 3 months Atherosclerotic vascular
disease
Modulate the expression of pro-atherothrombotic
genes
Virgin olive oil and MedDiet
Scoditti et al, 2012
121
In vitro Atherosclerotic vascular
disease
Polyphenols reduce inflammatory angiogenesis
through MMP-9 and COX-2 inhibition
Olive oil, red wine
Murie-Fernandez, et al,
2011
131
Intervention, 1 year Atherosclerotic vascular
disease
Reduction of cIMT (for elevated baseline IMTs >0.9 mm) MedDiet enriched with virgin
olive oil or nuts
Sala-Vila et al, 2014
132
Intervention, 2.4 years Atherosclerotic vascular
disease
Delayed progression of ICA-IMT and plaque MedDiet enriched with nuts
Giannini et al, 2014
133
Intervention 1 year in
prepubertal children with
hypercholesterolemia
Hypercholesterolemia Reduction of both lipid profile and cIMT MedDiet
Abbreviations: CVD, cardiovascular disease; EPIC, European Prospective Investigation into Cancer and Nutrition; CHD, congenital heart disease; DM, diabetes mellitus; NCEP III, National Cholesterol Education
Program; MMP-9, matrix metalloproteinase-9; COX-2, cyclooxygenase-2; PREDIMED study, PREvencio
´n con DIeta MEDiterra
´nea study; MedDiet, Mediterranean Diet; Apo B48, apolipoprotein B48; TAGs,
triacylglycerols; IL-6, interleukin 6; GFR, glomerular filtration rate; ACR; albumin–creatinine ratio; MUFA, monounsaturated fat; DASH, dietary approaches to stop hypertension; ROS, reactive oxygen species;
aMED, alternate Mediterranean diet; TCF7L2-rs7903146, transcription factor 7-like 2; MI, myocardial infarction; CBVD, cerebrovascular disease; OSAS, obstructive sleep apnoea syndrome; AHI, apnoea-
hypopnoea index; R-MDS, REGICOR-Mediterranean diet score; fMDS, food frequency-based Mediterranean Diet Score; MDS, Mediterranean Diet Score; Med-DQI, Mediterranean diet quality index; MSDPS,
Mediterranean style-dietary pattern score; IDEFICS study, Identification and prevention of Dietary—and lifestyle—induced health Effects In Children and infants; HOMA-IR, homeostatic model of insulin resis-
tance; MACCE, major adverse cardiac and cerebrovascular event; cIMT, carotid intima–media thickness; MetS, metabolic syndrome.
6
Mediterranean Diet and DM, MetS, and Dyslipideamia
A previous meta-analysis of 50 studies (2 prospective, 13 cross-
sectional, and 35 clinical trials; n ¼534 906) found that adher-
ence to the MedDiet was related to a decreased risk of MetS
(log hazard ratio: 0.69; 95%confidence interval [CI]: 1.24
to 1.16) as well as to lower values of WC (0.42 cm; 95%
CI: 0.82 to 0.02), glucose (3.89 mg/dL; 95%CI:5.84
to 1.95), triglycerides (TGs; 6.14 mg/dL; 95%CI: 10.35
to 1.93), systolic (2.35 mm Hg; 95%CI: 3.51 to 1.18)
and diastolic BP (1.58 mm Hg; 95%CI: 2.02 to 1.13), and
higher levels of high-density lipoprotein cholesterol (HDL-C;
1.17 mg/dL; 95%CI: 0.38 to 1.96) compared with the same
parameters before adhering to the MedDiet.
61
Improvement in
fasting glucose and glycosylated hemoglobin (HbA
1c
)levelswas
greater by adhering to a MedDiet pattern versus commonly used
diets and ranged from 7 to 40 mg/dL for fasting glucose and
from 0.1%to 0.6%for HbA
1c
in patients with type 2 DM
(T2DM).
62
In another study from the same group,
63
weight loss
and improvements in glycemic control and coronary risk
parameters were significantly greater in overweight patients with
newly diagnosed T2DM that were assigned to a low-
carbohydrate, Mediterranean-style diet compared with those
adhering to a low-fat diet; the initiation of antihyperglycemic
drugs was also delayed in the MedDiet group.
63
However, in the
PREDIMED study, patients with T2DM in both MedDiet group
(supplemented with olive oil or nuts) and low-fat diet group
achieved similar weight and glucose reductions.
64
In another
study,
65
a moderate-fat MedDiet intervention significantly
improved HAb
1c
(falling from 7.1%-6.8%;P¼.012) and diet
quality in 27 patients (47-77 years) with well-controlled
T2DM compared with their usual diet without leading to weight
gain.
65
Previous randomized trials showed that adoption of a
MedDiet pattern may help in preventing T2DM, as reported in
the Greek cohort of the EPIC study,
66
and in improving
glycemic control and CVD risk in patients with DM.
67
In this
context, the Mediterranean Island Study (MEDIS) including
1190 men and women, aged > 65 years, showed that animal pro-
tein consumption was associated with a higher prevalence of
DM among the elderly individuals, whereas no such relation was
observed with protein intake from cereals and vegetables.
68
Moreover, the Seguimiento Universidad de Navarra (SUN) trial,
a prospective cohort study conducted in a population of 13 380
Spanish university graduates,
69
showed that patients who
adhered closely to the MedDiet had a lower risk of developing
DM over 4.4 years of follow-up; a 2-point increase in the adher-
ence score was associated with a 35%relative reduction in the
risk of DM (P< .03). Similarly, lifestyle modification (including
a healthy diet and exercise) can prevent or at least delay T2DM
onset in patients with impaired glucose tolerance or impaired
fasting glucose (IFG); drug therapy is needed to achieve residual
risk reduction.
70
A protective effect of MedDiet on the develop-
ment of gestational DM has also been suggested.
71
In addition, in a cross-sectional analysis of the PREDIMED
study, including patients with a high CVD risk profile, adherence
to a MedDiet was significantly related to MetS prevalence, even
after adjusting for age, gender, smoking, physical activity, and
energy intake.
72
Recently published reviews support the inverse
link between the incidence of MedDiet and MetS.
73,74
A large
French prospective study (n ¼3232; 6 years of follow-up)
including individuals from the Supple´mentation en Vitamines
et Mine´raux AntioXydants (SU.VI.MAX) study showed that all
MetS components were significantly related to a MedDiet score
(inverse associations for WC, systolic BP, and TG and direct
association with HDL-C).
75
Similarly, in an Italian study, lower
MedDiet adherence was associated with higher MetS and preva-
lence of MetS components as well as with higher values of
homeostasis model assessment of insulin resistance (HOMA-IR)
and high-sensitivity C-reactive protein (hsCRP).
76
However, no
associations were observed between individual items of Med-
Diet and the development of MetS or IFG. This finding seems
to support the holistic approach rather than the elemental one for
MedDiet protective role. MedDiet-related beneficial effects on
hemostasismayalsobeobservedinpatientswithMetS.
77
Even in children with type 1 DM, training to a Mediterranean-
style diet improved the quality of nutrient intakes (ie, increased
fiber consumption and reduced lipids intake) and led to
decreased low-density lipoprotein cholesterol (LDL-C) and
non-HDL-C levels after 6-month follow-up.
78
Similarly,
MedDiet was reported to enhance LDL-C clearance and
decrease cholesterol absorption, thus leading to LDL-C lower-
ing, independent of weight reduction.
79
The MedDiet was also
shown to improve postprandial lipemia (as assessed by reduc-
tions in triacylglycerols [TAGs] and apolipoprotein B48 levels)
in a 3-month period in patients at moderate CVD risk.
80
Taking the aforementioned data into account, we would
associate MedDiet main component, virgin olive oil, and its
anti-inflammatory effect with a lower MetS prevalence
81,82
as also supported by the PREDIMED study.
83
In contrast, diet-
ary patterns including meat, alcohol, and fish intake, in 1442
adults from Hyvar Island (Adriatic Sea/Croatia) were signifi-
cantly associated with MetS as defined by the International
Diabetes Federation criteria (P¼.027).
84
Mediterranean Diet and CVD
Cardiovascular disease remains the leading cause of death and
disability in developed countries, thus increasing the interest in
enhancing dietary practices for CVD prevention.
85
Several
investigators have demonstrated an association between
MedDiet and reduced prevalence of traditional CVD risk
factors such as hypertension, dyslipidemia, and DM.
7,86,87
Similarly, in a cross-sectional analysis of 3204 asymptomatic
high-risk patients, an inverse relationship between MedDiet
score and the presence of CVD risk factors (ie, DM, obesity,
dyslipidemia, and hypertension), both separately and as a
whole, was observed.
88
Furthermore, significant reductions in
BP, hsCRP, total cholesterol (TC), LDL-C, and TG levels were
observed in patients with mild hypercholesterolemia following
a 4-month adherence to MedDiet.
89
However, the SUN trial
found that higher adherence to a MedDiet was associated with
Gotsis et al 7
lower mean levels of systolic and diastolic BP after 6 years of
follow-up but not with a reduced risk of hypertension.
90
Of
note, when exercise (in the form of moderate- to high-
intensity endurance training) was added to MedDiet, greater
improvements in cardiorespiratory fitness, endothelial progeni-
tor cell (EPC) numbers, BP, weight reduction, insulin sensitiv-
ity, and TAG were observed compared with MedDiet alone
91
;
ischemic reactive hyperemia was beneficially affected only in
the exercise group.
According to a previous meta-analysis,
92
MedDiet and
vegetable and nut consumption were protective against occur-
rence of coronary heart disease (CHD). In this context, a higher
aMED score was linked to reduced CHD and stroke prevalence
in a large cohort of women (n ¼74 886; aged 30-63 years) from
the Nurses’ Health Study.
93
Similarly, higher adherence to the
MedDiet was associated with significantly lower CHD risk in
the Spanish (n ¼41 078; mean follow-up ¼10.4 years) and the
Netherlands cohorts (n ¼40 011; follow-up ¼10-15 years) of
the EPIC study.
94,95
Furthermore, in the Greek cohort of EPIC
(n ¼23 601; median follow-up ¼10.6 years), morbidity and
mortality of cerebrovascular disease (CBVD) significantly
decreased with increasing adherence to the MedDiet.
96
Addi-
tionally, the comparative analysis of a case/case–control study
in 1000 Greek participants showed that adoption of the Med-
Diet protected against acute coronary syndromes and stroke
occurrence.
97
In another cross-sectional study involving 372
consecutive Greek patients with chronic heart failure, MedDiet
consumption improved systolic and diastolic ventricular func-
tion.
98
Moreover, at the cellular level, a randomized trial with
7018 participants from the PREDIMED study
99
reported that
the increased risk of T2DM and dyslipidemia (defined as high
levels of TC, LDL-C, and TG), which characterized patients
with transcription factor 7-like 2 (TCF7L2-rs7903146; C > T)
polymorphism, was significantly reduced in those on the
MedDiet compared with those on control diet; stroke prevalence
was also decreased in the MedDiet groups.
99
Furthermore,
MedDiet (supplemented with either extravirgin olive oil or nuts)
consumption was associated with significantly fewer major
CVD events (ie, myocardial infarction, stroke, or CVD mortal-
ity) than a low-fat diet in high-risk individuals as shown in the
recent PREDIMED trial.
100
Consistent with these findings in Mediterranean popula-
tions, the Northern Manhattan Study,
101
a population-based
cohort study (n ¼2568), also found that higher adherence to
a MedDiet correlated with decreased reduced risk of myocar-
dial infarction, stroke, or vascular mortality.
A higher MedDiet adherence was related to decreased
mortality from all causes, CVD and cancer, as well as reduced
morbidity from cancer, Parkinson, and Alzheimer diseases in a
meta-analysis involving 1 574 299 individuals.
102
An updated meta-analysis by the same group
103
confirmed
the significant protection provided by the adherence to a
MedDiet against CVD and cancer morbidity and mortality as
well as against development of neurodegenerative diseases.
103
Similarly, a recent prospective cohort study (n ¼17 415 patients
with CVD, median follow-up of 5.8 years for women and 7.7
years for men) found that a higher adherence to the aMED was
associated with a lower risk of CVD, cancer, and total mortal-
ity
104
; for every 2-point increase in aMED score, a 7%decrease
in total mortality risk was observed.
105
Interestingly, a Danish
Cohort study (n ¼1849, 11 years of follow-up) reported that the
Mediterranean Diet Score was negatively correlated with mor-
bidity and mortality of myocardial infarction as well as to
all-cause death but not with stroke prevalence and mortality.
105
Overall, adoption of the MedDiet is associated with a lower pre-
valence of fatal or nonfatal CVD events in both Mediterranean
and non-Mediterranean populations.
The Effects of MedDiet on Systemic Inflammation
and Atherosclerotic Disease
Several anti-inflammatory mechanisms have been proposed cor-
relating MedDiet and/or its components with the different steps
of the atherosclerotic process. Therefore, the MedDiet could be a
part of the therapeutic strategy for chronic inflammation-related
diseases.
106
In this context, a previous multicenter, longitudinal
study of 1003 myocardial infarction survivors from several
European regions showed a protective, inverse relationship
between a MedDiet score and the development of a proinflam-
matory state (as defined by levels of CRP and IL-6).
107
Similarly, other established plasma inflammation biomarkers,
cellular and circulating (ie, tumor necrosis factor receptor 60 and
80 and intercellular adhesion molecule 1), were significantly
decreased after 1 year of adhesion to the MedDiet-type pattern
in patients with high CVD risk.
108-110
The primary induction of atherosclerosis comes from the oxi-
dative stress that activates the inflammation process and impairs
the nitric oxide pathway and affects telomerase activity.
111
The
LDL-C particle oxidation is one of the initial steps of athero-
sclerosis, consequentially leading to CVD and CBVD.
112
Fruits
and vegetables (typically included in the MedDiet) are very rich
in carotenoids that exert significant antioxidant action; carote-
noids were inversely related to MetS, HOMA-IR, and CRP in
adolescents.
113
Carotenoids may act as scavengers of singlet
oxygen (1O
2
) and free radicals, thus downregulating the concen-
trations of reactive oxygen species (ROS).
114
Furthermore,
MedDiet was reported to reduce the production of ROS and cel-
lular apoptosis of endothelial cells
115
which can partially explain
the anti-atherogenic properties of the MedDiet. In the same con-
text, the ratio of reduced glutathione to oxidized glutathione, in a
well-controlled study of twins, was strongly associated with the
MedDiet and this relationship was not confounded by genetic or
environmental parameters.
116
It is known from previous studies that monocyte/leukocyte
adhesion to the endothelium is important in early atherogenesis;
antioxidant polyphenols of olive oil and red wine, within the
concentration range expected from MedDiet, inhibited the
expression of vascular cell adhesion molecule 1 and decreased
monocyte adhesion to the endothelium.
117,118
A 3-month dietary
intervention in 49 asymptomatic individuals with high CVD risk
found that MedDiet affected the expression of genes involved
in inflammation, foam cell formation, and thrombosis by
8Angiology
increasing cyclooxygenase 2 (COX-2) and LDL-C receptor-
related protein while decreasing expression of monocyte che-
moattractant protein 1.
119
In addition to its effect on the
above-mentioned proatherothrombotic genes, MedDiet can
also beneficially modulate the expression of genes related to
plaque stability (such as matrix metalloproteinase [MMP] 9),
even in an elderly high-risk population and after a short period
(ie, 3 weeks).
120
Inflammatory angiogenesis is a key patho-
genic process in atherosclerosis; MedDiet was reported to inhi-
bit the expression of the proinflammatory enzyme COX-2 and
the degrading enzymes MMPs, thus exerting anti-inflammatory
and anti-angiogenic properties.
121
As the inflammation progresses, different signaling pathways
are activated affecting cellular senescence. In this way, a study
on patients with MetS showed that adherence to MedDiet
reduces postprandial levels of oxidative stress biomarkers such
as lipid peroxide, protein carbonyl, superoxide dismutase activ-
ity, and plasma H
2
O
2
and attenuated the postprandial inflamma-
tory state, including nuclear transcription factor kB(NF-kb),
MMP-9, and tumor necrosis factor acompared with a saturated
fat-rich diet.
122
Furthermore, MedDiet reduced the release of
endothelial microparticles and increased the production of EPCs,
indicating an improvement in endothelial dysfunction in healthy
elderly individuals after a 4-week consumption.
123
The accumu-
lation of senescent cells provokes vascular aging, an important
determinant of atherosclerosis development rate, mainly by
maintaining a chronic low-grade inflammation state.
The MedDiet adherence was negatively related to the risk of
peripheral artery disease (PAD), thus suggesting its potential
contribution to PAD prevention.
123
Considering the multiple actions of MedDiet on the sequence
of the atherosclerotic process, we can support that this diet pat-
tern may represent a multivariate anti-atherosclerotic factor.
Mediterranean Diet and Carotid Intima–Media
Thickness
Carotid intima–media thickness (cIMT) is a valid marker for
generalized vascular disease.
124
B-mode ultrasonographic ima-
ging of the carotid arterial walls occupies a unique position in
atherosclerosis research because it enables sensitive, reproduci-
ble, and noninvasive assessment of cIMT as a continuous vari-
able. The cIMT can be used to evaluate CVD risk and monitor
disease progression in clinical trials.
125
Since it can be mea-
sured relatively simply and noninvasively, it is well suited for
use in large-scale population studies. The superiority of cIMT
over other modalities is that it does not involve radiation expo-
sure such as that caused by computerized tomography and is
not as time consuming and technically demanding with high
associated costs as magnetic resonance imaging. Based on epi-
demiological and clinical data, cIMT is considered a validated
marker for atherosclerosis and vascular disease risk.
126
A pre-
vious meta-analysis
127
supported that cIMT may predict future
vascular events. Furthermore, traditional CVD risk factors
(such as smoking, obesity, hypertension, DM, and dyslipide-
mia) were associated with increases in cIMT.
128
With regard to MedDiet, cIMT was inversely associated
with fiber intake as shown in a cross-sectional study from 2 cen-
ters of the PREDIMED trial.
129
Furthermore, fruit, whole grain,
and olive oil intake have been related to lower cIMT in high-risk
patients.
130
Interestingly, 1-year adherence to MedDiet in PRE-
DIMED trial
131
was related to significant reductions in cIMT
only in those individuals with elevated cIMT at baseline (ie,
0.9 mm) compared to those with baseline cIMT < 0.9 mm.
Similar findings have also been reported.
131
Of note, MedDiet
supplemented with nuts seemed to exert more beneficial effect
in terms of cIMT changes compared with MedDiet supplemen-
ted with olive oil.
132
The beneficial effects of MedDiet on lipids
andcIMTwerealsoobservedinchildrenwithhypercholestero-
lemiaaftera12-monthfollow-up.
133
We correlated MedDiet-related antiatherogenic effect on the
carotid arterial wall, taking under consideration common
cofounders. In our preliminary analysis of 231 participants
(105 men and 126 women) without CVD event from General
Hospitals and Health Centres, we found that a 20-point increase
in the MedDiet score correlated inversely with a 0.14 mm
decrease (P< .05) in right common cIMT in women aged older
than 60 years (Gotsis et al, unpublished data). Taking all the
above-mentioned data into account, the MedDiet seems to
exert protective vascular properties on the carotid wall which
is evaluated by cIMT measurements.
MedDiet and Nonalcoholic Fatty Liver Disease
Nonalcoholic fatty liver disease (NAFLD) is the hepatic
expression of MetS; both conditions are characterized by
increased vascular risk.
134-137
Of note, MetS prevalence as well
as vascular risk depends on the diagnostic criteria used.
138-140
Such discrepancies led to the Joint Interim Societies (JIS) MetS
definition.
141
With regard to NAFLD, adherence to the
MedDiet was associated with improved insulin resistance and
hepatic steatosis, thus reducing NAFLD severity.
142-145
Of
note, the effects of the MedDiet may reflect the changes in
abdominal obesity.
56
Both MetS and NAFLD have been linked to hyperurice-
mia.
146,147
Furthermore, elevated serum uric acid (SUA) levels
have been related to increased vascular risk.
148-150
Adherence
to the MedDiet was associated with lowerSUA concentrations.
151
General Comments
This narrative review cannot mention every condition that has
been linked with the MedDiet. We selected conditions that are
common and where the evidence is convincing. It is also worth
mentioning that the MedDiet has been linked with beneficial
effects on heart failure, bone mineral density, and erectile dys-
function.
152-154
Similarly, we cannot discuss in detail every
vascular risk factor. In this context, it is of interest that there
is evidence that the MedDiet exerts beneficial effects on LDL
subfractions as well as postprandial lipemia.
80,155,156
In turn,
small, dense LDL and postprandial TG levels are potential pre-
dictors of vascular risk.
157-159
There is even evidence of effects
Gotsis et al 9
deleted as it was
used again in a
previous sentence
A summary of the literature
about the effects of MedDiet
on chronic diseases and
their risk factors is provided
in Table 1
on lipoprotein(a) levels.
160
The effects of the MedDiet on coa-
gulation, platelets, and fibrinolysis are complex but largely
beneficial.
161,162
The MedDiet may also favorably affect
emerging predictors of vascular risk such as arterial stiffness
and adipokine levels.
163-165
It is also encouraging that imple-
menting the MedDiet seems to be a cost-effective preventive
measure.
166
Conclusions
A growing body of evidence supports the concept that the
MedDiet is one of the healthiest diets. This dietary pattern can
be adopted by different population groups and various cultures
and benefit in terms of primary and secondary prevention from
several chronic diseases. During the last 5 years, the findings of
several studies supported the protective role of MedDiet
against atherosclerosis, cancer, CVD, obesity, MetS, and DM
as well as respiratory, neurodegenerative, and kidney diseases.
The MedDiet and its components were shown to interfere with
the atherosclerotic inflammatory process by beneficially
altering oxidative stress, plasma inflammation biomarkers,
adhesion molecules, and cellular senescence as well as by
improving the regenerative capacity of the endothelium. The
application of a MedDiet adherencescoremaybehelpto
assess and understand the degree to which a community is
modifying or improving its dietary habits.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
AQ 4
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
AQ 5
References
1. Bhupathiraju SN, Tucker KL. Coronary heart disease preven-
tion: nutrients, foods, and dietary patterns. Clin Chim Acta.
2011;412(17-18):1493-1514.
2. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC Guideline
on lifestyle management to reduce cardiovascular risk: a report
of the American college of cardiology/American heart associa-
tion task force on practice guidelines [published online
November 7, 2013]. J Am Coll Cardiol. 2013.
3. Executive summary: standards of medical care in diabetes -
2014. Diabetes Care. 2014;37(suppl 1):56-57.
4. Nishida C, Uauy R, Kumanyika S, Shetty P. The joint WHO
FAO expert consultation on diet, nutrition and the prevention
of chronic diseases: process, product and policy implications.
Public Health Nutr. 2004;7(1A):245-250.
5. Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterra-
nean diet and health. Biofactors. 2013;39(4):335-342.
6. Sofi F. The Mediterranean diet revisited: evidence of its effec-
tiveness grows. Curr Opin Cardiol. 2009;24(5):442-446.
7. Sherzai A, Heim LT, Boothby C, Sherzai AD. Stroke, food
groups, and dietary patterns: a systematic review. Nutr Rev.
2012;70(8):423-435.
AQ 6
8. Panagiotakos DB, Pitsavos C, Arvaniti F, Stefanadis C. Adher-
ence to the Mediterranean food pattern predicts the prevalence
of hypertension, hypercholesterolemia, diabetes and obesity,
among healthy adults; the accuracy of the MedDietScore. Prev
Med. 2007;44(4):335-340.
9. Anna Bach, Serra-Majem L, Carrasco JL, et al. The use of
indexes evaluating the adherence to the Mediterranean diet in
epidemiological studies: a review. Public Health Nutr. 2006;
9(1A):132-146.
10. Baldini M, Pasqui F, Bordoni A, Maranesi M. Is the Mediterra-
nean lifestyle still a reality? Evaluation of food consumption and
energy expenditure in Italian and Spanish university students.
Public Health Nutr. 2009;12(2):148-155.
11. Tsakiraki M, Grammatikopoulou MG, Stylianou C, Tsigga M.
Nutrition transition and health status of Cretan women: evidence
from two generations. Public Health Nutr. 2011;14(5):793-800.
12. Vardavas CI, Linardakis MK, Hatzis CM, Saris WH, Kafatos
AG. Cardiovascular disease risk factors and dietary habits of
farmers from Crete 45 years after the first description of the
Mediterranean diet. Eur J Cardiovasc Prev Rehabil. 2010;
17(4):440-446.
13. Tourlouki E, Matalas AL, Bountziouka V, et al. Are current diet-
ary habits in Mediterranean Islands a reflection of the past?
Results from the MediS study. Ecol Food Nutr. 2013;52(5):
371-386.
14. Riccioni G, Bucciarelli T, Mancini B, Di Ilio C, Capra V,
D’Orazio N. The role of the antioxidant vitamin supplementa-
tion in the prevention of cardiovascular diseases. Expert Opin
Investig Drugs. 2007;16(1):25-32.
15. Katsiki N, Manes C. Is there a role for supplemented antioxi-
dants in the prevention of atherosclerosis? Clin Nutr. 2009;
28(1):3-9.
16. Shai I, Schwarzfuchs D, Henkin Y, et al. Weight loss with a low-
carbohydrate, Mediterranean, or low-fat diet. Eur Urol. 2009;55:
249-250.
AQ 7
17. Mila`-Villarroel R, Bach-Faig A, Puig J, et al. Comparison and
evaluation of the reliability of indexes of adherence to the
Mediterranean diet. Public Health Nutr. 2011;14(12A):2338-2345.
18. Behrens G, Fischer B, Kohler S, Park Y, Hollenbeck AR,
Leitzmann MF. Healthy lifestyle behaviours and decreased risk
of mortality in a large prospective study of U.S women and men.
Eur J Epidemiol. 2013;28(5):361-372.
19. Feart C, Alles B, Merle B, Samieri C, Barberger-Gateau P.
Adherence to a Mediterranean diet and energy, macro-, and
micronutrient intakes in older persons. J Physiol Biochem.
2012;68(4):691-700.
20. Hu EA, Toledo E, Diez-Espino J, et al. Lifestyles and risk factors
associated with adherence to the mediterranean diet: a baseline
assessment of the PREDIMED trial [published online April 29,
2013]. PLoS One. 2013.
21. Trichopoulou A, Bamia C, Trichopoulos D. Anatomy of health
effects of Mediterranean diet: Greek EPIC prospective cohort
study. BMJ. 2009;338:b2337.
10 Angiology
beneficial
helpful
22. Dilis V, Katsoulis M, Lagiou P, Trichopoulos D, Naska A,
Trichopoulou A. Mediterranean diet and CHD: the Greek
European prospective investigation into cancer and nutrition
cohort. Br J Nutr. 2012;108(4):699-709.
23. Li WQ, Park Y, Wu JW, et al. Index-based dietary patterns and
risk of head and neck cancer in a large prospective study. Am J
Clin Nutr. 2014;99(3):559-566.
24. Masala G, Assedi M, Bendinelli B, et al. Fruit and vegetables
consumption and breast cancer risk: the EPIC Italy study. Breast
Cancer Res Treat. 2012;132(3):1127-1136.
25. Azzini E, Polito A, Fumagalli A, et al. Mediterranean diet effect:
an Italian picture. Nutr J. 2011;10:125.
26. Jezierska-Drutel A, Rosenzweig SA, Neumann CA. Role of oxi-
dative stress and the microenvironment in breast cancer develop-
ment and progression. Adv Cancer Res. 2013;119:107-125.
27. Terlizzi M, Casolaro V, Pinto A, Sorrentino R. Inflammasome:
cancer’s friend or foe? [published online February 8, 2014]
Pharmacol Ther. 2014.
28. Couto E, Boffetta P, Lagiou P, et al. Mediterranean dietary pat-
tern and cancer risk in the EPIC cohort. Br J Cancer. 2011;
104(9):1493-1499.
29. Escrich E, Moral R, Solanas M. Olive oil, an essential compo-
nent of the Mediterranean diet, and breast cancer. Public Health
Nutr. 2011;14(12A):2323-2332.
30. Samoli E, Lagiou A, Nikolopoulos E, et al. Mediterranean diet
and upper aerodigestive tract cancer: the Greek segment of the
alcohol-related cancers and genetic susceptibility in Europe
study. Br J Nutr. 2010;104(9):1369-1374.
31. Lagiou P, Talamini R, Samoli E, et al. Diet and upper-
aerodigestive tract cancer in Europe: the ARCAGE study. Int J
Cancer. 2009;124(11):2671-2676.
32. Ferrı´s-Tortajada J, Berbel-Tornero O, Garcı´a-Castell J, Ortega-
Garcı´a JA, Lo´ pez-Andreu JA. Dietetic factors associated with
prostate cancer: protective effects of Mediterranean diet. Actas
Urol Esp. 2012;36(4):239-245.
33. Silver HJ, Kang H, Keil CD, et al. Consuming a balanced high
fat diet for 16 weeks improves body composition, inflammation
and vascular function parameters in obese premenopausal
women. Metabolism. 2014;63(4):562-573.
34. Bergouignan A, Momken I, Schoeller DA, Simon C, Blanc S.
Metabolic fate of saturated and monounsaturated dietary fats:
the Mediterranean diet revisited from epidemiological evi-
dence to cellular mechanisms. Prog Lipid Res. 2009;48(3-4):
128-147.
35. Caracciolo B, Xu W, Collins S, Fratiglioni L. Cognitive decline,
dietary factors and gut-brain interactions [published online
December 12, 2013]. Mech Ageing Dev. 2013.
36. Solfrizzi V, Frisardi V, Seripa D, et al. Mediterranean diet in pre-
dementia and dementia syndromes. Curr Alzheimer Res. 2011;
8(5):520-542.
37. Psaltopoulou T, Sergentanis TN, Panagiotakos DB, Sergentanis
IN, Kosti R, Scarmeas N. Mediterranean diet and stroke, cogni-
tive impairment, depression: a meta-analysis. Ann Neurol. 2013;
74(4):580-591.
38. Martı´nez-Lapiscina EH, Clavero P, Toledo E, et al. Mediterra-
nean diet improves cognition: the PREDIMED -NAVARRA
randomised trial. J Neurol Neurosurg Psychiatry. 2013;84(12):
1318-1325.
39. Hu N, Yu JT, Tan L, Wang YL, Sun L, Tan L. Nutrition and the
risk of Alzheimer’s disease. Biomed Res Int. 2013;2013:524820.
40. Milaneschi Y, Bandinelli S, Corsi AM, et al. Mediterranean diet
and mobility decline in older persons. Exp Gerontol. 2011;46(4):
303-308.
41. St-Laurent-Thibault C, Arseneault M, Longpre
´ F, Ramassamy
C. Tyrosol and hydroxytyrosol, two main components of olive
oil, protect N2a cells against amyloid-b-induced toxicity. Invol-
vement of the NF-kB signaling. Curr Alzheimer Res. 2011;8(5):
543-551.
42. Alle`s B, Samieri C, Fe´art C, Jutand MA, Laurin D,
Barberger-Gateau P. Dietary patterns: a novel approach to
examine the link between nutrition and cognitive function
in older individuals. Nutr Res Rev. 2012;25(2):207-222.
43. Vassallo N, Scerri C. Mediterranean diet and dementia of the
Alzheimer type. Curr Aging Sci. 2013;6(2):150-162.
44. Barros R, Moreira A, Fonseca J, et al. Adherence to the
Mediterranean diet and fresh fruit intake are associated with
improved asthma control. Allergy. 2008;63(7):917-923.
45. Garcia-Marcos L, Castro-Rodriguez JA, Weinmayr G,
Panagiotakos DB, Priftis KN, Nagel G. Influence of Mediterra-
nean diet on asthma in children: a systematic review and meta-
analysis. Pediatr Allergy Immunol. 2013;24(4):330-338.
46. Papandreou C, Schiza SE, Bouloukaki I, et al. Effect of Mediter-
ranean diet versus prudent diet combined with physical activity
on OSAS: a randomised trial. Eur Respir J. 2012;39(6):
1398-1404.
47. Vardavas CI, Flouris AD, Tsatsakis A, Kafatos AG, Saris WH.
Does adherence to the Mediterranean diet have a protective
effect against active and passive smoking? Public Health.
2011;125(3):121-128.
48. Chatzi L, Mendez M, Garcia R, et al. Mediterranean diet adher-
ence during pregnancy and fetal growth: INMA (Spain) and
RHEA (Greece) mother-child cohort studies. Br J Nutr. 2012;
107(1):135-145.
49. Vernaglione L. The Mediterranean diet: a matter of history,
tradition, culture and health. J Nephrol. 2009;22(suppl 14):
149-158.
50. Chrysochoou C, Panagiotakos DB, Pitsavos C, et al. Adherence
to the Mediterranean diet is associated with renal function
among healthy adults: the ATTICA study. J Ren Nutr. 2010;
20(3):176-184.
51. ´az-Lo´ pez A, Bullo´ M, Martı´nez-Gonza´lez MA
´, et al. Effects
of Mediterranean diets on kidney function: a report from the
PREDIMED trial. Am J Kidney Dis. 2012;60(3):380-389.
52. Mazaraki A, Tsioufis C, Dimitriadis K, et al. Adherence to the
Mediterranean diet and albuminuria levels in Greek adolescents:
data from the Leontio Lyceum ALbuminuria (3L study). Eur J
Clin Nutr. 2011;65(2):219-225.
53. Ben– Avraham S, Harman-Boehm I, Schwarzfuchs D, Shai I.
Dietary strategies for patients with type 2 diabetes in the era
of multi-approaches; review and results from the dietary inter-
vention Randomized Controlled Trial (DIRECT). Diabetes Res
Clin Pract. 2009;86(suppl 1):41-48.
Gotsis et al 11
54. Razquin C, Martinez JA, Martinez-Gonzalez MA, Ferna´ndez-
Crehuet J, Santos JM, Marti A. A Mediterranean diet rich in
virgin olive oil may reverse the effects of the -174G/C IL6 gene
variant on 3-year body weight change. Mol Nutr Food Res. 2010;
54(suppl 1):75-82.
55. Romaguera D, Norat T, Mouw T, et al. Adherence to the Med-
iterranean diet is associated with lower abdominal adiposity in
European men and women. J Nutr. 2009;139(9):1728-1737.
56. Funtikova AN, Benı´tez-Arciniega AA, Gomez SF, Fito´M,
Elosua R, Schro¨ der H. Mediterranean diet impact on changes
in abdominal fat and 10-year incidence of abdominal obesity
in a Spanish population. Br J Nutr. 2014;111(8):1481-1487.
AQ 8
57. Athyros VG, Tziomalos K, Karagiannis A, Anagnostis P,
Mikhailidis PDP. Should adipokines be considered in the choice
of the treatment of obesity-related health problems? Curr Drug
Targets. 2010;11(1):122-135.
58. Anagnostis P, Athyros VG, Kita M, Karagiannis A. Is there any
association between adiponectin gene polymorphisms and cardi-
ovascular disease? Angiology. 2013;64(4):253-256.
59. Razquin C, Martı´nez JA, Martı´nez-Gonza´lez MA, Salas-Salvado´J,
Estruch R, Marti A. A 3-year Mediterranean-style dietary inter-
vention may modulate the association between adiponectin gene
variants and body weight change. Eur J Nutr. 2010;49(5):
311-319.
60. Tognon G, Hebestreit A, Lanfer A, et al. Mediterranean diet,
overweight and body composition in children from eight Eur-
opean countries: Cross-sectional and prospective results from
the IDEFICS study. Nutr Metab Cardiovasc Dis. 2014;24(2):
205-213.
61. Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudeve-
nos 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):1299-1313.
62. Esposito K, Maiorino MI, Ceriello A, Giugliano D. Prevention
and control of type 2 diabetes by Mediterranean diet: a systema-
tic review. Diabetes Res Clin Pract. 2010;89(2):97-102.
63. Esposito K, Maiorino MI, Ciotola M, et al. Effects of a
Mediterranean-style diet on the need for antihyperglycemic drug
therapy in patients with newly diagnosed type 2 diabetes: a ran-
domized trial. Ann Intern Med. 2009;151(5):306-314.
64. Lasa A, Miranda J, Bullo´ M, et al. Comparative effect of two
Mediterranean diets versus a low-fat diet on glycaemic control
in individuals with type 2 diabetes [published online February
12, 2014]. Eur J Clin Nutr. 2014.
65. Itsiopoulos C, Brazionis L, Kaimakamis M, et al. Can the
Mediterranean diet ower HbA1c in type 2 diabetes? Results from
a randomized cross-over study. Nutr Metab Cardiovasc Dis.
2011;21(9):740-747.
66. Rossi M, Turati F, Lagiou P, et al. Mediterranean diet and gly-
caemic load in relation to incidence of type 2 diabetes: results
from the Greek cohort of the population-based European pro-
spective investigation into Cancer and nutrition (EPIC). Diabe-
tologia. 2013;56(11):2405-2413.
67. Mosharraf S, Sharifzadeh G, Darvishzadeh Boroujeni P, Rouhi
Boroujeni H. Impact of the components of Mediterranean
nutrition regimen on long-term prognosis of diabetic patients
with coronary artery disease. ARYA Atheroscler. 2013;9(6):
337-342.
68. Pounis GD, Tyrovolas S, Antonopoulou M, et al. Long-term
animal-protein consumption is associated with an increased pre-
valence of diabetes among the elderly: the Mediterranean Islands
(MEDIS) study. Diabetes Metab. 2010;36(6 pt 1):484-490.
69. Dominguez LJ, Bes-Rastrollo M, de la Fuente-Arrillaga C, et al.
Similar prediction of total mortality, diabetes incidence and
cardiovascular events using relative-and absolute component
Mediterranean diet score: the SUN cohort. Nutr Metab Cardio-
vasc Dis. 2013;23(5):451-458.
70. Athyros VG, Tziomalos K, Karagiannis A, Mikhailidis DP.
Preventing Type 2 diabetes mellitus: room for residual risk
reduction after lifestyle changes. Curr Pharm Des. 2010;
16(34):3939-3947.
71. Karamanos B, Thanopoulou A, Anastasiou E, et al. Relation of
the Mediterranean diet with the incidence of gestational dia-
betes. Eur J Clin Nutr. 2014;68(1):8-13.
72. Babio N, Bullo M, Basora J, et al. Adherence to the Mediterra-
nean diet and risk of metabolic syndrome and its components.
Nutr Metab Cardiovasc Dis. 2009;19(8):563-570.
73. Grosso G, Mistretta A, Marventano S, et al. Beneficial effects of
the mediterranean diet on metabolic syndrome [published online
December 5, 2013]. Curr Pharm Des. 2013.
74. Esposito K, Kastorini CM, Panagiotakos DB, Giugliano D.
Mediterranean diet and metabolic syndrome: an updated sys-
tematic review. Rev Endocr Metab Disord. 2013;14(3):255-263.
75. Kesse-Guyot E, Ahluwalia N, Lassale C, Hercberg S, Fezeu L,
Lairon D. Adherence to Mediterranean diet reduces the risk of
metabolic syndrome: a 6-year prospective study. Nutr Metab
Cardiovasc Dis. 2013;23(7):677-683.
76. Viscogliosi G, Cipriani E, Liguori ML, et al. Mediterranean diet-
ary pattern adherence: associations with prediabetes, metabolic
syndrome, and related microinflammation. Metab Syndr Relat
Disord. 2013;11(3):210-216.
77. Kostapanos MS, Florentin M, Elisaf MS, Mikhailidis DP.
Hemostatic factors and the metabolic syndrome. Curr Vasc
Pharmacol. 2014;11(6):880-905.
78. Cadario F, Prodam F, Pasqualicchio S, et al. Lipid profile and
nutritional intake in children and adolescents with Type 1 dia-
betes improve after a structured dietician training to a Mediter-
ranean-style diet. J Endocrinol Invest. 2012;35(2):160-168.
79. Richard C, Couture P, Desroches S, et al. Effect of the Mediter-
ranean diet with and without weight loss on surrogate markers of
cholesterol homeostasis in men with the metabolic syndrome. Br
J Nutr. 2012;107(5):705-711.
80. Defoort C, Vincent-Baudry S, Lairon D. Effects of 3-month
Mediterranean-type diet on postprandial TAG and apolipopro-
tein B48 in the Medi-RIVAGE cohort. Public Health Nutr.
2011;14(12A):2302-2308.
AQ 9
81. Martinez -Gonzalez MA, Martin-Calvo N. The major European
dietary patterns and metabolic syndrome. Rev Endocr Metab
Disord. 2013;14(3):265-271.
82. Perez– Martinez P, Garcia– Rios A, Delgado– Lista J, Perez–
Limenez F, Lopez– Miranda J. Mediterranean diet rich in olive
12 Angiology
oil and obesity, metabolic syndrome and diabetes mellitus. Curr
Pharm Des. 2011;17(8):769-777.
83. Salas-Salvado´ J, Bulo M, Estruch R, et al. Prevention of diabetes
with Mediterranean diets: a subgroup analysis of a randomized
trial. Ann Intern Med. 2014;160(1):1-10.
84. Sahay RD, Couch SC, Missoni S, et al. Dietary patterns in adults
from an Adriatic Island of Croatia and their associations with
metabolic syndrome and its components. Coll Antropol. 2013;
37(2):335-342.
85. Go AS, Mozaffarian D, Roger VL, et al. Executive summary:
heart disease and stroke statistics–2013 update: a report from the
American heart association. Circulation. 2013;127(1):143-152.
86. Pe´rez-Lo´ pez FR, Chedraui P, Haya J, Cuadros JL. Effects of the
Mediterranean diet on longetivity and age-related morbid condi-
tions. Maturitas. 2009;64(2):67-79.
87. Martinez-Gonzalez MAC, Nunez-Cordoba JM, et al. Adherence
to Mediterranean diet and risk of developing diabetes: prospec-
tive cohort study. BMJ. 2008;336(7657):1348-1351.
88. Sanchez-Tainta A, Estruch R, Bullo´ M, et al. Adherence to a
Mediterranean type diet and reduced prevalence of clustered car-
diovascular risk factors in a cohort of 3204 high-risk patients.
Eur J Cardiovasc Prev Rehabil. 2008;15(5):589-593.
89. Athyros VG, Kakafika AI, Papageorgiou AA, et al. Effect of a
plant stanol ester-containing spread, placebo spread, or Mediter-
ranean diet on estimated cardiovascular risk and lipid, inflamma-
tory and haemostatic factors. Nutr Metab Cardiovasc Dis. 2011;
21(3):213-221.
90. Nunez-Cordoba JM, Valencia-Serrano F, Toledo E, Toledo E,
Alonso A, Martı´nez-Gonza´ lez MA. The Mediterranean diet and
incidence of hypertension. The seguimiento universidad de
navarra (SUN) study. Am J Epidemiol. 2009;169(3):339-346.
91. Fernadez JM, Rosado-A
´lvarez D, Da Silva Grigoletto ME, et al.
Moderate to high intensity training and a hypocaloric Mediterra-
nean diet enhance endothelial progenitor cells and fitness in sub-
jects with the metabolic syndrome. Clin Scie (Lond). 2012;
123(6):361-373.
92. Mente A, de Koning L, Shannon HS, Anand SS. A systematic
review of the evidence supporting a causal link between dietary
factors and coronary heart disease. Arch Intern Med. 2009;
169(7):659-669.
93. Fung TT, Rexrode KM, Mantzoros CS, Manson JE, Willett WC,
Hu FB. Mediterranean diet and incidence of and mortality from
coronary heart disease and stroke in women. Circulation. 2009;
119(8):1093-1100.
94. Buckland G, Gonza´lez CA, Agudo A, et al. Adherence to the med-
iterranean diet and risk of coronary heart disease in the Spanish
EPIC cohort study. Am J Epidemiol. 2009;170(12):1518-1529.
95. Hoevenaar-Blom MP, Nooyens AC, Kromhout D, et al. Mediter-
ranean style diet and 12-year incidence of cardiovascular dis-
eases: the EPIC-NL cohort study. PLoS One. 2012;7(9):e45458.
96. Misirli G, Benetou V, Lagiou P, Bamia C, Trichopoulos D,
Trichopoulou A. Relation of the traditional Mediterranean
diet to cerebrovascular disease in a Mediterranean population.
Am J Epidemiol. 2012;176(12):1185-1192.
97. Kastorini CM, Millionis HJ, Ioannidi A, et al. Adherence to the
Mediterranean diet in relation to acute coronary syndrome or
stroke non fatal events: a comparative analysis of a case/case-
control study. Am Heart J. 2011;162(4):717-724.
98. Chrysohoou C, Pitsavos C, Metallinos G, et al. Cross-sectional
relationship of a Mediterranean type diet to diastolic heart func-
tion in chronic heart failure patients. Heart Vessels. 2012;27(6):
576-584.
99. Corella D, Carrasco P, Sorlı´ JV, et al. Mediterranean Diet
Reduces the Adverse Effect of the TCF7L2-rs7903146 Poly-
morphism on Cardiovascular Risk Factors and Stroke Incidence:
A randomized controlled trial in a high-cardiovascular-risk pop-
ulation. Diabetes Care. 2013;36(11):3803-3811.
100. Estruch R, Ros E, Salas-Salvado´ J, et al. Primary prevention of
cardiovascular disease with a Mediterranean diet. N Engl J Med.
2013;368(14):1279-1279.
101. Gardener H, Wright CB, Gu Y, et al. Mediterranean-style diet
and risk of ischemic stroke, myocardial infarction, and vascular
death: the Northern Manhattan study. Am J Clin Nutr. 2011;
94(6):1458-1464.
102. Sofi F, Cesari F, Abbate R, Gensini GF, Casini A. Adherence to
Mediterranean diet and health status. A meta-analysis. BMJ.
2008;337:a1344.
103. Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on
benefits of adherence to the Mediterranean diet on health: an
updated systematic review and meta-analysis. Am J Clin Nutr.
2010;92(5):1189-1196.
104. Lopez-Garcia E, Rodriguez-Artalejo F, Li TY, et al. The Mediter-
ranean-style diet pattern and mortality among men and women
with cardiovascular disease. Am J Clin Nutr. 2014;99(1):172-180.
105. Tognon G, Lissner L, Sæbye D, Walker KZ, Heitmann BL. The
Mediterranean diet in relation to mortality and CVD: a Danish
cohort study. Br J Nutr. 2014;111(1):151-159.
106. Babio N, Bullo´ M, Salas-Salvado´ J. Mediterranean diet and
metabolic syndrome: the evidence. Public Health Nutr. 2009;
12(9A):1607-1617.
107. Panagiotakos DB, Dimakopoulou K, Katsouyanni K, et al.
Mediterranean diet and inflammatory response in myocardial
infarction survivors. Int J Epidemiol. 2009;38(3):856-866.
108. Urpi-Sarda M, Casas R, Chiva-Blanch G, et al. Virgin olive oil
and nuts as key foods of the Mediterranean diet effects on
inflammatory biomarkers related to atherosclerosis. Pharmacol
Res. 2012;65(6):577-583.
109. Urpi-Sarda M, Casas R, Chiva-Blanch G, et al. The Mediterra-
nean diet pattern and its main components are associated with
lower plasma concentrations of tumor necrosis factor receptor
60 in patients at high risk for cardiovascular disease. J Nutr.
2012;142(6):1019-1025.
110. Richard C, Couture P, Desroches S, Lamarche B. Effect of the
mediterranean diet with and without weight loss on markers of
inflammation in men with metabolic syndrome. Obesity (Silver
Spring). 2013;21(1):51-57.
111. Marı´n C, Yubero-Serrano EM,Lo´ pez-Miranda J, Pe´ rez-Jime´nezF.
Endothelial aging associated with oxidative stress can be
modulated by a healthy Mediterranean diet. Int J Mol Sci.
2013;14(5):8869-8889.
112. Huang H, Ma R, Liu D, et al. Oxidized low-density lipoprotein
cholesterol and the ratio in the diagnosis and evaluation of
Gotsis et al 13
therapeutic effect in patients with coronary artery disease. Dis
Markers. 2012;33(6):295-302.
113. Beydoun MA, Canas JA, Beydoun HA, Chen X, Shroff MR,
Zonderman AB. Serum antioxidant concentrations and meta-
bolic syndrome are associated among U.S. adolescents in recent
national surveys. J Nutr. 2012;142(9):1693-1704.
114. Giordano P, Scicchitano P, Locorotondo M, et al. Carotenoids and
cardiovascular risk. Curr Pharm Res. 2012;18(34):5577-5589.
115. Marin C, Delgado-Lista J, Ramirez R, et al. Mediterranean die-
treduces senescence-associated stress in endothelial cells. Age
(Dordr). 2012;34(6):1309-1316.
116. Dai J, Jones DP, Goldberg J, et al. Association between adher-
ence to the Mediterranean diet and oxidative stress. Am J Clin
Nutr. 2008;88(5):1364-1370.
117. Carluccio MA, Siculella L, Ancora MA, et al. Olive oil and red
wine antioxidant polyphenols inhibit endothelial activation:
antiatherogenic properties of Mediterranean diet phytochem-
icals. Arteriosclerosis Throm Vasc Biol. 2003;23(4):622-629.
118. Thomazella MC, Go´ es MF, Andrade CR, et al. Effects of high
adherence to Mediterranean or low-fat diets in medicated
secondary prevention patients. Am J Cardiol. 2011;108(11):
1523-1529.
119. Llorente-Corte´s V, Estruch R, Mena MP, et al. Effect of Medi-
terranean diet on the expression of pro-atherogenic genes in a
population at high cardiovascular risk. Atherosclerosis. 2010;
208(2):442-450.
120. Camargo A, Delgado-Lista J, Garcia-Rios A, et al. Expression of
proinflammatory, proatherogenic genes is reduced by the Medi-
terranean diet in elderly people. Br J Nutr. 2012;108(3):500-508.
121. Scoditti E, Calabriso N, Massaro M, et al. Mediterranean diet
polyphenols reduce inflammatory angiogenesis through
MMP-9 and COX-2 inhibition in human vascular endothelial cells:
a potentially protective mechanism in atherosclerotic vascular
disease and cancer. Arch Biochem Biophys. 2012;527(2):81-89.
122. Marin C, Ramirez R, Delgado-Lista J, et al. Mediterranean die-
treduces endothelial damage and improves the regenerative
capacity of endothelium. Am J Clin Nutr. 2011;93(2):267-274.
123. Ruiz-Canela M, Martı´nez-Gonza´lez MA. Lifestyle and dietary
risk factors for peripheral artery disease. Circ J. 2014;7 8(3):
553-559.
124. Pignoli P, Tremoli E, Poli A, Oreste P, Paoletti R. Intimal plus
medial thickness of the arterial wall: a direct measurement with
ultrasound imaging. Circulation. 1986;74:1399-1406.
125. O’Leary DH, Bots ML. Imaging of atherosclerosis: carotid
intima-media thickness. Eur Heart J. 2010;31(14):1682-1689.
126. De Groot E, van Leuven SI, Duivenvoorden R, et al. Measure-
ment of carotid intima-media thickness to assess progression and
regression of atherosclerosis. Nat Clin Pract Cardiovasc Med.
2008;5(5):280-288.
127. Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M. Predic-
tion of clinical cardiovascular events with carotid intima – media
thickness: a systematic review and meta-analysis. Atherosclero-
sis. 2007;115(4):459-467.
128. Niu L, Zhang Y, Qian M, et al. Impact of multiple cardiovascular
risk factors on carotid intima- media thickness and elasticity.
PLoS One. 2013;8(7):e67809.
129. Buil-Cosiales P, Irimia P, Ros E, et al. Dietary fibre intake is
inversely associated with carotid intima-media thickness: a
cross-sectional assessment in the PREDIMED study. Eur J Clin
Nutr. 2009;63(10):1213-1219.
130. Petersen KS, Clifton PM, Keogh JB. The association between
carotid intima media thickness and individual dietary compo-
nents and patterns [published online November 1, 2013]. Nutr
Metab Cardiovasc Dis. 2013.
131. Murie-Fernandez M, Irimia P, Toledo E, et al. Carotid intima-
media thickness changes with Mediterranean diet: a randomized
trial (PREDIMED-Navarra). Atherosclerosis. 2011;219(1):
158-162.
132. Sala-Vila A, Romero-Mamani ES, Gilabert R, et al. Changes in
ultrasound-assessed carotid intima-media thickness and plaque
with a Mediterranean diet: A substudy of the PREDIMED trial.
Arterioscler Thromb Vasc Biol. 2014;34(2):439-445.
133. Giannini C, Diesse L, D’Adamo E, et al. Influence of the Med-
iterranean diet on carotid intima-media thickness in hypercho-
lesterolaemic children: A 12-month intervention study. Nutr
Metab Cardiovasc Dis. 2014;24(1):75-82.
134. Kostapanos MS, Athyros VG, Karagiannis A, Mikhailidis DP.
Mechanisms linking nonalcoholic fatty liver disease with coron-
ary artery disease. Dig Dis Sci. 2012;57(4):1109.
135. Athyros VG, Katsiki N, Karagiannis A. Nonalcoholic fatty liver
disease and severity of cardiovascular disease manifestations.
Angiology. 2013;64(8):572-575.
136. Katsiki N, Athyros VG, Karagiannis A, Mikhailidis DP. Meta-
bolic syndrome and non-cardiac vascular diseases: an update
from human studies[published online December 5, 2013]. Curr
Pharm Des. 2013.
137. Katsiki N, Athyros VG, Karagiannis A, Mikhailidis DP. Charac-
teristics Other than the diagnostic criteria associated with meta-
bolic syndrome: an overview [published online April 25, 2013].
Curr Vasc Pharmacol. 2013.
138. Athyros VG, Ganotakis ES, Tziomalos K, et al. Comparison of
four definitions of the metabolic syndrome in a Greek (Mediter-
ranean) population. Curr Med Res Opin. 2010;26(3):713-719.
139. Athyros VG, Ganotakis ES, Elisaf MS, et al. Prevalence of vas-
cular disease in metabolic syndrome using three proposed defi-
nitions. Int J Cardiol. 2007;117(2):204-210.
140. Milionis HJ, Kostapanos MS, Liberopoulos EN, et al. Different
definitions of the metabolic syndrome and risk of first-ever acute
ischaemic non-embolic stroke in elderly subjects. Int J Clin
Pract. 2007;61(4):545-551.
141. Alberti KG, Eckel RH, Grundy SM, et al. Harmonizing the meta-
bolic syndrome: a joint interim statement of the international
diabetes federation task force on epidemiology and prevention;
national heart, lung, and blood institute; American heart associ-
ation; world heart federation; international atherosclerosis soci-
ety; and international association for the study of obesity.
Circulation. 2009;120(16):1640-1645.
142. Assy N, Nassar F, Nasser G, Grosovski M. Olive oil consump-
tion and non-alcoholic fatty liver disease. World J Gastroen-
terol. 2009;15(15):1809-1815.
143. Ryan MC, Itsiopoulos C, Thodis T, et al. The Mediterranean diet
improves hepatic steatosis and insulin sensitivity in individuals
14 Angiology
with non-alcoholic fatty liver disease. J Hepatol. 2013;59(1):
138-143.
144. Kontogianni MD, Tileli N, Margariti A, et al. Adherence to the
Mediterranean diet is associated with the severity of non-
alcoholic fatty liver disease [published online September 7,
2013]. Clin Nutr. 2013.
145. Trovato FM, Catalano D, Martines GF, Pace P, Trovato GM.
Mediterranean diet and non-alcoholic fatty liver disease: the
need of extended and comprehensive interventions [published
online January 31, 2014]. Clin Nutr. 2014.
146. Rizzo M, Obradovic M, Labudovic-Borovic M, et al. Uric acid
metabolism in pre-hypertension and the metabolic syndrome
[published online April 25, 2013]. Curr Vasc Pharmacol. 2013.
147. Katsiki N, Athyros VG, Karagiannis A, Mikhailidis DP.
Hyperuricaemia and non-alcoholic fatty liver disease (NAFLD):
a relationship with implications for vascular risk? Curr Vasc
Pharmacol. 2011;9(6):698-705.
148. Katsiki N, Karagiannis A, Athyros VG, Mikhailidis DP.
Hyperuricaemia: more than just a cause of gout? J Cardiovasc
Med (Hagerstown). 2013;14(6):397-402.
149. Katsiki N, Papanas N, Fonseca VA, Maltezos E, Mikhailidis DP.
Uric acid and diabetes: is there a link? Curr Pharm Des. 2013;
19(27):4930-4937.
150. Athyros VG, Mikhailidis DP. Uric acid, chronic kidney disease
and type 2 diabetes: A cluster of vascular risk factors. J Diabetes
Complications. 2014;28(2):122-123.
151. Kontogianni MD, Chrysohoou C, Panagiotakos DB, et al.
Adherence to the Mediterranean diet and serum uric acid: the
ATTICA study. Scand J Rheumatol. 2012;41(6):442-449.
152. Fito´ M, Estruch R, Salas-Salvado´ J, et al. Effect of the Mediter-
ranean diet on heart failure biomarkers: a randomized sample
from the PREDIMED trial [published online February 24,
2014]. Eur J Heart Fail. 2014.
153. Rivas A, Romero A, Mariscal-Arcas M, et al. Mediterranean diet
and bone mineral density in two age groups of women. Int J
Food Sci Nutr. 2013;64(2):155-161.
154. Esposito K, Giugliano F, Maiorino MI, Giugliano D. Dietary
factors, Mediterranean diet and erectile dysfunction. J Sex Med.
2010;7(7):2338-2234.
155. Damasceno NR, Sala-Vila A, Cofa´n M, et al. Mediterranean diet
supplemented with nuts reduces waist circumference and shifts
lipoprotein subfractions to a less atherogenic pattern in subjects
at high cardiovascular risk. Atherosclerosis. 2013;230(2):347-353.
156. Fernemark H, Jaredsson C, Bunjaku B, Rosenqvist U, Nystrom
FH, Guldbrand H. A randomized cross-over trial of the
postprandial effects of three different diets in patients with type
2 diabetes. PLoS One. 2013;8(11):e79324.
157. Mikhailidis DP, Elisaf M, Rizzo M, et al. ‘‘European panel on
low density lipoprotein (LDL) subclasses’’: a statement on the
pathophysiology, atherogenicity and clinical significance of
LDL subclasses: executive summary. Curr Vasc Pharmacol.
2011;9(5):531-532.
158. Mikhailidis DP, Elisaf M, Rizzo M, et al. ‘‘European panel on
low density lipoprotein (LDL) subclasses’’: a statement on the
pathophysiology, atherogenicity and clinical significance of
LDL subclasses. Curr Vasc Pharmacol. 2011;9(5):533-571.
159. Kolovou GD, Mikhailidis DP, Kovar J, et al. Assessment and
clinical relevance of non-fasting and postprandial triglycerides:
an expert panel statement. Curr Vasc Pharmacol. 2011;9(3):
258-270.
160. Jones JL, Comperatore M, Barona J, et al. A Mediterranean-
style, low-glycemic-load diet decreases atherogenic lipoproteins
and reduces lipoprotein (a) and oxidized low-density lipoprotein
in women with metabolic syndrome. Metabolism. 2012;61(3):
366-372.
161. Delgado-ListaJ, Garcia-Rios A, Perez-Martinez P, Lopez-Miranda
J, Perez-Jimenez F. Olive oil and haemostasis: platelet function,
thrombogenesis and fibrinolysis. Curr Pharm Des. 2011;17(8):
778-785.
162. Carter SJ, Roberts MB, Salter J, Eaton CB. Relationship
between Mediterranean diet score and atherothrombotic risk:
findings from the third national health and nutrition examination
survey (NHANES III), 1988-1994. Atherosclerosis. 2010;210(2):
630-636.
163. Be´dard A, Tchernof A, Lamarche B, Corneau L, Dodin S,
Lemieux S. Effects of the traditional Mediterranean diet on adi-
ponectin and leptin concentrations in men and premenopausal
women: do sex differences exist? [published online March 5,
2014] Eur J Clin Nutr. 2014.
164. Richard C, Royer MM, Couture P, et al. Effect of the mediterra-
nean diet on plasma adipokine concentrations in men with meta-
bolic syndrome. Metabolism. 2013;62(12):1803-1810.
165. van de Laar RJ, Stehouwer CD, van Bussel BC, Prins MH,
Twisk JW, Ferreira I. Adherence to a Mediterranean dietary pat-
tern in early life is associated with lower arterial stiffness in
adulthood: the amsterdam growth and health longitudinal study.
J Intern Med. 2013;273(1):79-93.
166. Saulle R, Semyonov L, La Torre G. Cost and cost-effectiveness
of the Mediterranean diet: results of a systematic review. Nutri-
ents. 2013;5(11):4566-4586.
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Gotsis et al 15
... Olive oil and low-to-moderate alcohol intake (especially red wine) also contribute to the benefits of MD via their polyphenol content [42,43]. Overall, potential mechanisms underlying the beneficial effects of MD include improvements in oxidative stress, inflammation, thrombosis, insulin sensitivity, lipid profile, endothelial dysfunction, and gut microbiota [44][45][46] (Fig. 1). ...
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Purpose of Review Obesity is a chronic disease, a major public health problem due to its association with non-communicable diseases and all-cause mortality. Indeed, people with obesity are at increased risk for a variety of obesity-related disorders including hypertension, dyslipidemia, type 2 diabetes mellitus, cardiovascular disease, and several cancers. Many popular diets with very different macronutrient composition, including the Mediterranean diet (MD), have been used, proposed, and studied for prevention and management of obesity. In particular, MD has been the subject of countless studies over the years and now boasts a large body of scientific literature. In this review, we aimed to update current knowledge by summarizing the most recent evidence on the effect of MD on obesity and obesity-related disorders. Recent Findings The negative effects of obesity are partly reversed by substantial weight loss that can be achieved with MD, especially when low-calorie and in combination with adequate physical activity. In addition, the composition of MD has been correlated with an excellent effect on reducing dyslipidemia. It also positively modulates the gut microbiota and immune system, significantly decreasing inflammatory mediators, a common ground for many obesity-related disorders. Summary People with obesity are at increased risk for a variety of medical disorders including hypertension, dyslipidemia, type 2 diabetes mellitus, and cardiovascular disease. Therefore, there is an inevitable need for measures to manage obesity and its related disorders. At this point, MD has been proposed as a valuable nutritional intervention. It is characterized by a high consumption of vegetables, fruit, nuts, cereals, whole grains, and extra virgin olive oil, as well as a moderate consumption of fish and poultry, and a limited intake of sweets, red meat, and dairy products. MD proves to be the healthiest dietary pattern available to tackle obesity and prevent several non-communicable diseases, including cardiovascular disease and type 2 diabetes.
... It also emphasises regular social interaction at meals and physical activity. The MDP has been linked to decreased risks of various chronic diseases such as cardiovascular diseases, obesity, hypertension, diabetes and cognitive decline [5][6][7]. Some mechanisms by which the MDP decreases the risks of NCDs is by reducing metabolic risk factors, including oxidative stress and inflammation, as well as improved blood pressure, lipid profiles and insulin sensitivity [8,9]. ...
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The aim of this cross-sectional study was to understand how the public in a non-Mediterranean multi-ethnic society perceived the Mediterranean dietary pattern (MDP) and its general health benefits. A total of 373 participants took part in this study. Most of the sample were young adults, females and had been living in Australia for over 10 years. Knowledge of the MDP score, attitudes towards the MDP score and an adherence to the MPD score were measured. Normality of variables was tested. Simple linear regression and Chi-squared tests were conducted to examine associations. ANOVA tests were used to report participants’ demographics across various attitudes scores. Less than half of participants were aware of the MDP guidelines, food choices and health benefits. As for adherence to the MDP, 20% of the sample were found to have high adherence to the MDP. Results also showed that participants with high knowledge about the MDP were twice more likely to have higher MDP adherence rates, OR 95% CI = 2.3 (1.3, 4.0), p-value = 0.002. This paper provided new insights about the association between nutritional knowledge and adherence to the MDP in a multi-ethnic non-Mediterranean setting.
... The findings of the current study indicate that a greater intake of vegetables, consuming alcohol less frequently, meeting Australian carbohydrate intake recommendations and a lower intake of sodium may be related to higher EO. Although dietary patterns have not been assessed in the current study, the variables identified above are aligned with a Mediterranean dietary pattern, which encourages high intakes of vegetables, fruit, nuts, grains, legumes, olive oil, and fish, moderate consumption of alcohol, and small amounts of high-fat dairy and red meat (48) . Indeed, a recent review indicated that the Mediterranean Dietary Pattern is the most beneficial diet for overall health, mental and academic outcomes in university students (49) . ...
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Objective This study aimed to examine cross-sectional and longitudinal associations between dietary intake and educational outcomes (EO) in Australian first-year university students. Design This cross-sectional and longitudinal study measured outcomes of interest at three points over one year. Measures included self-reported dietary patterns and dietary intake via a three-day estimated food record. Objective EO [corresponding semester grade point average (GPA), overall GPA, graduation status] variables were extracted from academic records. Cross-sectional and longitudinal associations were examined using regressions models and Generalized Estimating Equation, respectively. Participants/setting Participants ( n =80) were recruited from a large university in X, X. Participants were first year students and had completed high school in the previous year. Results Some significant associations were found with semester GPA, including (a) moderate positive associations between serves of vegetables and semester GPA at time point two and over time, and (b) a weak negative association between sodium intake and semester GPA at time point two. Although insignificant, meaningful negative associations were found between alcohol consumption and semester GPA at time point one and over time. Some significant associations were also found with graduation status, including (a) a positive association between meeting Australian carbohydrate recommendations and graduation status, and (b) a negative association between iron intake and graduation status, both at time point one. Conclusions Both cross-sectional and longitudinal findings highlight positive associations between vegetable intake and EO and negative associations between alcohol consumption and EO. Further relevant work is needed with larger, more variable samples in demographic, dietary and EO characteristics.
... The Mediterranean diet (MD) is a widespread dietary pattern associated with anti-inflammatory properties due to its high consumption of olive oil, nuts, seeds, vegetables, fruits, whole grains, low-fat dairy, and low intake of meats and dairy products (22)(23)(24)(25). The MD is a healthy dietary approach that promotes overall well-being (26) and is associated with risk reduction of the common comorbidities observed in COVID-19 patients (27). Indeed, MD patterns have a preventive effect on cardiovascular diseases and diabetes, which are risk factors for severe COVID-19 infection and its associated complications (28). ...
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Background and Aims Adherence to the Mediterranean diet (MD) has been associated with a decreased risk of developing a variety of chronic diseases that are comorbidities in COVID-19 patients. However, its association to the severity and symptoms of COVID-19 are still unknown. This study aimed to examine the association between adherence to the MD pattern and COVID-19 severity and symptoms in Iranian hospitalized patients. Methods In this cross-sectional study, 250 COVID-19 patients aged 18 to 65 were examined. We employed a food frequency questionnaire (FFQ) to obtain data on dietary intake of participants in the year prior to their COVID-19 diagnosis. COVID-19 severity was determined using the National Institutes of Health's Coronavirus Disease 2019 report. Additionally, symptoms associated with COVID-19, inflammatory markers, and other variables were evaluated. The scoring method proposed by Trichopoulou et al. was used to assess adherence to the MD. Results The participants' mean age was 44.1 ± 12.1 years, and 46% of them had severe COVID-19. Patients who adhered more closely to the MD had lower serum C-reactive protein levels (7.80 vs. 37.36 mg/l) and erythrocyte sedimentation rate (14.08 vs. 42.65 mm/h). Those with the highest MD score were 77% less likely to have severe COVID-19 after controlling for confounding variables. The MD score was also found to be inversely associated with COVID-19 symptoms, including dyspnea, cough, fever, chills, weakness, myalgia, nausea and vomiting, and sore throat. Conclusion Higher adherence to the MD was associated with a decreased likelihood of COVID-19 severity and symptoms, as well as a shorter duration of hospitalization and convalescence, and inflammatory biomarkers.
... Within the international debate on changing diets and food systems to more adequate ones, the Mediterranean diet (MD) is potentially the best diet based on evidence as it is at once healthy and sustainable. The MD combines: 1. Important health benefits: a growing body of evidence supports the protective role of the MD, in terms of primary and secondary prevention, against cardiovascular disease, arteriosclerosis, cancer, diabetes mellitus, metabolic syndrome, excess weight/obesity, respiratory disease (asthma and sleep apnea), mental disorders (cognitive decline and depression) and renal disease [2][3][4][5][6]. Non-nutritional aspects, linked in one way or another to food consumption, have been suggested to contribute to the beneficial effect of the MD; these include, among others, physical activity [7]; and 2. Sustainability [6,[8][9][10][11][12][13]: an aspect which has been under debate in recent years regarding dietary patterns is that they should not only be beneficial for all people but also for the environment, for all countries and, as such, for the planet [6,8]. ...
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Daily routines may influence eating patterns; however, differences in intake on weekdays and at weekends have rarely been explored. Furthermore, these differences have not been analyzed among university students (a particularly interesting group among the younger generations). The aim of the study was to evaluate weekend–weekday variation in the Mediterranean diet among Spanish university students, while investigating the potential influence of age, gender, studies, body mass index, smoking status and physical activity status. A repeated-measurement 28-day cross-sectional observational study with self-reported dietary intake collected using the e12HR app was conducted. There were 361 participants: average age 20.6 years; 72.9% women; 58.2% students of Pharmacy; average BMI 21.9 kg/m2; 91.4% nonsmokers; 77.6% performed ≥150 min/week of physical activity. Outcome measurements were adherence to the Mediterranean diet (AMD) index and percentage of participants meeting recommendations for each food group on weekdays and at weekends. In all subgroups, Spanish university students’ global diet was associated with low AMD, with poorer diet quality (>12% reductions in mean scores of AMD index and >26% reductions in adequate adherence scores (≥9)) at weekends. In conclusion, weekend health behaviors of Spanish university students displayed less favorable eating behavior, making the weekend an important target for public health interventions aiming to improve dietary intake.
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Mediterranean diet (MD) is potentially one of the best diets regarding health benefits and sustainability. However, it is faced with serious difficulties staying alive, even in traditionally Mediterranean regions. The objective was to evaluate the effectiveness of an application (e-12HR) to improve adherence to the MD (AMD) in university students. This study was a controlled, randomized, and multicentric clinical trial with two parallel groups (control group (CG) and intervention group (IG)), a 28-day follow-up period, and 286 participants (74.1% women). There were two versions of e-12HR: ‘feedback’ e-12HR (IG) and ‘non-feedback’ e-12HR (CG). Only the ‘feedback’ e-12HR had two specific automatic functions: 1. Evaluation of the user’s AMD; 2. Identification of the food groups for which the user has not fulfilled the MD recommendations. Both versions of the application allowed the collection of data on dietary intake in order to calculate the AMD. When comparing CG and IG at 14-, 21-, and 28-days follow-up (no significant statistical differences at baseline), there were significant statistical improvements in favor of IG in AMD index (0.71, 1.56, and 1.43 points, respectively), and in the percentage of participants with medium/high AMD index (14.4%, 20.6%, and 23.7%, respectively). In conclusion, e-12HR could improve AMD among university students.
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Introduction: Nutritional status impacts the survival of patients with cancer. There are few studies that investigate the role of nutritional status on breast cancer survival in women with breast cancer, and even fewer regarding the impact of adhering to the Mediterranean diet (MD). The present study aims to assess the nutritional status, MD adherence, physical activity levels and health-related quality of life (HRQOL) in women diagnosed with breast cancer and evaluate these parameters regarding recurrence-free survival. Methods: A total of 114 women, aged 35–87 years old, diagnosed with breast cancer in Larissa, Greece, participated in the study. Tumor histopathology was reported, and anthropometric indices were measured by a trained nurse, while questionnaires regarding nutritional status (via mini nutritional assessment), HRQOL via EORTC QLQ-C30, physical activity levels via IPAQ and Mediterranean diet adherence via MedDietScore were administered. The participants were followed-up for a maximum time interval of 42 months or until recurrence occurred. Results: A total of 74% of patients were overweight or obese, while 4% of women were undernourished, and 28% were at risk of malnutrition. After 42 months of follow-up, 22 patients (19.3%) had relapsed. The median time to recurrence was 38 months (IQR: 33–40 months) and ranged between 23 to 42 months. Higher levels of MD adherence were significantly associated with lower body mass index (BMI) values, earlier disease stage, smaller tumor size, absence of lymph node metastases and better physical activity levels (p < 0.05). Normal nutritional status was significantly associated with higher BMI values and better health-related quality of life (p ≤ 0.05). In univariate analysis, patients with higher levels of MD adherence and well-nourished patients had significantly longer recurrence-free survival (p < 0.05). In multivariate analysis, MD adherence and nutritional status were independently associated with recurrence-free patients’ survival after adjustment for several confounding factors (p < 0.05). Conclusions: The impact of MD on time to recurrence is still under investigation, and future interventional studies need to focus on the role of adhering to the MD before and after therapy in survival and breast cancer progression. Furthermore, the present study also highlights the importance of an adequate nutritional status on disease progression, and the need for nutritional assessment, education and intervention in women with breast cancer.
Chapter
Sufficiency of nutrition in terms of macro and micronutrients is crucial during the period of pregnancy and lactation to shape not only the health of the mother but also the health and development of the baby and may predispose future health problems for the baby. The ideal behavior of feeding infants during the first 6 months is exclusive breastfeeding, it is an essential source of energy and nutrients and protects against gastrointestinal and other infections [1]. Strong immune and digestive systems are considered to develop in breastfeeding infants because of the growth of positive bacteria in the gut that provides a healthy microbial population [1]. Nutritional intakes should be planned by a dietitian considering the body mass index (BMI), ethnicity, food selection according to culture, ability to reach food, and the socioeconomic status of the patient [2].KeywordsFood allergyFood intolarenceNutritionPregnancyPostpartum period
Chapter
O livro enfatiza fatores que regem a vida humana do início ao fim e que podem ser muito diferentes entre indivíduos e populações: 1) caracteres genéticos herdados diretamente de nossos pais e indiretamente de nossos ancestrais, os quais permanecem relativamente estáveis ao longo da vida; 2) fatores ambientais (alimentação, condição e estilo de vida) até certo ponto controláveis, sendo a alimentação o mais importante. A primeira parte do livro trata da definição e da conceituação do processo de envelhecimento e seus efeitos na saúde. Seguem-se a apresentação e a discussão de mecanismos que promovem degradação molecular e celular responsáveis por distúrbios metabólicos que podem resultar em doenças crônico-degenerativas. A maior parte do texto é dedicada à apresentação de alimentos e compostos bioativos que agem combatendo o envelhecimento precoce e retardando doenças da idade. Por fim, faz-se uma discussão sobre conceitos de dietas saudáveis com sugestões para pesquisas, visando melhorar o perfil alimentar do brasileiro.
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Non-alcoholic fatty liver disease (NAFLD) is the most frequent hepatic disease globally. NAFLD patients are at an increased risk of both liver and cardiovascular morbidity and mortality, as well as all-cause death. NAFLD prevalence is rapidly increasing worldwide and, thus, there is an urgent need for health policies to tackle its development and complications. Currently, since there is no drug therapy officially indicated for this disease, lifestyle interventions remain the first-line therapeutic option. In the present narrative review, we discuss the effects of certain dietary patterns on NAFLD incidence and progression. The Mediterranean diet is regarded as the diet of choice for the prevention/treatment of NAFLD and its complications, based on the available evidence. Other plant-based dietary patterns (poor in saturated fat, refined carbohydrates, red and processed meats) are also beneficial [i.e., Dietary Approaches to Stop Hypertension (DASH) and vegetarian/vegan diets], whereas more data are needed to establish the role of ketogenic, intermittent fasting and paleo diets in NAFLD. Nevertheless, there is no “one-size-fits-all” dietary intervention for NAFLD management. Clinicians should discuss with their patients and define the diet that each individual prefers and is able to implement in his/her daily life.
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Objective : The purpose of the present study was to investigate the value of ox-LDL and oxidation ratio of LDL (ox-LDL/TC, ox-LDL/HDL-C and ox-LDL/LDL-C) in diagnosis and prognosis evaluation in CAD patients. Also, we aimed to observe the effect of statins on reducing level of ox-LDL and oxidation ratio of LDL, and explore whether statins still have similar effect on ox-LDL in a short period of therapy (within 2 weeks). Methods : Blood ox-LDL, TC, HDL-C, LDL-C, and TG were measured in cases with acute myocardial infarction (AMI, n = 177), unstable angina pectoris (UAP, n = 195), stable angina pectoris (SAP, n = 228), normal control ( n = 120), and high risk control ( n = 140). Results : Mean value of ox-LDL and oxidation ratio of LDL was significantly higher in the CAD group than in the two control groups. The AUC of ROC curve of ox-LDL, ox-LDL/TC, ox-LDL/HDL-C, ox-LDL/LDL-C and apoA1/apoB were more than 0.50 ( P < 0.001). Multivariate logistic regression analysis showed that age and ox-LDL/LDL-C related with short-term, while ox-LDL/LDL-C and ox-LDL/TC related with long-term prognosis ( P < 0.05). Furthermore, after treatment with statins for 2 weeks, TC, LDL-C, ox-LDL, ox-LDL/TC, ox-LDL/HDL-C and ox-LDL/LDL-C decreased by 22%, 28%, 38%, 29%, 23% and 25% respectively. And the reduction of ox-LDL by statins is independent of lowering of LDL-C and TC. Conclusions : Ox-LDL and oxidation ratio of LDL are closely related with AS, and they are better biomarkers for discriminating between patients with coronary artery disease and healthy subjects. In addition, statins can decrease level of ox-LDL significantly, which is independent of lowering of LDL-C and TC.
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Objective: To systematically review all the prospective cohort studies that have analysed the relation between adherence to a Mediterranean diet, mortality, and incidence of chronic diseases in a primary prevention setting. Design: Meta-analysis of prospective cohort studies. Data sources: English and non-English publications in PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials from 1966 to 30 June 2008. Studies reviewed Studies that analysed prospectively the association between adherence to a Mediterranean diet, mortality, and incidence of diseases; 12 studies, with a total of 1 574,299 subjects followed for a time ranging from three to 18 years were included. Results: The cumulative analysis among eight cohorts (514,816 subjects and 33,576 deaths) evaluating overall mortality in relation to adherence to a Mediterranean diet showed that a two point increase in the adherence score was significantly associated with a reduced risk of mortality (pooled relative risk 0.91, 95% confidence interval 0.89 to 0.94). Likewise, the analyses showed a beneficial role for greater adherence to a Mediterranean diet on cardiovascular mortality (pooled relative risk 0.91, 0.87 to 0.95), incidence of or mortality from cancer (0.94, 0.92 to 0.96), and incidence of Parkinson's disease and Alzheimer's disease (0.87, 0.80 to 0.96). Conclusions: Greater adherence to a Mediterranean diet is associated with a significant improvement in health status, as seen by a significant reduction in overall mortality (9%), mortality from cardiovascular diseases (9%), incidence of or mortality from cancer (6%), and incidence of Parkinson's disease and Alzheimer's disease (13%). These results seem to be clinically relevant for public health, in particular for encouraging a Mediterranean-like dietary pattern for primary prevention of major chronic diseases.
Article
Scarce data are available on the effect of the traditional Mediterranean diet (TMD) on heart failure biomarkers. We assessed the effect of TMD on biomarkers related to heart failure in a high cardiovascular disease risk population. A total of 930 subjects at high cardiovascular risk (420 men and 510 women) were recruited in the framework of a multicentre, randomized, controlled, parallel-group clinical trial directed at testing the efficacy of the TMD on the primary prevention of cardiovascular disease (The PREDIMED Study). Participants were assigned to a low-fat diet (control, n = 310) or one of two TMDs [TMD + virgin olive oil (VOO) or TMD + nuts]. Depending on group assignment, participants received free provision of extra-virgin olive oil, mixed nuts, or small non-food gifts. After 1 year of intervention, both TMDs decreased plasma N-terminal pro-brain natriuretic peptide, with changes reaching significance vs. control group (P < 0.05). Oxidized low-density lipoprotein decreased in both TMD groups (P < 0.05), the decrease in TMD + VOO group reaching significance vs. changes in control group (P = 0.003). Changes in lipoprotein(a) after TMD + VOO were less than those in the control group (P = 0.046) in which an increase (P = 0.035) was observed. No changes were observed in urinary albumin or albumin/creatinine ratio. Individuals at high risk of cardiovascular disease (CVD) who improved their diet toward a TMD pattern reduced their N-terminal pro-brain natriuretic peptide compared with those assigned to a low-fat diet. The same was found for in vivo oxidized low-density lipoprotein and lipoprotein(a) plasma concentrations after the TMD + VOO diet. From our results TMD could be a useful tool to mitigate against risk factors for heart failure. From our results TMD could modify markers of heart failure towards a more protective mode.