The Mediterranean Diet
What makes the Mediterranean diet so healthy? That question arises every time a new study reveals another health benefit associated with this eating pattern.
The answer: closely followed, the Mediterranean diet can potentially lower the risks of heart disease, coronary events, and death (even after a prior heart attack),1 as well as stroke, type 2 diabetes, and metabolic syndrome, a group of conditions that includes high blood pressure, insulin resistance or elevated blood sugar, increased fat around the midsection, and elevated blood lipids such as cholesterol and triglycerides.
Sticking to the Mediterranean diet has also been shown to reduce cognitive impairment, the decline in mental functioning considered a forerunner of dementia, and some types of depression. Research such as the 2011 European Prospective Investigation into Cancer and Nutrition study (a multicenter prospective study of more than half a million people followed for nearly nine years) has also shown that the Mediterranean diet was protective against certain cancers, notably stomach, colorectal, and breast cancers.
Not surprisingly, the Mediterranean diet has also been associated with greater longevity and, perhaps more importantly, living longer in a healthier state.
Origins of the Mediterranean Diet
The physiologist Ancel Keys is often cited as the first mainstream American researcher to shed light on the health benefits of the Mediterranean diet. His studies on starvation led to the development of the K-rations used for military nutrition. He began exploring the role of diet and other cultural differences on heart disease in the 1950s. Later that decade he launched the Seven Countries Study, first published in 1967, in which he characterized the heart disease risk among middle-aged men in Finland, Greece, Italy, Japan, the Netherlands, the then Yugoslavia, and the United States.
Despite dietary variations across the then 18 countries around the Mediterranean Sea and beyond, there were surprises among Keys’s findings:
- There were significantly higher rates of heart attack and heart disease among those population groups consuming greater amounts of animal protein and saturated fat.
- Populations consuming the Mediterranean diet—characterized by a high intake of grains, legumes, vegetables, fruits, and mostly unsaturated fats such as olive oil; moderate fish consumption; and a low intake of dairy and meat—had lower rates of heart disease and death from any cause.
Keys’s studies triggered research efforts worldwide that examined different eating patterns and foods to understand their metabolic significance, nutrient actions, and potential for disease prevention. For example, thousands of studies have examined the various antioxidants plentiful in the colorful fresh fruits and vegetables that constitute a significant part of healthy diets such as the Mediterranean diet and DASH (dietary approaches to stop hypertension) diets.
Research has shown that various diet-derived antioxidants have been linked to improved eye, brain, immune, and vascular health through a variety of actions, ranging from their anti-inflammatory effects to their infection-fighting properties. The Mediterranean diet emphasizes multiple servings of fruits and vegetables daily, including legumes and beans, thereby ensuring a continuous supply of these much-needed nutrients.
Recently, an observational study2 of more than 1,000 individuals in southern Italy with a history of heart disease showed that the Mediterranean diet outperformed statin medications, reducing the risk of dying by 37 percent among those who adhered to the diet most strictly compared with those who scored lowest for diet adherence. By comparison, statins reduce the risk of cardiac events by 24 percent on average.
While some researchers tout the specific health benefits of certain foods that are typically part of the Mediterranean diet, such as olive oil, most researchers agree that the diet’s benefits are greater than the sum of its parts. That is, eating a single food within the Mediterranean diet can’t be expected to confer the health benefits borne out by studies of adopting this eating pattern in general.
Foundational Foods of the Mediterranean Diet
The Mediterranean diet encompasses a wide range of foods and preparation techniques, but there are a few key ingredients that typically provide its foundation.
Olive oil, typically extravirgin, is the primary dietary fat in many types of Mediterranean cooking. It is considered beneficial for a variety of reasons. Cooking with this oil rich in monounsaturated fat replaces the use of butter and lard, both of which are high in animal-derived and pro-inflammatory saturated fats. Olive oil is also rich in oleic acid and polyphenols—plant-derived chemicals that have a range of anti-inflammatory and antioxidant properties that improve blood lipid profiles (lowering levels of LDL, or “bad” cholesterol, and improving blood vessel health to help lower blood pressure, for example).
The Mediterranean diet includes numerous daily servings of whole grains, which are typically rich in B vitamins and loaded with fiber, boosting antioxidant levels, reducing inflammation, and improving blood lipid profiles and blood pressure. Other benefits of regular whole-grain consumption include favorable effects on blood sugar and sugar-related metabolism. Whole grains also aid weight loss or maintenance by increasing satiety, or sense of fullness, and by inhibiting the absorption of fats and simple carbohydrates.
Pasta, a staple of an Italian-style Mediterranean diet, has been associated with greater satiety and weight maintenance, which reinforces another pattern of the diet: three regular meals (with lunch and dinner more sizable than breakfast) each day, with little snacking in between. Desserts, when consumed, are generally considered occasional treats and are usually offered in smaller portions than are typical of Western or industrialized diets.
The Mediterranean diet is generally marked by smaller portions of lean protein overall than a typical industrialized diet; fish is more frequent, and red meat appears less often. Fatty fish contain greater amounts of healthful omega-3 fatty acids (shown to exert beneficial effects mostly related to their anti-inflammatory, vessel-stabilizing, and lipid-lowering abilities), along with vitamins A, D, and B and minerals such as zinc, selenium, iron, and iodine. Fish is also generally lower in calories compared with its protein value, especially when prepared in the Mediterranean style: sautéed briefly in olive or canola oil or baked, grilled, or broiled with herbs and a squirt of lemon. The diet rarely features cream- or butter- based sauces and breading.
Many Mediterranean diets include small and regular servings of red wine, almost always consumed slowly and with food, typically at dinner. Moderate alcohol consumption has been associated with improved heart health, most likely due to its antiplatelet effects; modest elevation of HDL, or “good” cholesterol; and anti-inflammatory effects, notably on the inner lining of blood vessels. Various studies have shown lower rates of diabetes and fewer cardiac events such as heart attacks and even some types of stroke with moderate alcohol consumption.3,4 As with eating, the pattern of drinking (small amounts, slowly, with food, in a social milieu, and without bingeing) appears to significantly correlate with the beneficial effects associated with consumption.
Taking the Science to the Kitchen
Food preparation is generally characterized by basic techniques that are focused on preserving fresh and clean flavors—think blanching, quick sautés, baking, and grilling. The resulting dishes are fresh, vibrant, and packed with nutrients.
Salads are topped with a simple herbed olive oil and vinegar dressing. Vegetable dishes include minimally processed ingredients, exhibiting a range of bright red, yellow, purple, and green hues that denote the plants’ generous concentrations of anthocyanins, the pigment-derived plant chemicals so important to a wide range of protective and immune-enhancing biochemical activities. Fresh fruits, often accompanied by healthful fat-laden nuts, are typically consumed at the end of the Mediterranean meal in place of sugary, calorie-dense desserts. Water and wine are the beverages of choice, including an occasional antioxidant-packed espresso or cappuccino.
Diet Is One Part of the Bigger Picture
Notably, the individual dietary components of the Mediterranean diet appear to provide the most benefit when consumed as part of a bigger picture or pattern of behavior—a lifestyle that includes customs of shopping and food preparation, social engagement, regular physical activity, and moderate alcohol intake, usually in the form of red wine. The lifestyle also involves cultural significance, identity, sharing, and connection in the form of common traditions, family or social gatherings, sociability, and conviviality. In essence, the benefits of the Mediterranean diet appear to be closely linked to the lifestyle.
These life-enhancing, intangible anchors prompted the United Nations Educational, Scientific and Cultural Organization in late 2013 to include the Mediterranean diet as an Intangible Cultural Heritage of Humanity, recognizing the diet as encompassing far more than food. Through its customs, along with respect and cultivation of regional biodiversity, the diet also promotes all-important connectivity through nourishing and satisfying communal meals that foster engagement through a range of social customs and joy-infused celebrations. Salute, indeed.
Tips from the Italian Mediterranean
The Mamma Agata cooking and wine school on the Amalfi Coast in Italy specializes in teaching home cooks to make the most of Mediterranean ingredients. Here, Chiara Lima, who runs the school with her mother and husband, shares tips for cooking Mediterranean food infused with flavor and joy.
Less is more. For optimal flavor, use just a few fresh, seasonal ingredients; incorporating too many tastes and textures can diminish flavor.
Respect the season. Build your dishes around seasonal produce to ensure that the full flavor of the fruits and vegetables comes through.
Choose quality over quantity. If you do need to use tomatoes or other products out of season, for the best flavor seek the highest-quality produce, picked and processed at the height of the season. We grow our own tomatoes and harvest them at peak ripeness, when they are most sweet, canning them ourselves to use throughout the year.
Use this garlic guidance. The key to incorporating garlic in Mediterranean cooking is to infuse the flavor of the garlic into the extravirgin olive oil. To do this do not heat the olive oil and then drop the garlic in; that will burn the garlic and create a bitter flavor. Instead add whole cloves to the oil and then heat slowly at a low temperature, allowing the oil to be infused with the flavor of the garlic. And use either garlic or onion, but not both, because the two flavors will overlap and neither will come through.
Don’t skimp on the olive oil. Extravirgin olive oil is the staple of the Mediterranean diet. Choose high-quality oil (ideally one that is organic, harvested by hand, and cold pressed), and use it liberally.
Avoid black pepper. As Mediterranean cooks, we find that black pepper can camouflage the flavors of other ingredients, so we don’t use it in our dishes.
Find the right flour. We use “00” flour (sometimes called “doppio zero” flour) in all of our pasta, pizza, and baked goods. This flour is very finely ground durum wheat, and the texture and protein content create the lighter quality you might notice in authentic Italian products.
For more information about the Mamma Agata cooking and wine school, visit mammaagata.com.
- de Lorgeril M, Renaud S, Mamelle N, et al. Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease. Lancet 1994;343(8911):1454-59.
- Bonaccio M, Pounis G, Cerletti C, Donati MB, Iacoviello L, de Gaetano G. Mediterranean diet, dietary polyphenols and low-grade inflammation: Results from the MOLI-SANI study. British Journal of Clinical Pharmacology [early online publication]. March 3, 2016. doi: 10.1111/bcp.12924.
- Renaud S, Lanzmann-Petithory D, Gueguen R, Conard P. Alcohol and mortality from all causes. Biological Research 2004;37(2):183-87.
- Beulens, JW, van der Schouw YT, Bergmann MM, et al. Alcohol consumption and risk of type 2 diabetes in European men and women: Influence of beverage type and body size—the EPIC-InterAct study. Journal of Internal Medicine 2012;272(4):358-70.