Angelos K. Sikalidis^1,*, Aleksandra S. Kristo¹

¹Department of Food Science and Nutrition, California Polytechnic State University, San Luis Obispo, CA 93407, USA

^*Correspondence: Dr. Angelos K. Sikalidis, California Polytechnic State University, San Luis Obispo, 1 Grand Avenue, CA 93407, USA.

 E-mail: asikalid@calpoly.edu 

  The Mediterranean Sea is a sea connected to the Atlantic Ocean through the straights of Gibraltar (historically know as: Pillars of Hercules) [1-3]. While the sea is nearly completely enclosed by land: on the north by Europe (Greece, Adriatic countries, Italy, France, Spain), on the south by North Africa, and on the east by Anatolia and the Levant, the sea is technically a part of the Atlantic Ocean, although it is usually identified as a separate body of water. From a geographical standpoint the Mediterranean is a geographical region populated since the early days of civilization on earth, around a closed sea in the “middle of the earth” surrounded by land of characteristic climate and soil conditions [1].

  Regarding the region’s climate, it is characterized by typically hot, dry summers and mild, rainy winters. As far as the soil is regarded; in the wet winters, there is leaching of clays and carbonates and the release of iron, which imparts a red color to the soil. Leaching is slight during the dry summers so there is often a build-up of a carbonate horizon in the soil. The climate and soil conditions of the Mediterranean are almost unique in the world since there are only very limited other areas in California, Australia and Chile with what would be termed “the Mediterranean or Mediterranean-like” climate. Such a climate gives rise to an interesting variety and excellent quality of crops. These crops include olives and grapes (being the most characteristic) as well as oranges, tangerines and cork, as well as a unique variety of herbs and spices. Ancient Greece was the cradle of the Mediterranean food tradition [4], while the basis of such tradition was characterized by the Mediterranean "eternal trinity" wheat - olive oil - wine, enriched by a culture of sharing and commensality [4]. 

  In the early days, according to ancient descriptions such as those of Homer, cereals, legumes, olives, olive oil and wine. In Homeric times, among the aristocratic heroes we read about, salted meat from cattle, sheep, and goats, and bread were staples. Which portion/part of the meat was served, corresponded with level of social status [1,3]. Like their south Mediterranean neighbors, the Egyptians, the Greeks favored the allium family, which includes onion, garlic, and leek. Other vegetables eaten included turnip, radish, lettuce, artichoke, cabbage, celery, cucumber, parsley, and thyme. Fruit included dates (imported), figs, and grapes. The wealthy could acquire walnuts and almonds from the East. Mushrooms and honey were available [1,3,5]. Fish was eaten fresh, dried, or pickled. Tomatoes and Potatoes came later in the region but were very quickly and massively adopted.

  In the Mediterranean, the diet is built around plant-based foods, such as vegetables, fruits, whole grains, nuts and seeds. These provide hearty doses of antioxidants, significant loads of fiber as well as vitamins and minerals. Increase healthy fats, especially olive, nuts, and fatty fish (such as salmon and sardines). These are all high in heart-healthy monounsaturated fat and are often used to replace saturated and trans fats found in fatty meats and cheese. There is also low intake of saturated fats, which are often present in red meat while moderate amounts of fish and poultry, and much less red meat is consumed. Dairy products are also moderately consumed. Moreover, spices and herbs are commonly used to flavor foods rather than salt. Whereas, moderate consumption of red wine with meals and desserts in the form of fresh fruit is habitually received [4-6].

  Interestingly, tomato, one of the staples of the Mediterranean diet (and its products) was not endemic to the region in the ancient times. However almost no-one can imagine the Mediterranean cuisine today without tomatoes. How are these two points reconciled? We need to think that from a dietary scheme perspective when we refer to the term “Mediterranean diet” in the literature, we mainly mean the dietary pattern of: South Italy and Greece (mainly Crete), at the time period: 1950’s - 60’s [6,7].

  Herbs and spices play a very important/central role in the Mediterranean diet concept. Basil originates from southern France and Italy and comes from the mint family. Oregano grows wild throughout the Mediterranean and is a cooking staple related to marjoram but has a significantly stronger flavor. Thyme originates in the Mediterranean, and has a herbal, minty flavor.Cilantro has been found in both Southern Europe and the Middle/Far East. Chives belong to the onion family but are milder and more delicate in flavor than onions. They are native to Europe, Asia and North America. Fennel originated by the shores of the Mediterranean. It has a sweet, mild licorice taste. Onions are extremely popular to Mediterranean cuisine, as it enhances other vegetables. Mint is used in eastern Mediterranean cooking, and peppermint and spearmint According to Greek mythology, the word mint comes from Minthe; a Greek nymph who was loved by Pluto and was changed into a plant Peppermint. Other popular herbs and spices include cinnamon, cloves, bay leaves, rosemary chervil and coriander. All the spices and herbs used, are excellent sources of phytochemicals and compounds in general that have been shown to yield important health benefits [1,6,8].

  Olives and olive oil are central in the Mediterranean culture and diet. The first olive tree sprung in the greater Mediterranean basin. Greece was the first to start cultivation of the Olive tree in 3500BC (Crete island). The olive tree became a central symbol in ancient Greece and olive oil was not only used for its valuable nutritional quality but also for medicinal and religious purposes. An olive tree branch wreath (kotinos - ΚΟΤΙΝΟΣ) was awarded to the Olympic game winner along with olive oil – 5 tons for the first place. Olive oil is rich in vitamins A, B-1, B-2, C, D, E, and K and iron. It is beneficial to the digestive system; acts as a mild laxative. Olive oil also benefits people with heart diseases; protects the stomach from ulcers; treats urinary tract infections and gall balder problems, slows down aging processes. Beauty oil-body’s cells incorporate the fatty acids from oil, making arteries more supple and skin more lustrous. Many herbs and spices can be added to olive oil to prevent oxidation and improve its flavor [1,3].

  Descriptions from Homer and many depictions on pottery and frescos show clearly that people in the Mediterranean from the ancient Greek times knew a series of foods and practices like fish and sea food, olives and olive oil, wine, various meats (like pork, goat, sheep and beef). Many storage facilities found on Crete and other places in southern Greece have proven that the ancients would store seeds and wheat, olive oil and wine and had methods for storage and preservation like salting and seasoning. An example of how much widespread the food culture is in the Mediterranean since the ancient times can be found in the Odyssey by Homer. Homer is very precise and much detailed in his descriptions regarding cooking and food preparation methods as well as the scene of the symposia. He makes extensive references to several types of foods. Given how extensively Ancient Greek King Odysseus has traveled throughout the Mediterranean it is expected that the food culture of the region has been intermixed extensively throughout the centuries [1].

  Homer again underlines another important element of the Mediterranean culture around the table which has to do with the community and social dimension of the table. For the people of the Mediterranean the activity of taking a meal is an important social activity. Problems are discussed, issues are resolved, jokes and fun are made, philosophy is being celebrated, stories are heard. People are brought together and bonded in a very unique way. In modern times there have been many recorded experiments from several archeology schools (such as University of Pennsylvania) on Crete and in the Mycenae where there was a simulation of the preparation ways, methods of cooking and recipes as preserved in the ancient texts and depictions. The results were rather interesting and definitely revealed that the ancients had a much-developed culture of cooking. Food Preparation and Cooking Methods included: Grilling, frying, grinding, and stewing as the most common ways of preparing meats in countries bordering the Mediterranean Basin. Seasoning, salting and fermentation also constitute popular preparation methods [1,3,4,6].

  According to the American Heritage Dictionary the terms “diet” derives from Middle English diete (from Old French) àfrom Latin diaeta (way of living /diet) àfrom Greek diaita, back-formation from ancient Greek diaitāsthai (διαιτάσθαι), to live one's life, middle voice of diaitān (διαιτάν), to treat. Hence diet means:  A way/view of life including but not limited to nutrition [9].

  Therefore one can approach the Mediterranean Diet as a way/view of life including but not limited to nutrition developed and adopted by people in a geographical region populated since the early days of civilization on earth, around a closed sea in the “middle of the earth” surrounded by land of characteristic climate and soil conditions. The Mediterranean style cuisine is not a diet to lose weight per se. It is a “way of eating and cooking” which is unique because it is not just very healthy but also arguably tasty. It is postulated as a rather healthy, fad-free way of eating. In this context, the Mediterranean diet was inscribed in 2013 on the Representative List of the Intangible Cultural Heritage of Humanity Countries: Greece, Italy, Spain, Morocco, Cyprus, Croatia, Portugal.  The Mediterranean diet involves a set of skills, knowledge, rituals, symbols and traditions concerning crops, harvesting, fishing, animal husbandry, conservation, processing, cooking, and particularly the sharing and consumption of food. Eating together is the foundation of the cultural identity and continuity of communities throughout the Mediterranean basin. It is a moment of social exchange and communication, an affirmation and renewal of family, group or community identity [10].

Mediterranean Diet and Health

  The Mediterranean region carries a rich history and food tradition dated in antiquity. As olive trees originated and thrive in the area olives and olive oil lie at the core of the food tradition. Other shared elements in the region are mostly plant products such as grains, nuts, beans and a wide variety of fruits and vegetables. Use of seafood, and animal products (meat, dairy, eggs) vary broadly. Mediterranean diet is not a single diet (i.e. way of eating) consumed by all the people in the Mediterranean region as diets vary between the countries bordering the Mediterranean Sea (approx. 20 countries), but also between regions within a country.

  Differences in agriculture production, economy, culture, ethnic background and religion result in diverse diets in these countries.  For example olive oil is the main cooking oil in Greece and Southern Italy, but not in France or Northern Italy where butter or lard are used for cooking, while olive oil is used mostly in salads.

  What we know today as Mediterranean Diet is a modern concept. It is a nutrition guide, aset of dietary recommendations inspired and based on traditional food patterns observed in the island of Crete and Southern Italy in the 50s and 60s. Something extraordinary was happening in these regions at that time. Despite all predictions, despite limited medical services, the rates of chronic disease among these populations were among the lowest in the world and adult life expectancy was among the highest. The American physiologist Ancel Keys identified the connection between what the people were eating and their low disease and mortality rate, with his Seven Country Study, thus bringing the health benefits of the Mediterranean Diet to the attention of the modern scientific community [7,11,12].

  Mediterranean diet became widely known to the public a few decades later after a conference in Cambridge, Massachusetts (USA) in 1993 where the classic Mediterranean Diet was introduced by Oldways, a nonprofit food and nutrition education organization, the Harvard School of Public Health, and the European Office of the World Health Organization. The modern recommendations of the diet were represented visually with a pyramid graphic [13]. The Mediterranean diet of the early 60s can be described by the following broad characteristics: an abundance of plat food (fruit, vegetable, breads, other forms of cereals, potatoes, beans, nuts and seeds); minimally processed, seasonally fresh and locally grown foods; fresh fruit as the typical daily dessert, with sweets containing concentrated sugars or honey consumed a few times per week; olive oil as the principal source of fat; dairy products (mainly cheese and yoghurt) consumed daily in low to moderate amounts; fish and poultry in low to moderate amounts; 0-4 eggs weekly; red meat in low mounts; and wine consumed in low to moderate amounts, normally with meals. This diet was low in saturated fat (less than 7-8%) and total fat ranges widely from less than 20 to more than 35 depending on the area. Work in the field or kitchen resulted in a lifestyle that included regular physical activity [11,12].

  The Mediterranean Diet pyramid recommends the types and the frequency of foods that should be consumed daily, weekly and monthly. Fruits, vegetables, grains (mostly whole), olive oil, beans, nuts, legumes, seeds, herbs and spices are the foods every meal should be based upon. Fish and seafood should be consumed often, at least twice a week. Poultry, eggs, cheese and yoghurt are consumed in moderate portions, daily to weekly. Meats and sweets are consumed less often. Τhe pyramid provides the sense of proportions across a variety of different foods and emphasizes food proportions and balancing energy intake from food with energy consumed through daily physical activity. The serving sizes, how much of each food should be consumed, need to be adjusted according to the individual needs.  Rather than a single food or nutrient emphasized, the diet is provided as a whole.It is not a restrictive diet where certain nutrients or foods are emphasized or omitted, hence nutrient deficiencies linked to long term restrictive diets can be prevented. The quality, rather than quantity of nutrients, is highlighted: unsaturated versus saturated fats, whole versus refined carbohydrate or sugar.Offers variety, taste, satiety and fullness making it easy to follow.The model promotes natural versus processed foods, which can maximize the health-promoting micronutrient and antioxidant content of these foods [6,8].

 MEDITERRANEAN DIET KEY RESEARCH STUDIES

  The Seven Countries Study, probably the most influential epidemiological study of our time, spurred a host of epidemiological and experimental nutrition research that continue to attest to the healthfulness of the Mediterranean diet. Mediterranean Diet is a topic of research at many universities worldwide, not just in the Mediterranean region. The scientific studies are using different variations and elements of the Med Diet. For historical reasons, I would like to go back in 1948, to study by researchers of Rockefeller Foundation, that was the first to examine the Mediterranean diet in the post-war island of Crete in Greece. In fact they were invited by the Greek Government at the time to help improve the poor living conditions. The researchers investigated thoroughly the eating habits of Cretans and they were surprised to discover that these habits were nutritionally sound, with minor exceptions in areas of low income and very limited food production by the families themselves. According to the report “olives, cereal grains, pulses, fruit, wild greens and herbs, together with limited quantities of goat meat and milk, game and fish consist the basic Cretan foods…no meal was complete without bread…Olives and olive oil contributed heavily to the energy intake…food seemed literally to be “swimming in oil”. The researchers concluded that "in general, nutrition and eating habits were very well adapted to the natural and economic resources of the area, as well as to the needs of the inhabitants." Therefore no improvement was needed as Cretan diet was surprisingly good and very conducive to heart health [14].

 Cardiovascular Disease studies

 The Seven Countries Study

In 1958 professor Ancel Keys, from University of Minnesota, launched 
theSeven Countries Study. For more than a decade Keys and his international team, studied the diet, lifestyle and incidence of coronary heart disease among nearly 13.000 randomly selected middle-aged men (40-55 years old) from seven countries: The United States, Japan, Italy, Greece, the Netherlands, Finland and what was then Yugoslavia. Data analysis revealed a clear dietary pattern. In the Mediterranean regions (Greece, and Southern Italy)—where vegetables, grains, fruits, beans and fish took center stage—heart disease was found to be rare. But in those countries where people filled their plates with red meat, cheese and other foods high in saturated fat—such as in the US and Finland—the rates of heart disease were found to be very high [14].

While Ancel Keys was convinced that diet played the primary role in the onset of coronary heart disease, he also realized that food may not be the only factor involved. Mediterranean peoples were physically active, family ties were strong, and the pace of life was relaxed. Taking these factors also into consideration, Keys concluded that although diet was the single most important factor, it was ultimately a combination of dietary and lifestyle factors that were responsible for the remarkably low rates of heart disease in the Mediterranean region, at the time he conducted his studies [14,15].

A surprising finding of the Seven Countries Study was that people of Crete consumed up to 40 percent of their calories from fat, yet they had the lowest rate of heart disease and the highest average life expectancy in the world (along with Japan). However, Professor Keys found that unlike the saturated fat from meat and dairy that was prevalent in American and Finnish diets, the majority of the fat in the Cretan diet came from olive oil and fish which are rich in unsaturated fats.

 The Lyon Diet Heart Study

The Lyon Diet Heart studywas another landmark study conducted on patients with known coronary artery disease [16]. The study diet was high in fat, 40% of calories from fat – from olive oil and special high monounsaturated spread, high in an omega-3 fatty acid. The Lyon Diet was also high in fruits, vegetables, whole grains, and emphasized legumes and fish.

The study found that the people following the Mediterranean-style diet had a 70 percent lower death rate compared to those following the low-fat diet. The results were spectacular and of unexpected magnitude. The protective effects of the diet began to occur within two months of observation. In fact, the results of the Lyon Diet Heart Study hadn't been seen in any other diet, drug or medical procedure [16]. Although the study was originally scheduled to last for five years, after only two years researchers were so astounded by the differences in the two groups that the study was abruptly ended for ethical reasons.

 The PREDIMED Study

This study recruited men (55 to 80 years of age) and women (60 to 80 years of age) with no cardiovascular disease at enrollment, but 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.  Participants were randomly assigned, to one of three dietary intervention groups: 1. Mediterranean diet supplemented with extra-virgin olive oil (approximately 1 liter per week); 2. 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); 3. Control low-fat diet. No total calorie restriction was advised, nor was physical activity promoted. The study found that among persons at high cardiovascular risk, a Mediterranean diet supplemented with extra-virgin olive oil or nuts reduced the incidence of major cardiovascular events [17].

 Weight Loss

According to a study by researchers at Harvard Medical School a Mediterranean-style diet can help you lose weight and maintain that loss. 61 overweight men and women were instructed to consume the same amounts of total calories, but in one of two different diets: a low-fat diet, or a Mediterranean-style diet with regular moderate consumption of healthy monounsaturated fat from olive oil, olives, nuts and nut products (such as nut oils and peanut butter). After 6 months both groups had lost roughly the same weight. However, at the end of the study, 12 months later, a large number of the Mediterranean diet group had continued to eat the diet and maintained their weight loss. On the other hand, many of those on the low-fat diet could not adhere to it and had not only regained their lost weight but weighed more than they did before the study began. The researchers concluded that: "Motivation and adherence are very hard to sustain in any weight loss programs, but the results from this study suggest that the tastier the food, the greater overall success of the diet plan" [18].

 Longevity

Several large prospective observational studies overwhelmingly confirm the benefits of adopting a Mediterranean diet on longevity. A six-year study found that people who live in Greece and consume a traditional Mediterranean-style diet have much lower mortality rates than Greeks who have adopted Western dietary practices. The researchers classified the traditional Greek diet into eight separate components including low consumption of red meat, high consumption of grains, high consumption of vegetables, moderate consumption of wine. Each component was assigned a "diet score”. The study found that for each traditional dietary component included in a person's diet, the risk of death dropped by 17 percent.

The study leader Dr. Dimitrios Trichopoulos from Harvard School of Public Health stated "Fruits and vegetables help prevent cancer and heart disease, and that modest amounts of wine are cardio-protective, now we know that the overall dietary pattern—rather than individual components—is important for health and longevity. Mediterranean diet is a diet you can easily introduce or use even in the American diet because it does not require sacrifice" [19].

A similar study in Melbourne, Australia by the same team of international researchers, showed similar results, indicating that a diet that adheres to the principles of the traditional Mediterranean diet is associated with longer survival among people of either Greek or Anglo-Celtic origin [20].

The HALE study, The Healthy Ageing: a Longitudinal study in Europe, observed healthy elderly men and women aged 70-90 and confirmed that following a Mediterranean diet and healthful lifestyle is associated with a more than 50% lower rate of all-causes and cause-specific mortality [21].

 Cancer

In a follow-up report of the Lyon Diet Heart the researchers also discovered that cancer rates among the Mediterranean group were 61 percent lower than those of the other group. In the Greek EPIC (European Prospective Investigation into Cancer and Nutrition) cohort with over 25,000 participants, a 12% reduction in cancer incidence was seen in those adhering to a traditional Mediterranean diet to a greater degree [22].

A review study analyzing previous studies on the Mediterranean diet published in the British Medical Journal showed that following strictly the Mediterranean diet reduced the risk of dying from cancer and cardiovascular disease by 9% and 6%, as well as the risk of developing Parkinson's and Alzheimer's disease by 13% [23].

 Metabolic Syndrome& Type 2 Diabetes Mellitus

A collection of 50 original research studies (35 clinical trials, 2 prospective and 13 cross-sectional), with over half a million participants, were included in another review and analysis that assessed the effect of a Mediterranean diet on metabolic syndrome (MS) as well as its components. Metabolic syndrome (MS), an important worldwide problem, is a cluster of abnormalities including abdominal obesity, raised fasting plasma glucose, high cholesterol, high triglycerides and high blood pressure, a state of low-grade chronic immune activation. It is major risk factor for cardiovascular disease and type 2 diabetes. According to this study following a Mediterranean dietary pattern is associated with lower MS prevalence and progression. Moreover, greater adherence to this traditional dietary pattern was associated with favorable effects on the MS components [24].

It is important to note that the Mediterranean dietary pattern in the included is not homogeneous; however, all the studies included had the basic characteristicsof this diet: high consumption of monounsaturated fatty acids, primarily from olives and olive oil, daily consumption of fruits, vegetables, whole grain cereals, weekly consumption of fish, poultry, tree nuts, and legumes; a relatively low consumption of red meat, approximately twice/month; as well as a moderate daily consumption of alcohol, normally with meals. In a prospective study of more than 13000 people, those with greater adherence to a traditional Mediterranean diet were 83% less likely to develop type 2 diabetes mellitus [25].

 COGNITIVE FUNCTION

High intake of monounsaturated fats, wine and grains were associated with less cognitive decline. Higher adherence to a Mediterranean diet was associated with 28% less risk of developing mild cognitive impairment in older Americans, and 40% less risk for developing Alzheimer’s. A meta-analysis comprising of 1.5 million subjects from 3 continents concluded that greater adherence to Mediterranean diet determines at 13% reductions in incidence of Parkinson’s and Alzheimer’s disease [26].

 COMPONENTS OF THE MEDITERRANEAN DIET

The antioxidant and anti-inflammatory effects of the MD as a whole as well as the effects of the individual components of the MD and specifically olive oil, fruits and vegetables, whole grains, and fish could explain, at least partially, the beneficial findings.

OLIVE OIL

High quantity – 77% – of monounsaturated fats (MUFA).

Less prone to oxidization – only one susceptible double bond.

High in antioxidants – tocopherol, hydroxytyrosol, and oleuropein.

High in sterols which help reduce LDL and increase HDL.

Can favorably affect gene expression related to atherosclerosis development.

May modify inflammatory cytokines production, decreasing severity of autoimmune disorders.

May also possess some NSAID-like activity, similar to aspirin.

Extra virgin (or “first-press”) olive oil has been shown to have more health benefits than refined olive oil.

FISH

High in omega-3 fatty acids, especially anti-inflammatory EPA and DHA, less

prone to conversion to pro-inflammatory cytokines.

Omega-3 fatty acids increase production of nitric oxide by 43% - promotes

arterial relaxation.

Regular consumption lowers risk of fatal Myocardial Infarction.

Very long chain omega-3 fatty acids (EPA, DHA) decrease risk of cardiac death by 30-45%.

Fish consumption of about 150 g per week was associated with 38% lower odds of developing Acute Coronary Syndrome as compared to no consumption.

2-year overall mortality was reduced by 29% in survivors of a first myocardial infarction who consumed omega-3 rich fish at least twice a week.

Of note, benefits of fish consumption exceed the potential risks of heavy metal exposure.

NUTS

High in polyunsaturated or monounsaturated fats, low in saturated fats, high in fiber.

Walnuts particularly high in omega-3 fatty acids – addition of walnuts to

Mediterranean Diet lowered LDL by another 6%.

In two large, independent cohorts of nurses (76,464 women) and other health professionals (42,498 men), the frequency of nut consumption was inversely associated with total and cause-specific mortality, independently of other predictors of death.

VEGETABLES AND FRUIT

In addition to vitamins, minerals and water, the considerable amount and variety of plant foods in the Mediterranean diet, contribute a large proportion of the overall intake of dietary fiber and bioactive compounds named phytonutrients.

Fiber is essential to bowel health, while help increase satiety of a meal and delay hunger.

The phytonutrients are usually color-rich substances synthesized by plants for protection in response to environmental stress, such as heat, drought, pests, acidic soils. When a variety of these phytonutrients (phenolics, flavonoids, anthocyanins) are consumed by humans, they offer protection against oxidative stress and inflammation, and thereby hold potential in preventing/delaying chronic degenerative diseases and associated abnormalities.

This is the reason behind recommendations for color-rich fruit and vegetable diet, as well as inclusion of a high variety of herbs and spices.

When fruit consumption is low, the cancer risk can double.

Tomatoes, central to Mediterranean cooking, are rich in the antioxidant, lycopene, associated with decreased cancer risk, especially prostate, lung, stomach.

Interestingly, when tomatoes are cooked in olive oil, serum lycopene almost doubles.

LEGUMES AND BEANS

Rich in protein, fiber, iron and B vitamins.

Increased legume consumption is associated with decreased coronary heart disease.

Regular consumption of chickpeas can help lower LDL cholesterol and decrease

fasting insulin.

HERBS AND SPICES

Herbs and spices grown in the mountainous and coastal regions in the Mediterranean area offer an abundance of phytochemicals. They can play essential roles as antioxidant and anti-inflammatory agents in our diet, improving insulin sensitivity, counteracting dyslipidemia and weight gain, and slowing down aging process.

Also, spices so ubiquitous in traditional Mediterranean cooking enhance the taste and freshness of olive oil with their high content of antioxidants.

WINE

Recommended daily intake is 2 glasses for men/1 for women (1 glass = 150 ml)

Wine is rich in phytochemicals (similar to fruits, olive oil) and provides antiatherogenic properties.

 Of note, several studies suggest that there is no one factor to pinpoint its health benefits on and truly the whole diet is better than the sum of component parts. Important characteristics of the Mediterranean diet as a whole are a low glycemic index due to the bulk of diet and a high satiating effect, which prevents overeating and the sense of being on a diet.

These results of the research on the health effect of the Mediterranean diet are of considerable public health importance, because this dietary pattern can be easily adopted by all population groups and various cultures, and cost-effectively serve for the primary and secondary prevention of, cardiovascular disease, metabolic syndrome and cancer. The incidence of non-communicable disease has drastically increased in recent years and is very unlikely to decrease, unless drastic measures are applied.

However, in spite of efforts to promote a healthy lifestyle and encourage a healthier diet and increase physical activity, dietary habits in the developed world and in some developing countries are changing toward the opposite direction. Even around the Mediterranean basin, consumption of fat, meat, eggs, dairy products, and sugar has increased, and consumption of cereals, legumes, vegetables, and seafood has decreased.

References

1. The Odyssey. Translated by Robert Fitzgerald. (New York, Everyman’s Library, 1992), Book IX.
2. Theogony, Works and Days, Testimonia (Cambridge, MA, Loeb Classical Library, 2006), p. 119.
3. Skiadas PK, Lascaratos JG. Dietetics in ancient Greek philosophy: Plato’s concepts of healthy dietEur J Clin Nutr. 2001;55(7):532-7.
4. Minelli P, Montinari MR.The Mediterranean Diet And Cardioprotection: Historical Overview And Current Research. Multidiscip Healthc. 2019 Sep 27;12:805-815. doi: 10.2147/JMDH.S219875.
5. Conti AA, Lippi D, Gensini GF. Obesity and nutritional behavior within a historical perspective. Minerva Gastroenterol Dietol. 2004;50(2):171-7.
6. Trichopoulou A.Mediterranean diet: the past and the present.Nutr Metab Cardiovasc Dis. 2001 Aug; 11(4 Suppl):1-4.
7. Aboul-Enein BH, Puddy WC, Bernstein J. Ancel Benjamin Keys (1904-2004): His early works and the legacy of the modern Mediterranean diet. J Med Biogr. 2017; 967772017727696.
8. Simopoulos AP. The Mediterranean diets: What is so special about the diet of Greece? The scientific evidence. J Nutr. 2001; 131(11 Suppl):3065S-73S.
9. The American Heritage Dictionary of the English Language; https://ahdictionary.com
10. UNESCO, Intangible Cultural Heritage; https://ich.unesco.org/en/RL/mediterranean-diet-00884.
11. Nestle M. Mediterranean diets: historical and research overview. Am J Clin Nutr. 1995 Jun;61(6 Suppl):1313S-1320S. doi: 10.1093/ajcn/61.6.1313S.
12. Menotti A, Puddu PE. How the Seven Countries Study contributed to the definition and development of the Mediterranean diet concept: a 50-year journey. Nutr Metab Cardiovasc Dis. 2015;25(3):245-52. doi: 10.1016/j.numecd.2014.12.001.
13. The Mediterranean Diet Pyramid; https://oldwayspt.org/resources/oldways-mediterranean-diet-pyramid
14. Ancel Keys (ed),Seven Countries: A multivariate analysis of death and coronary heart disease, 1980. Cambridge, Mass.: Harvard University Press. ISBN 0-674-80237-3.
15. Aboul-Enein BH, Puddy WC, Bernstein J. Ancel Benjamin Keys (1904-2004): His early works and the legacy of the modern Mediterranean diet. J Med Biogr. 2017 Jan 1:967772017727696. doi: 10.1177/0967772017727696.
16. de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterraneandiet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999 Feb 16;99(6):779-85.
17. Martínez-González MA, Salas-Salvadó J, Estruch R, Corella D, Fitó M, Ros E;PREDIMED Benefits of the Mediterranean Diet: Insights From the PREDIMED Study. Prog Cardiovasc Dis. 2015 Jul-Aug;58(1):50-60. doi: 10.1016/j.pcad.2015.04.003.
18. McManusK, Antinoro L, Sacks F.   A randomized controlled trial of a moderate-fat, low-energy diet compared with a low fat, low-energy diet for weight loss in overweight adults.Int J Obes Relat Metab Disord. 2001 Oct;25(10):1503-11.
19. Trichopoulos D. In defense of theMediterranean diet. Eur J Clin Nutr. 2002;56(9):928-9; author reply 930-1.
20. Kouris-Blazos A, Gnardellis C, Wahlqvist ML, Trichopoulos D, Lukito W, Trichopoulou A. Are the advantages of the Mediterranean diet transferable to other populations? A cohort study in Melbourne, Australia. Br J Nutr. 1999 Jul;82(1):57-61.
21. Knoops KT, de Groot LC, Kromhout D, Perrin AE, Moreiras-Varela O, Menotti A, van Staveren WA. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA. 2004;292(12):1433-9.
22. Bradbury KE, Appleby PN, Key TJ. Fruit, vegetable, and fiber intake in relation tocancer risk: findings from the European Prospective Investigation into Cancer and Nutrition (EPIC). Am J Clin Nutr. 2014 Jul;100 Suppl 1:394S-8S. doi: 10.3945/ajcn.113.071357.
23. Grosso G, Buscemi S, Galvano F, Mistretta A, Marventano S, La Vela V, Drago F, Gangi S, Basile F, Biondi A. Mediterranean diet and cancer: epidemiological evidence and mechanism of selected aspects. BMC Surgery 2013, 13:S14. doi:10.1186/1471-2482-13-S2-S14.
24. KastoriniCM, Milionis HJ, Esposito K, Giugliano D, Goudevenos 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 Mar 15;57(11):1299-313. doi: 10.1016/j.jacc.2010.09.073.
25. Martínez-González MA, de la Fuente-Arrillaga C, Nunez-Cordoba JM, Basterra-Gortari FJ, Beunza JJ, Vazquez Z, Benito S, Tortosa A, Bes-Rastrollo M. Adherenceto Mediterranean diet and risk of developing diabetes: prospective cohort study. BMJ. 2008;336(7657):1348-51. doi: 10.1136/bmj.39561.501007.BE.
26. Panza F, Solfrizzi V, Colacicco AM, D'Introno A, Capurso C, Torres F, Del Parigi A, Capurso S, Capurso A. Mediterranean diet and cognitive decline. Public Health Nutr. 2007; 7(7):959-963. doi:10.1079/PHN2004561.