Value of the Mediterranean diet

1. Value of the Mediterranean Diet
Johns Hopkins Preventive Cardiology Conference
Joonseok Kim, MD
Department of Internal Medicine
Michigan State University
03/04/2013
* No disclosures for this talk

3. Muller-Nordhorn, J. et al. An update on regional variation in cardiovascular mortality within Europe, European Heart Journal, (2007). 29, 1316–1326

4. What is the Mediterranean Diet?
• High consumption of fruits, vegetables, bread
and other cereals, potatoes, beans, nuts and
seeds
• Olive oil is an important monounsaturated fat
source
• Dairy products, fish and poultry are consumed in
low to moderate amounts, and little red meat is
consumed
• Eggs are consumed zero to four times a week
• Wine is consumed in low to moderate amounts
http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/Mediterranean-Diet_UCM_306004_Article.jsp#mainContent

5. USDA vs. Mediterranean Dietary
Recommendations
USDA=United States Department of Agriculture

6. Current AHA Diet Recommendations
• Consume a diet rich in vegetables and fruits
• Choose whole-grain, high-fiber foods
• Consume fish, especially oily fish, at least twice a week
• Limit intake of saturated fat to <7% of energy, trans fat to
<1% of energy, and cholesterol to <300 mg/day by choosing
lean meats and vegetable alternative
• Minimize intake of beverages and foods with added sugars
• Choose and prepare foods with little or no salt
• If you consume alcohol, do so in moderation
American Heart Association Nutrition Committee et al. (2006). Circulation, 114, 82–96
http://www.heart.org/HEARTORG/GettingHealthy/Diet-and-Lifestyle-Recommendations_UCM_305855_Article.jsp

7. Current AHA Diet Recommendations
• More than half the fat calories in a Mediterranean diet
come from monounsaturated fats (mainly from olive oil).
Monounsaturated fat doesn't raise blood cholesterol
levels the way saturated fat does.
• The incidence of heart disease in Mediterranean
countries is lower than in the United States. Death rates
are lower, too. But this may not be entirely due to the
diet.
• Before advising people to follow a Mediterranean diet,
we need more studies to find out whether the diet itself
or other lifestyle factors account for the lower deaths
from heart disease.
American Heart Association Nutrition Committee et al. (2006). Circulation, 114, 82–96
http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/Mediterranean-Diet_UCM_306004_Article.jsp#mainContent

8. Estruch, R. et al. (2013). N Engl J Med,

9. PREDIMED trial
• Parallel-group, multicenter, randomized trial
• Inclusion criteria
– Men (55 to 80 years of age) and women (60 to 80
years of age)
– With no cardiovascular disease at enrollment
– Who had either type 2 diabetes mellitus or at least
three of the following major risk factors
• smoking, hypertension, elevated LDL cholesterol levels,
low HDL cholesterol levels, overweight or obesity, or a
family history of premature coronary heart disease
Estruch, R. et al. (2013). N Engl J Med,

10. PREDIMED trial
• Participants were randomly assigned, in a 1:1:1 ratio, to
one of three dietary intervention groups:
• Mediterranean diet supplemented with extra-virgin olive
oil
– Received extra-virgin olive oil (approximately 1 liter per week)
• Mediterranean diet supplemented with nuts
– 30 g of mixed nuts per day (15 g of walnuts, 7.5 g of hazelnuts,
and 7.5 g of almonds)
• Control diet
– Received small nonfood gifts
• No total calorie restriction was advised, nor was physical
activity promoted
Estruch, R. et al. (2013). N Engl J Med,

11. PREDIMED trial
• Two Mediterranean diet groups
– Dietitians ran individual and group dietary-training sessions at the
baseline visit and quarterly thereafter
– In each session, a 14-item dietary screener was used to assess adherence
to the Mediterranean diet and personalized advice was provided
– Uinary hydroxytyrosol levels and plasma alpha-linolenic acid levels, were
measured in random subsamples of participants at 1, 3, and 5 years
• Control group
– Dietitians ran dietary-training sessions at the baseline
– 14-item dietary screener was used to assess adherence at the baseline
– Received a leaflet explaining the low- fat on a yearly basis
– After 3 years, they received personalized advice and were invited to group
sessions with the same frequency and intensity as those in the
Mediterranean-diet groups
Estruch, R. et al. (2013). N Engl J Med,

12. PREDIMED trial
• A total of 7447 persons were enrolled (age range, 55
to 80 years)
• End points
– Primary end point
• Composite of myocardial infarction, stroke, and death from
cardiovascular causes.
– Secondary end point
• Stroke, myocardial infarction, death from cardiovascular causes,
and death from any cause.
• A median follow-up of 4.8 years.
Estruch, R. et al. (2013). N Engl J Med,

13. Estruch, R. et al. (2013). N Engl J Med,

14. Estruch, R. et al. (2013). N Engl J Med,

15. Estruch, R. et al. (2013). N Engl J Med,

16. Estruch, R. et al. (2013). N Engl J Med,

17. Estruch, R. et al. (2013). N Engl J Med,

18. Estruch, R. et al. (2013). N Engl J Med,

19. Estruch, R. et al. (2013). N Engl J Med,

20. Conclusion
• Among persons at high cardiovascular risk, a
Mediterranean diet supplemented with extra-
virgin olive oil or nuts reduced the incidence
of major cardiovascular events

21. Weakness
• Failed to find significant results for the secondary
endpoints except for stroke
– There was no significant reduction in myocardial
infarction, death from cardiovascular causes, or death
from any cause.
• The generalizability of the findings is limited because
all the study participants lived in a Mediterranean
country
• Study dropouts were twice as common in the control
diet group as in the Mediterranean diet group (11.3%
vs 4.9%).
Estruch, R. et al. (2013). N Engl J Med,

22. Weakness
• The control group didn’t get a fair chance
– During the first 3 years of the trial, the control
group received a leaflet explaining the low fat diet
on a yearly basis

23. Weakness
• The control group did not follow a low-fat diet.
– In the “low-fat” group, total fat consumption
decreased insignificantly from 39% to 37% (Table S7,
appendix). This is much higher than the American
Heart Association guidelines of a low-fat diet (<30%
fat) or ours for reversing heart disease (<10% fat).
• The "low-fat" diet group patients were
discouraged from eating fatty fish that are rich in
omega‑3 fatty acids that are highly protective
from cardiovascular disease.
Dean Ornish, M.D. Does a Mediterranean Diet Really Beat Low-Fat for Heart Health?
http://www.huffingtonpost.com/dr-dean-ornish/mediterranean-diet_b_2755940.html?utm_hp_ref=yahoo&ir=Yahoo

24. Esposito, K. et al. (2004). JAMA, 292, 1440–1446

25. Esposito Mediterranean Diet Trial
Concept: Does the Mediterranean Diet
reduce features of metabolic syndrome? Changes from baseline to 2 years
Population: 180 patients with the NCEP
ATPIII metabolic syndrome
Intervention: Counseling to adhere to
Mediterranean Diet vs. standard “prudent” diet
(55-60% carbs, 15-20% protein, <30% fat)
Follow-up: Mean 2 years
Results: Mediterranean Diet reduced hsCRP,
fasting blood sugar and insulin, insulin
resistance, and metabolic syndrome (40 vs.
78 cases). Endothelial function improved.
Conclusion: The Mediterranean Diet improves
features of the metabolic syndrome, and causes
P <0.001 P =0.01
reversal of the overall condition.
Esposito, K. et al. (2004). JAMA, 292, 1440–1446

26. Mediterranean Diet, Traditional Risk Factors, and the Rate of Cardiovascular
Complications After Myocardial Infarction : Final Report of the Lyon Diet Heart Study
Michel de Lorgeril, Patricia Salen, Jean-Louis Martin, Isabelle Monjaud, Jacques Delaye and
Nicole Mamelle
Circulation. 1999;99:779-785
doi: 10.1161/01.CIR.99.6.779
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1999 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circ.ahajournals.org/content/99/6/779.citationde Lorgeril, M. et al. (1999). Circulation, 99, 779–785

27. Lyon Diet Heart Study
605 patients following a MI randomized to a Mediterranean* or Western** diet
100 for 4 years
Percent without Cardiac death
or myocardial infarction
90
Mediterranean diet
Western diet
80
P=0.0001
70
1 2 3 4 5
Year
A “Mediterranean” diet reduces CVD event rates
*High in polyunsaturated fat and fiber
**High in saturated fat and low in fiber
de Lorgeril, M. et al. (1999). Circulation, 99, 779–785

28. Howard, B.V. et al. (2006). JAMA, 295, 655–666

29. The Women’s Health Initiative Randomized
Controlled Dietary Modification Trial
48835 post-menopausal women randomized to a low-fat* diet or usual diet for
8.1 years
• A dietary intervention that
reduced total fat intake
and increased intakes of
vegetables, fruits, and
grains
• Low fat diet did not
significantly reduce the
risk of CHD, stroke, or CVD
in postmenopausal
women
* Less then 20% of energy intake
Howard, B.V. et al. (2006). JAMA, 295, 655–666

30. Ornish Diet
• Rich in fruits, vegetables,
whole grains, legumes, and
soy products in their natural,
unrefined forms.
• Low in total fat (<10 percent
fat), saturated fats, and trans
fats.
• High in omega‑3 fatty acids
(fish oil, flax oil, salmon).
• Low in refined carbohydrates
such as sugar, white flour
(bread, pasta), white rice, and
sugar-sweetened beverages.
• Low in processed and refined
foods.
http://www.huffingtonpost.com/dr-dean-ornish/mediterranean-diet_b_2755940.html?utm_hp_ref=yahoo&ir=Yahoo

31. Ornish, D. et al. (1998). JAMA, 280, 2001–2007

32. The Lifestyle Heart Trial
48 patients with moderate to severe CAD randomized to an intensive lifestyle
change* group or to a usual-care control group for 5 years.
20 (71%) of 28 patients made and
maintained comprehensive
lifestyle changes for 5 years
Intensive lifestyle with low fat
diet decreases coronary
atherosclerosis
* 10%-fat vegetarian diet
Exercise 3 hours/week
Stress management training 1 hour/day
Smoking cessation
Group psychosocial support
Ornish, D. et al. (1998). JAMA, 280, 2001–2007

33. Discussion
• Will the PREDIMED findings have a big effect
on practice?
• Should we recommend the Mediterranean
diet to patients?
• Should AHA change dietary recommendations
based on PREDIMED findings?

34. Will the PREDIMED findings have a
big effect on practice?
• I hope this trial will encourage physicians and the general
public to embrace the principles of the Mediterranean diet.
Prospective diet-intervention trials are naturally difficult to
perform in the real world because subjects cannot be blinded
to what they eat and confounding variables are common. In
the PREDIMED study, the interventions were simple, making
compliance practical and limiting the potential effect of
confounders.
– Arthur Agatston, M.D.

35. Should we recommend the
Mediterranean diet to patients?
• We should be recommending the Mediterranean diet
because of its record of efficacy and excellent compliance,
but I vary my particular approach across patient subgroups.
For patients with an atherogenic lipid profile (high
triglycerides, low HDL, small LDL particles, high insulin levels),
I am very aggressive about fairly strict diet recommendations
and consultation with a nutritionist.
– Arthur Agatston, M.D.

36. Discussion
• Will the PREDIMED findings have a big effect
on practice?
• Should we recommend the Mediterranean
diet to patients?
• Should AHA change dietary recommendations
based on PREDIMED findings?

37. References
1. Estruch, R. et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. N Engl J Med
(2013).doi:10.1056/NEJMoa1200303
2. de Lorgeril, M. et al. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications
after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 99, 779–785 (1999).
3. Esposito, K. et al. Effect of a mediterranean-style diet on endothelial dysfunction and markers of vascular
inflammation in the metabolic syndrome: a randomized trial. JAMA 292, 1440–1446 (2004).
4. Howard, B. V. et al. Low-Fat Dietary Pattern and Risk of Cardiovascular DiseaseThe Women's Health Initiative
Randomized Controlled Dietary Modification Trial. JAMA 295, 655–666 (2006).
5. Fuentes, F. et al. Mediterranean and Low-Fat Diets Improve Endothelial Function in Hypercholesterolemic Men.
Ann. Intern. Med. 134, 1115–1119 (2001).
6. Fitó, M. et al. Effect of a traditional Mediterranean diet on lipoprotein oxidation: a randomized controlled trial.
Arch Intern Med 167, 1195–1203 (2007). 1. Couto, E. et al. Mediterranean dietary pattern and cancer risk in
the EPIC cohort. Br. J. Cancer 104, 1493–1499 (2011).
7. MSc, C.-M. K. et al. Adherence to the Mediterranean diet in relation to acute coronary syndrome or stroke
nonfatal events: A comparative analysis of a case/case-control study. American Heart Journal 162, 717–724
(2011).
8. Trichopoulou, A., Bamia, C. & Trichopoulos, D. Anatomy of health effects of Mediterranean diet: Greek EPIC
prospective cohort study. BMJ: British Medical Journal 338, (2009).
9. American Heart Association Nutrition Committee et al. Diet and lifestyle recommendations revision 2006: a
scientific statement from the American Heart Association Nutrition Committee. Circulation 114, 82–96 (2006).
10. Sofi, F., Abbate, R., Gensini, G. F. & Casini, A. Accruing evidence on benefits of adherence to the Mediterranean
diet on health: an updated systematic review and meta-analysis1. American Journal of Clinical Nutrition 92,
1189–1196 (2010).
11. Bendinelli, B. et al. Fruit, vegetables, and olive oil and risk of coronary heart disease in Italian women: the
EPICOR Study. The American journal of clinical nutrition 93, 275–283 (2011).