The Mediterranean diet is constantly lauded in the nutrition world—in fact, U.S. News has named it the “best diet overall” for five years straight—but as a registered dietitian, I think it’s time to think about it a little differently: It’s time to dethrone the Mediterranean diet as being the very best way to eat.
Now, the Mediterranean diet—which emphasizes whole grains and plant foods such as fruits, vegetables, legumes, tree nuts, seeds, and olives, and limits red meat, sugar, and saturated fat—is not the only culturally based way of eating that’s been celebrated. The Japanese diet, rich in foods such as seafood, steamed rice, tofu, natto, seaweed, and pickled fruits and vegetables, has been promoted for its longevity-promoting aspects as well. But as scrolling through social media or even many news and health websites will show, it still doesn’t come close to the Mediterranean diet in terms of widespread recognition.
As an RD, I’ve noticed an overwhelming belief in our society that eating Mediterranean-style is just the way to go. So if your cultural foods don’t hail from one of the countries that make up that area, how does this make you feel?
Spoiler: Probably not so good—and that’s why I believe we need to rethink how we talk about cultural foods and ways of eating.
You know I’m a Mediterranean diet advocate. There are other healthy ways of eating. I’m an advocate of free speech and open debate. No censorship here! Read it and see what you think. I’m not sure what the “Japanese diet” is. I’ve written good things about the Okinawan diet as discussed in Dan Buettner’s Blue Zones books. Click for my review of Blue Zones.
Right off the bat, I don’t like that they studied both diabetics and prediabetics. There were only 40 original study participants, with complete data on only 33. Why lump the two together?
Participants followed each diet for 12 weeks then lab data and body weight were assessed.
The researchers conclusions:
HbA1c [a measure of blood sugar control] was not different between diet phases after 12-weeks, but improved from baseline on both diets, likely due to several shared dietary aspects. WFKD [ketogenic diet] was beneficial for greater decrease in triglycerides, but also had potential untoward risks from elevated LDL-C, and lower nutrient intakes from avoiding legumes, fruits, and whole intact grains, as well as being less sustainable.
Triglycerides dropped more on the keto diet, no surprise. Body weight dropped the same for both diets, 7-8%. HDL-cholesterol (the “good cholesterol”) rose 11% on keto and 7% on Mediterranean diet. HgbA1c dropped the same on both diets, about 8% from baseline. Both diets lead to eating ~300 calories less per day than baseline consumption.
The authors reported that LDL “dangerously” rose 10% on the keto diet. But was it really a dangerous change? Triglycerides went down on the keto diet, as we would expect. And as we saw in 2018 with the Virta Health trial, on average, LDL went up 10%. However, the calculated cardiac risk score went down 12%.
In terms of answering the headline question, Keto Versus Mediterranean Diet: Which Is Best for T2 Diabetics and Prediabetics?, the answer really depends on long-term data concerning longevity and various diseases. This study doesn’t answer the question.
Examining a variety of diet quality methodologies will inform best practice use of diet quality indices for assessing all-cause and CVD [cardiovascular disease] mortality.
To examine the association between three diet quality indices (Australian Dietary Guideline Index, DGI; Dietary Inflammatory Index, DII; Mediterranean-DASH Intervention for Neurodegenerative Delay, MIND) and risk of all-cause mortality, CVD mortality and non-fatal CVD events up to 19 years later.Design
Data on 10,009 adults (51.8 years; 52% female) from the Australian Diabetes, Obesity and Lifestyle study were used. A food frequency questionnaire was used to calculate DGI, DII and MIND at baseline. Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% CI of all-cause mortality, CVD mortality and non-fatal CVD events (stroke; myocardial infarction) according to 1 SD increase in diet quality, adjusted for age, sex, education, smoking, physical activity, energy intake, history of stroke or heart attack, and diabetes and hypertension status.Results
Deaths due to all-cause (n = 1,955) and CVD (n = 520), and non-fatal CVD events (n = 264) were identified during mean follow-ups of 17.7, 17.4 and 9.6 years, respectively. For all-cause mortality, HRs associated with higher DGI, DII and MIND were 0.94 (95% CI: 0.89, 0.99), 1.08 (95% CI: 1.02, 1.15) and 0.93 (95% CI: 0.89, 0.98), respectively. For CVD mortality, HRs associated with higher DGI, DII and MIND were 0.93 (95% CI: 0.85, 0.99), 1.10 (95% CI: 1.00, 1.24) and 0.90 (95% CI: 0.82, 0.98), respectively. There was limited evidence of associations between diet quality and non-fatal CVD events.Conclusions
Better quality diet predicted lower risk of all-cause and CVD mortality in Australian adults, while a more inflammatory diet predicted higher mortality risk. These findings highlight the applicability of following Australian dietary guidelines, a Mediterranean style diet and a low-inflammatory diet for the reduction of all-cause and CVD mortality risk.
“If you’re looking to improve your heart health, you may want to try eating a low-carb, high-fat Mediterranean diet. Why? Because a new study published in The American Journal of Clinical Nutrition found that eating a low-carb (no more than 20% of daily calories from carbs), the high fat-style Mediterranean diet may reduce the risk of cardiovascular disease (CVD).For the study, obese study participants reported both improved insulin resistance and cholesterol levels compared to those who ate a moderate carb (40%) or high carb (60%) diet over a five-month period.”
Most patients with a heart attack have underlying atherosclerosis (“hardening of the arteries”) in the heart, called coronary artery disease. Around the time of a heart attack (if not before), doctors and patients should focus on mitigating risk factors for future heart attacks and other cardiac events. This is called “secondary prevention.” Risk factor modification might include smoking cessation, regular exercise, stress reduction, and diet modification. For years, I’ve been recommending the Mediterranean diet. Many others recommend a low-fat diet instead. A recent study supports my diet recommendation.
One way to assess risk of progressive atherosclerosis is to measure the thickness of the the carotid artery wall by ultrasound. Increasing thickness of the artery wall is linked to higher risk of atherosclerotic complications like heart attack and stroke. To drill down deeper, it’s the thickness of the innermost two layers of the artery wall, called the intima-media, that matters. The study at hand showed a reduction in carotid artery intima-media thickness over five years on a Mediterranean diet compared to a low-fat diet. Here’s the abstract:
Background and Purpose:
Lifestyle and diet affect cardiovascular risk, although there is currently no consensus about the best dietary model for the secondary prevention of cardiovascular disease. The CORDIOPREV study (Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention) is an ongoing prospective, randomized, single-blind, controlled trial in 1002 coronary heart disease patients, whose primary objective is to compare the effect of 2 healthy dietary patterns (low-fat rich in complex carbohydrates versus Mediterranean diet rich in extra virgin olive oil) on the incidence of cardiovascular events. Here, we report the results of one secondary outcome of the CORDIOPREV study. Thus, to evaluate the efficacy of these diets in reducing cardiovascular disease risk. Intima-media thickness of both common carotid arteries (IMT-CC) was ultrasonically assessed bilaterally. IMT-CC is a validated surrogate for the status and future cardiovascular disease risk.
From the total participants, 939 completed IMT-CC evaluation at baseline and were randomized to follow a Mediterranean diet (35% fat, 22% monounsaturated fatty acids, <50% carbohydrates) or a low-fat diet (28% fat, 12% monounsaturated fatty acids, >55% carbohydrates) with IMT-CC measurements at 5 and 7 years. We also analyzed the carotid plaque number and height.
The Mediterranean diet decreased IMT-CC at 5 years (−0.027±0.008 mm; P<0.001), maintained at 7 years (−0.031±0.008 mm; P<0.001), compared to baseline. The low-fat diet did not modify IMT-CC. IMT-CC and carotid plaquemax height were higher decreased after the Mediterranean diet, compared to the low-fat diet, throughout follow-up. Baseline IMT-CC had the strongest association with the changes in IMT-CC after the dietary intervention.
Long-term consumption of a Mediterranean diet rich in extra virgin olive oil, if compared to a low-fat diet, was associated with decreased atherosclerosis progression, as shown by reduced IMT-CC and carotid plaque height. These findings reinforce the clinical benefits of the Mediterranean diet in the context of secondary cardiovascular prevention.
Parker here again. Undoubtedly, it would be more helpful if the investigators reported the actual rates of heart attack, stroke, and death in the two diet groups over five years. I suspect that will be in a future report.
An article in Clinical Cardiology states the serious nature of coronary artery disease (CAD) in those with diabetes (DM): “CAD is the main cause of death in both type 1 and type 2 DM, and DM is associated with a 2 to 4-fold increased mortality risk from heart disease. Over 70% of people >65 years of age with DM will die from some form of heart disease or stroke. Furthermore, in patients with DM there is an increased mortality after MI [myocardial infarction], and worse overall long-term prognosis with CAD.”
In the study at hand, frailty was measured by exhaustion, weakness, physical activity, walking speed, and weight loss. From the Journal of the American Medical Medical Directors Association way back in 2014:
Background and objective: Low intake of certain micronutrients and protein has been associated with higher risk of frailty. However, very few studies have assessed the effect of global dietary patterns on frailty. This study examined the association between adherence to the Mediterranean diet (MD) and the risk of frailty in older adults.
Design, setting, and participants: Prospective cohort study with 1815 community-dwelling individuals aged ≥60 years recruited in 2008-2010 in Spain.
Measurements: At baseline, the degree of MD [Mediterranean Diet] adherence was measured with the Mediterranean Diet Adherence Screener (MEDAS) score and the Mediterranean Diet Score, also known as the Trichopoulou index. In 2012, individuals were reassessed to detect incident frailty, defined as having at least 3 of the following criteria: exhaustion, muscle weakness, low physical activity, slow walking speed, and weight loss. The study associations were summarized with odds ratios (OR) and their 95% confidence interval (CI) obtained from logistic regression, with adjustment for the main confounders.
Results: Over a mean follow-up of 3.5 years, 137 persons with incident frailty were identified. Compared with individuals in the lowest tertile of the MEDAS score (lowest MD adherence), the OR (95% CI) of frailty was 0.85 (0.54-1.36) in those in the second tertile, and 0.65 (0.40-1.04; P for trend = .07) in the third tertile. Corresponding figures for the Mediterranean Diet Score were 0.59 (0.37-0.95) and 0.48 (0.30-0.77; P for trend = .002). Being in the highest tertile of MEDAS was associated with reduced risk of slow walking (OR 0.53; 95% CI 0.35-0.79) and of weight loss (OR 0.53; 95% CI 0.36-0.80). Lastly, the risk of frailty was inversely associated with consumption of fish (OR 0.66; 95% CI 0.45-0.97) and fruit (OR 0.59; 95% CI 0.39-0.91).
Conclusions: Among community-dwelling older adults, an increasing adherence to the MD was associated with decreasing risk of frailty.
Did you notice another good reason to eat fish?
I wonder why the research was published in the Journal of the American Medical Medical Directors Association?
The title above sums it up. If you’re eating pasta frequently and trying to lose weight, you do have to be careful not to over-eat. In other words, you generally have to restrict calories. In the study at hand, I don’t know how many daily calories were allowed since I haven’t read the full report. Here’s the abstract:
Background & aims
The effect of pasta consumption within a low-energy [read: calorie-restricted] Mediterranean diet on body weight regulation has been scarcely explored. This paper investigates the effect of two Mediterranean diets, which differed for lower or higher pasta intake, on body weight change in individuals with obesity.
Methods & Results
Forty-nine volunteers finished a quasi-experimental 6-month two–parallel group dietary intervention. Participants were assigned to a low-energy high pasta (HP) or to a low-energy low Pasta (LP) group on the basis of their pasta intake (HP ≥ 5 or LP ≤ 3 times/week). Anthropometrics, blood pressure and heart rate were measured every month. Weight maintenance was checked at month 12. Body composition (bioelectrical impedance analysis, BIA), food intake (24-h recall plus a 7-day carbohydrate record) and the perceived quality of life (36-item short-form health survey, SF-36) were assessed at baseline, 3 and 6 months. Blood samples were collected at baseline and month 6 to assess glucose and lipid metabolism. After 6-month intervention, body weight reduction was −10 ± 8% and −7 ± 4% in HP and LP diet, respectively, and it remained similar at month 12. Both dietary interventions improved anthropometric parameters, body composition, glucose and lipid metabolism, but no significant differences were observed between treatment groups. No differences were observed for blood pressure and heart rate between treatments and among times. HP diet significantly improved perception of quality of life for the physical component.
Independent of pasta consumption frequency, low-energy Mediterranean diets were successful in improving anthropometrics, physiological parameters and dietary habits after a 6-month weight-loss intervention.
“The person without the Spirit does not accept the things that come from the Spirit of God but considers them foolishness, and cannot understand them because they are discerned only through the Spirit.”