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Accruing evidence on benefits of adherence to the Mediterranean diet on health: An updated systematic review and meta-analysis
Abstract and Figures
The Mediterranean diet has long been reported to be protective against the occurrence of several different health outcomes.
We aimed to update our previous meta-analysis of published cohort prospective studies that investigated the effects of adherence to the Mediterranean diet on health status.
We conducted a comprehensive literature search through electronic databases up to June 2010.
The updated review process showed 7 prospective studies published in the past 2 y that were not included in the previous meta-analysis (1 study for overall mortality, 3 studies for cardiovascular incidence or mortality, 1 study for cancer incidence or mortality, and 2 studies for neurodegenerative diseases). These recent studies included 2 health outcomes not previously investigated (ie, mild cognitive impairment and stroke). The meta-analysis for all studies with a random-effects model that was conducted after the inclusion of these recent studies showed that a 2-point increase in adherence to the Mediterranean diet was associated with a significant reduction of overall mortality [relative risk (RR) = 0.92; 95% CI: 0.90, 0.94], cardiovascular incidence or mortality (RR = 0.90; 95% CI: 0.87, 0.93), cancer incidence or mortality (RR = 0.94; 95% CI: 0.92, 0.96), and neurodegenerative diseases (RR = 0.87; 95% CI: 0.81, 0.94). The meta-regression analysis showed that sample size was the most significant contributor to the model because it significantly influenced the estimate of the association for overall mortality.
This updated meta-analysis confirms, in a larger number of subjects and studies, the significant and consistent protection provided by adherence to the Mediterranean diet in relation to the occurrence of major chronic degenerative diseases.
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... Several specific dietary patterns have been described in the literature which have been demonstrated to be associated with a reduced risk of cardiometabolic disorders in the general population, including the Mediterranean diet (MD), Dietary Approaches to Stop Hypertension (DASH) and the Alternative Healthy Eating Index (AHEI) [34][35][36][37][38][39][40][41][42][43][44]. Diets which have a low Glycaemic Index (GI) have also been demonstrated to be beneficial in reducing the incidence of T2DM in the general population and improving blood glucose control [45][46][47]. ...
... Finally, no studies evaluated the association between dietary patterns and incident CVD. Women with a history of GDM are twice as likely to develop CVD as their normoglycaemic counterparts [4], and further research is required to evaluate whether specific dietary patterns can reduce this risk, as has been demonstrated in the general population [36,37,41]. If specific dietary patterns were identified which reliably reduced T2DM and CVD risk and/or improved modifiable cardiometabolic risk factors in women with a history of GDM, it would allow for a tailored approach to risk reduction interventions in this cohort, optimising primary prevention and reducing morbidity secondary to cardiometabolic disease. ...
Gestational diabetes mellitus is associated with a significantly increased risk of later type 2 diabetes (T2DM) and cardiovascular disease (CVD). Post-natal interventions aim to reduce this risk by addressing diet and lifestyle factors and frequently focus on restricting energy or macronutrient intake. With increased interest in the role of complete dietary patterns in the prevention of cardiometabolic disease, we sought to evaluate what is known about the role of dietary patterns in reducing cardiometabolic risk in women with previous GDM. A systematic search was conducted to identify studies relating to dietary pattern and cardiometabolic parameters in women with a history of GDM. The search criteria returned 6014 individual studies. In total, 71 full texts were reviewed, with 24 studies included in the final review. Eleven individual dietary patterns were identified, with the Alternative Health Eating Index (AHEI), Mediterranean diet (MD), and low glycaemic index (GI) as the most commonly featured dietary patterns. Relevant reported outcomes included incident T2DM and glucose tolerance parameters, as well as several cardiovascular risk factors. Dietary patterns which have previously been extensively demonstrated to reduce the risk of cardiovascular and metabolic disorders in the general population, including AHEI, MD, and DASH, were found to be associated with a reduction in the incidence of T2DM, hypertension, and additional risk factors for cardiometabolic disease in women with a history of GDM. Notable gaps in the literature were identified, including the relationship between dietary patterns and incident CVD, as well as the relationship between a low GI diet and the development of T2DM in this population.
... Among dietary patterns, the Mediterranean diet is the most widely investigated (Sofi et al., 2010;Trichopoulou et al., 2003;Hutchins-Wiese et al., 2021). It is characterized by a high intake of vegetables, legumes, fruits and nuts, cereals and olive oil, a low intake of saturated lipids, a moderately high intake of fish, a low-tomoderate intake of dairy products, a low intake of meat and poultry, and a regular but moderate intake of ethanol, primarily in the form of wine and generally during meals (Willett et al., 1995). ...
... Previous studies including some meta-analysis studies have investigated the associations of healthy dietary patterns with cardiovascular and all-cause mortality and reached consistent findings with ours. They indicated that the inverse relationships of healthy dietary patterns with cardiovascular and all-cause mortality were statistically significant in both general populations and other people (11,12,(17)(18)(19)(20)(21). For instance, according to a linear doseresponse meta-analysis, each 5-point increment in compliance with Dietary Approaches to Stop Hypertension (DASH) significantly reduced the all-cause mortality risk (assessed in 13 cohort studies, 9 publications, including 1,240,308 participants) and cardiovascular mortality (assessed in 12 cohorts, 9 publications, including 1,314,675 participants) for 5% (6-4%) and 4% (5-2%), respectively (20). ...
Background:
Studies regarding the impact of the Healthy Eating Index-2010 (HEI-2010) on the mortality of adults with hypertension are lacking.
Objectives:
This study aimed to prospectively explore the relationships between HEI-2010 and mortality from heart disease and all causes in adults with hypertension based on the National Health and Nutrition Examination Survey (NHANES), 2007-2014.
Methods:
This is a prospective cohort study including 6,690 adults with hypertension from NHANES (2007-2014). National Death Index data up to 31 December 2019 were used to determine the number of deaths due to heart disease and all other causes. We evaluated hazard ratios (HRs) and 95% confidence intervals (CIs) using the Cox proportional hazards model.
Results:
A total of 1,259 deaths from all causes, including 338 due to heart disease, were documented over an average follow-up duration of 8.4 years. In comparison with the lowest quartile of HEI-2010 scores, multivariable-adjusted HRs (95% CIs) for all-cause mortality were 0.82 (0.70, 0.97), 0.78 (0.64, 0.95), and 0.68 (0.54, 0.85) for the second, third, and fourth quartiles of the HEI-2010 scores (P-trend < 0.001) and for heart disease mortality were 0.60 (0.44, 0.81), 0.59 (0.40, 0.89), and 0.53 (0.35, 0.80) (P-trend = 0.010). Each increment in natural-log-transformed HEI-2010 scores was linked to a 43% reduction in the risk of all-cause mortality (P < 0.001) and a 55% reduction in the risk of heart disease mortality (P = 0.003). Among the 12 components of HEI-2010, adherence to a higher intake of greens and beans, vegetables, total protein foods, seafood and plant proteins, and unsaturated fatty acids, as well as moderate consumption of empty calories, were related to a 21-29% lower risk of all-cause mortality.
Conclusion:
In the current study, there was a statistically significant inverse relationship between HEI-2010 and mortality from heart disease and all causes among adults with hypertension. Based on the findings, it may help guide the dietary intake for adults with hypertension.
... The dietary recommendations are based on the Mediterranean diet(38) with minor modi cations based on the results of a recent scoping review which identi ed and collated all of the existing research on diet factors and anxiety (39). The Mediterranean diet has been studied extensively and shown to have a large range of health bene ts (40). In relation to mental health, a meta-analysis has demonstrated an association between reduced risk of depression and greater adherence to the Mediterranean diet (41) and this diet has served as the intervention in other clinical trials where diet was used in the treatment of depression (10,12,13), with positive outcomes. ...
Background
Anxiety disorders are prevalent and disabling conditions involving excessive worry and tension. Generalized anxiety disorder (GAD), the most common anxiety disorder, affects 5% of individuals from high-income countries and many individuals report that treatment options are not accessible, effective, or tolerable. Clinical evidence suggests that nutrition interventions, based on the Mediterranean diet and supplementation of omga-3 fatty acids, can significantly improve symptoms of depression; however, the effect of nutrition interventions on anxiety symptoms has not been studied in a clinical population. The primary objective of the present study is to assess the feasibility and acceptability of a dietary counselling and omega-3 fatty acid supplementation intervention delivered to adult women with GAD. The secondary objectives include assessing changes in anxiety symptom severity, assessing changes in quality of life, assessing changes in biomarkers and evaluation of the components of the program.
Methods
This study is a randomized, wait-list controlled pilot trial delivering a 12-week, dietary counseling intervention and omega-3 supplementation to 50 adult women with GAD. Participant will complete seven individual counselling sessions which include education, personalized recommendations, mindful eating techniques, motivational interviewing, and goal setting. They will be provided with recipes, instructional videos, and food items. The intervention is designed based on the Social Cognitive Theory and previous research that has been done by the author team to identify dietary constituents with the most evidence to support their use in the treatment of anxiety disorders. Questionnaires and blood work will be completed at baseline, after the wait period (for those in the waitlist group) and after the intervention.
Discussion
Results from this study will lay the foundation for future large-scale studies in this area and may provide preliminary evidence of the role of diet counselling and omega-3 supplementation in the management of GAD. Research on the role of nutrition in psychiatric care has been identified as a priority by a number of international organizations. The present trial directly addresses the call for the research that is most needed to advance the field. This protocol was registered at Clinicaltrials.gov on October 10, 2022; NCT05573672; https://clinicaltrials.gov/ct2/show/NCT05573672.
... In Italy, the highest adherence has been reported in the central regions, whereas people living in the north seem to have the lowest adherence [7]. The Mediterranean diet was shown to reduce cardiovascular risk [8] and to help prevent [9] or delay the progression [10] of chronic kidney disease (CKD). At present, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in CKD suggests the Mediterranean diet for adults with CKD stage 1-5 not on dialysis or post-transplantation to improve lipid profile [1]. ...
Patients on renal replacement therapy are typically subject to several dietary restrictions; however, this approach has been questioned in recent years, with some suggesting that the Mediterranean diet might be beneficial. Data on the adherence to this diet and factors that influence it are scarce. We conducted a web survey among individuals on renal replacement therapy (dialysis or kidney transplant, KT) using the MEDI-LITE questionnaire to assess adherence to the Mediterranean diet and dietary habits in this population. Adherence to the Mediterranean diet was generally low, and significantly lower among participants on dialysis versus KT recipients (19.4% vs. 44.7%, p < 0.001). Being on dialysis, adopting fluid restrictions, and having a basic level of education were predictors of low adherence to the Mediterranean diet. Consumption of foods typically included in the Mediterranean diet, including fruit, legumes, fish, and vegetables, was generally low, particularly among those on dialysis. There is a need for strategies to improve both the adherence to and the quality of the diet among individuals on renal replacement therapy. This should be a shared responsibility between registered dietitians, physicians, and the patient.
... Conceivably, the beneficial effects of high potassium intake may be part of the effects of a Mediterranean diet, typically featuring a large consumption of plant-based foods with a high potassium content. Indeed, a high adherence to the Mediterranean diet has been associated with a reduction of cardiovascular risk [36,37] and an improvement of endothelial function [38]. ...
(1) Background: Endothelial dysfunction is an early predictor of cardiovascular diseases. Although a large body of evidence shows an inverse association between potassium intake and cardiovascular risk, the studies on endothelial function provided contrasting results. Thus, we carried out a systematic review and a meta-analysis of the available intervention studies of the potassium supplementation on endothelial function. (2) Methods: A systematic search of the online databases available (up to December 2022) was conducted including the intervention trials that reported flow-mediated dilation (FMD) changes—a non-invasive method of assessing endothelial function—after two different potassium intake regimens. For each study, the mean difference (MD) and 95% confidence intervals were pooled using a random effect model. (3) Results: Five studies met the pre-defined inclusion criteria and provided eight cohorts with 332 participants. In the pooled analysis, potassium supplementation was associated with a significant increase in FMD (MD: 0.74%), with a higher effect for a urinary potassium excretion higher than 90 mmol/day. There was a moderate heterogeneity among studies (I2 = 59%), explained by the different amount of potassium supplementation. (4) Conclusions: The results of our meta-analysis indicate that dietary potassium supplement improves endothelial function. This effect is directly associated with the amount of potassium supplement. The findings support the campaigns in favour of an increase in dietary potassium intake to reduce cardiovascular risk.
PurposeThe purpose of this pilot study was to determine the impact a culinary medicine teaching activity had on interprofessional healthcare students’ knowledge, confidence, and intent to apply practical dietary principles in practice.Methods
Thirteen interprofessional students (n = 13) completed a 3-h, hands-on culinary medicine session focused on recipe conversion and nutritional coaching skills to modify a favorite comfort food into a significantly more nutritious, Mediterranean diet–based meal. Participants produced variations of a recipe to gain a deeper understanding of how diet modifications that consider both taste and nutritional value can treat health conditions. Pre- and post-session surveys were administered to evaluate participants’ knowledge and intent to apply culinary medicine principles into their respective healthcare practices.FindingsStudents reported an increase in the belief that nutritional counseling should be included in routine appointments, as well as increased confidence in their ability to implement culinary medicine into practice. All students reported the intent to integrate culinary medicine into practice, and a likelihood that they would recommend culinary medicine training to other healthcare professionals.Conclusion
Interprofessional students reported learning satisfaction throughout the hands-on, chef-led and faculty-facilitated culinary medicine teaching activity and found the nutritional content to be especially transferable to working with patients.
The field of nutrigenomics studies the interaction between nutrition and genetics, and how certain dietary patterns can impact gene expression and overall health. The Mediterranean diet (MedDiet), characterized by a high intake of fruits, vegetables, whole grains, and healthy fats, has been linked to better cardiovascular health (CVH) outcomes. This review summarizes the current state of research on the effects of nutrigenomics and MedDiet on cardiovascular health. Results suggest that MedDiet, through its impact on gene expression, can positively influence CVH markers such as blood pressure, lipid profile, and inflammation. However, more research is needed to fully understand the complex interactions between genetics, nutrition, and CVH, and to determine the optimal dietary patterns for individualized care. The aim of this scientific review is to evaluate the current evidence on the effects of nutrigenomics and MedDiet on cardiovascular health. The review summarizes the available studies that have investigated the relationship between nutrition, genetics, and cardiovascular health, and explores the mechanisms by which certain dietary patterns can impact CVH outcomes. The review focuses on the effects of MedDiet, a dietary pattern that is rich in whole foods and healthy fats, and its potential to positively influence CVH through its impact on gene expression. The review highlights the limitations of current research and the need for further studies to fully understand the complex interplay between nutrition, genetics, and cardiovascular health.
Dementia represents a clinical syndrome characterised by progressive decline in memory, language, visuospatial and executive function, personality, and behaviour, causing loss of abilities to perform instrumental or essential activities of daily living. The most common cause of dementia is Alzheimer’s disease (AD), which accounts for up to 80% of all dementia cases. Despite that extensive studies regarding the etiology and risk factors have been performed in recent decades, and how the current knowledge about AD pathophysiology significantly improved with the recent advances in science and technology, little is still known about its treatment options. In this controverted context, a nutritional approach could be a promising way to formulate improved AD management strategies and to further analyse possible treatment strategy options based on personalised diets, as Nutritional Psychiatry is currently gaining relevance in neuropsychiatric disease treatment. Based on the current knowledge of AD pathophysiology, as well as based on the repeatedly documented anti-inflammatory and antioxidant potential of different functional foods, we aimed to find, describe, and correlate several dietary compounds that could be useful in formulating a nutritional approach in AD management. We performed a screening for relevant studies on the main scientific databases using keywords such as “Alzheimer’s disease”, “dementia”, “treatment”, “medication”, “treatment alternatives”, “vitamin E”, “nutrition”, “selenium”, “Ginkgo biloba”, “antioxidants”, “medicinal plants”, and “traditional medicine” in combinations. Results: nutrients could be a key component in the physiologic and anatomic development of the brain. Several nutrients have been studied in the pursuit of the mechanism triggered by the pathology of AD: vitamin D, fatty acids, selenium, as well as neuroprotective plant extracts (i.e., Ginkgo biloba, Panax ginseng, Curcuma longa), suggesting that the nutritional patterns could modulate the cognitive status and provide neuroprotection. The multifactorial origin of AD development and progression could suggest that nutrition could greatly contribute to the complex pathological picture. The identification of adequate nutritional interventions and the not yet fully understood nutrient activity in AD could be the next steps in finding several innovative treatment options for neurodegenerative disorders.
Background The Mediterranean food pattern (MeDiet) has been suggested to have beneficial effects on cardiovascular risk factors. Scarcity of assessment of this effect on large samples of patients at high risk is, however, observed. Our objective was to estimate the association between adherence to MeDiet and the prevalence of risk factors in 3204 asymptomatic high-risk patients.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
Background:
The Mediterranean dietary pattern is believed to protect against cancer, although evidence from cohort studies that have examined particular cancer sites is limited.
Objective:
We aimed to explore the association between adherence to a relative Mediterranean diet (rMED) and incident gastric adenocarcinoma (GC) within the European Prospective Investigation into Cancer and Nutrition study.
Design:
The study included 485,044 subjects (144,577 men) aged 35-70 y from 10 European countries. At recruitment, dietary and lifestyle information was collected. An 18-unit rMED score, incorporating 9 key components of the Mediterranean diet, was used to estimate rMED adherence. The association between rMED and GC with respect to anatomic location (cardia and noncardia) and histologic types (diffuse and intestinal) was investigated. A calibration study in a subsample was used to control for dietary measurement error.
Results:
After a mean follow-up of 8.9 y, 449 validated incident GC cases were identified and used in the analysis. After stratification by center and age and adjustment for recognized cancer risk factors, high compared with low rMED adherence was associated with a significant reduction in GC risk (hazard ratio: 0.67; 95% CI: 0.47, 0.94). A 1-unit increase in the rMED score was associated with a decreased risk of GC of 5% (95% CI: 0.91, 0.99). There was no evidence of heterogeneity between different anatomic locations or histologic types. The calibrated results showed similar trends (overall hazard ratio for GC: 0.93; 95% CI: 0.89, 0.99).
Conclusion:
Greater adherence to an rMED is associated with a significant reduction in the risk of incident GC.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
No known cohort study has investigated whether the Mediterranean diet can reduce incident coronary heart disease (CHD) events in a Mediterranean population. This study examined the relation between Mediterranean diet adherence and risk of incident CHD events in the 5 Spanish centers of the European Prospective Investigation into Cancer and Nutrition. Analysis included 41,078 participants aged 29-69 years, recruited in 1992-1996 and followed up until December 2004 (mean follow-up:10.4 years). Confirmed incident fatal and nonfatal CHD events were analyzed according to Mediterranean diet adherence, measured by using an 18-unit relative Mediterranean diet score. A total of 609 participants (79% male) had a fatal or nonfatal confirmed acute myocardial infarction (n = 468) or unstable angina requiring revascularization (n = 141). After stratification by center and age and adjustment for recognized CHD risk factors, high compared with low relative Mediterranean diet score was associated with a significant reduction in CHD risk (hazard ratio = 0.60, 95% confidence interval: 0.47, 0.77). A 1-unit increase in relative Mediterranean diet score was associated with a 6% reduced risk of CHD (95% confidence interval: 0.91, 0.97), with similar risk reductions by sex. Mediterranean diet adherence was associated with a significantly reduced CHD risk in this Mediterranean country, supporting its role in primary prevention of CHD in healthy populations.
Higher adherence to a Mediterranean-type diet is linked to lower risk for mortality and chronic diseases, but its association with cognitive decline is unclear.
To investigate the association of a Mediterranean diet with change in cognitive performance and risk for dementia in elderly French persons.
Prospective cohort study of 1410 adults (> or = 65 years) from Bordeaux, France, included in the Three-City cohort in 2001-2002 and reexamined at least once over 5 years. Adherence to a Mediterranean diet (scored as 0 to 9) was computed from a food frequency questionnaire and 24-hour recall.
Cognitive performance was assessed on 4 neuropsychological tests: the Mini-Mental State Examination (MMSE), Isaacs Set Test (IST), Benton Visual Retention Test (BVRT), and Free and Cued Selective Reminding Test (FCSRT). Incident cases of dementia (n = 99) were validated by an independent expert committee of neurologists.
Adjusting for age, sex, education, marital status, energy intake, physical activity, depressive symptomatology, taking 5 medications/d or more, apolipoprotein E genotype, cardiovascular risk factors, and stroke, higher Mediterranean diet score was associated with fewer MMSE errors (beta = -0.006; 95% confidence interval [CI], -0.01 to -0.0003; P = .04 for 1 point of the Mediterranean diet score). Performance on the IST, BVRT, or FCSRT over time was not significantly associated with Mediterranean diet adherence. Greater adherence as a categorical variable (score 6-9) was not significantly associated with fewer MMSE errors and better FCSRT scores in the entire cohort, but among individuals who remained free from dementia over 5 years, the association for the highest compared with the lowest group was significant (adjusted for all factors, for MMSE: beta = -0.03; 95% CI, -0.05 to -0.001; P = .04; for FCSRT: beta = 0.21; 95% CI, 0.008 to 0.41; P =.04). Mediterranean diet adherence was not associated with the risk for incident dementia (fully adjusted model: hazard ratio, 1.12; 95% CI, 0.60 to 2.10; P = .72), although power to detect a difference was limited.
Higher adherence to a Mediterranean diet was associated with slower MMSE cognitive decline but not consistently with other cognitive tests. Higher adherence was not associated with risk for incident dementia.
The PREDIMED (Prevencion con Dieta Mediterránea, meaning Prevention with Mediterranean Diet) study is a large-scale, ongoing, multicenter, randomized, primary prevention trial in a high-risk population to assess the effects of three healthy diets (low-fat diet, Mediterranean diet rich in olive oil, and Mediterranean diet rich in tree nuts) on cardiovascular outcomes (http://www.unav.es/preventiva/predimed).17 In the pilot study, 772 asymptomatic persons aged 55 to 80 years with at least one of the two following eligibility criteria were included: 1) type 2 diabetes and 2) ≥3 major cardiovascular risk factors (current smoker, hypertension, LDL cholesterol ≥160 mg/dL, HDL cholesterol ≤40 mg/dL, BMI ≥ 25 kg/m2, or a family history of premature cardiovascular disease). Personalized dietary advice, which included recommendations on the desired frequency of intake of specific foods as well as advice to reduce the intake of all types of fat, was given to each participant during a 30-minute session, along with a leaflet that included American Heart Association recommendations. Those assigned to the two Mediterranean diet groups had a more intense behavioral and educational intervention. Depending on the group, participants allocated to the two Mediterranean-type diets were given either complimentary virgin olive oil or walnuts (15 g/day), hazelnuts (7.5 g/day), and almonds (7.5 g/day). A 1-hour group session at baseline was conducted specifically for each Mediterranean group, during which participants were provided with written materials. Body weight, blood pressure, lipid profile, glucose levels, and inflammatory molecules were evaluated at 3 months of follow-up.
The Mediterranean diet is considered a model for healthy eating. However, prospective evidence in Mediterranean countries evaluating the relationship between this dietary pattern and non-fatal cardiovascular events is scarce. The aim of the present study was to evaluate the association between the adherence to the Mediterranean diet and the incidence of fatal and non-fatal cardiovascular events among initially healthy middle-aged adults from the Mediterranean area.
We followed-up 13,609 participants (60 percent women, mean age: 38 years) initially free of cardiovascular disease (CVD) during 4.9 years. Participants were part of a prospective cohort study of university graduates from all regions of Spain. Baseline diet was assessed using a validated 136-item food-frequency questionnaire. A 9-point score was used to appraise adherence to the Mediterranean diet. Incident clinical events were confirmed by a review of medical records. We observed 100 incident cases of CVD. In multivariate analyses, participants with the highest adherence to the Mediterranean diet (score>6) exhibited a lower cardiovascular risk (hazard ratio=0.41, 95% confidence interval [CI]: 0.18-0.95) compared to those with the lowest score (<3). For each 2-point increment in the score, the adjusted hazard ratios were 0.80 (95% CI: 0.62-1.02) for total CVD and 0.74 (0.55-0.99) for coronary heart disease.
There is an inverse association between adherence to the Mediterranean diet and the incidence of fatal and non-fatal CVD in initially healthy middle-aged adults.