The Mediterranean Diet, Dietitian's Review

Shirley Valentine didn’t just boost her love life when she swapped her humdrum life in Liverpool for a holiday in Greece! Replacing egg and chips with a glass of wine and plate of traditional Greek food almost certainly gave her health a boost, too.

Many health experts around the world agree there’s something special about the Mediterranean way of eating that helps to keep us healthy, particularly when it comes to reducing the risk of heart disease.

This is good news considering that recent figures from the British Heart Foundation reveal that diseases of the heart and circulatory system – known as cardiovascular disease – are still the main causes of death in the UK, with 38 percent of people dying each year from this disease.

In contrast, the death rate from cardiovascular disease in most countries surrounding the Mediterranean Sea is much lower.

What’s most surprising though is that many people living in these countries have relatively high intakes of fat. In fact, as many as 40 percent of calories can come from fat in a typical Mediterranean-style diet – far more than the maximum of 33 percent of calories recommended by health experts in the UK. So just why is the Mediterranean diet considered to be so healthy?

What is the Mediterranean diet?

The Mediterranean diet isn’t actually a specific diet like the Atkins programme or the F-plan diet. It’s simply a collection of eating habits that are traditionally followed by people living in Mediterranean countries. At least 16 countries border the Mediterranean Sea including Spain, France, Italy, Greece, Turkey, Morocco, Tunisia, Libya, Israel and Egypt.

Naturally, the culture, religion and lifestyles of people living in these countries vary considerably. But, the eating habits of people living in these countries tend to have a number of common characteristics.

Mediterranean Diet Guidelines

Traditional Mediterranean diets tend to include lots of fresh, natural foods and few processed foods.

In general, people eat lots of fruit, vegetables, bread, pasta, rice, beans and nuts and use lots of olive oil in cooking and as a salad dressing. Fish tends to be eaten in good amounts and small amounts of red wine are often consumed with meals.

Furthermore, food tends to be flavoured with fresh herbs, garlic, black pepper and red wine – although salt is still often added to many dishes.

In contrast, intakes of red meat, eggs and full-fat dairy products are usually only eaten in small amounts.

It’s thought that when combined, all these factors help to keep the heart healthy and reduce the risk of cardiovascular disease.

Is there any proof that the Med diet is healthy?

Since the 1950’s, scientific research has shown that people who follow traditional Mediterranean diets have lower rates of heart disease.

In 1958, Professor Ancel Keys launched the Seven Countries Study and studied the diets, lifestyle and incidence of coronary heart disease of almost 13,000 middle-aged men for 10 years from seven different countries. His research discovered that heart disease was rare in Greece and Southern Italy, where good amounts of veg, fruit, olive oil, grains, beans and fish were eaten. In contrast, he discovered the incidence of heart disease was much higher in America and Finland where large amounts of foods rich in saturates were eaten.

Since then, many other studies have provided similar findings, particularly in healthy people, but also in those at risk of heart disease or following a heart attack.

Nevertheless, some health experts still believe caution is needed before recommending a Med-style diet that contains more fat.

The American Heart Association – which recommends that diets provide no more than 30 percent of calories from fat – believes further research is needed to confirm the heart benefits of a Mediterranean-style diet and to identify whether it’s the diet itself or other lifestyle factors such as being more active that account for fewer deaths from heart disease in Mediterranean countries.

Why is a Mediterranean diet thought to protect against heart disease?

Good intakes of olive oil and red wine are often cited as two of the main reasons why a traditional Mediterranean diet keeps the heart healthy. But most experts believe it’s more likely to be the whole package that reduces the risk of heart disease.

In general, Mediterranean meals are usually based on fresh, natural ingredients rather than processed foods, which mean they are more likely to contain plenty of vitamins and minerals. For example, pasta dishes are more likely to be served with a homemade tomato sauce rather than a jar of sauce, fresh fruit is more likely to be served as a desert than a ready-made chilled pudding and seafood stews are made from fresh fish, stock and vegetables.

Large amounts of vegetables – which are good sources of fibre, vitamins, antioxidants and phytochemicals – tend to be included in most savoury dishes like moussaka, spaghetti Bolognese, kebabs and risotto. Salad is also usually served as an integral part of a meal and is often eaten as a course on its own – and there’s always a basket of bread on the table at meal times.

Mediterranean Diet Foods

Here’s the lowdown on how the different foods typically eaten in a Mediterranean diet can help to keep the heart healthy:

Fruit and vegetables

Fresh fruits and veggies including aubergines, courgettes, avocado, tomatoes, peppers, onions, melons, oranges and peaches are an important part of the Mediterranean diet. This is good news as most fruit and veg are low in fat and high in fibre – both of which are important for a healthy heart and helping you to lose weight if necessary.

Fruit and veg are also good sources of antioxidant vitamins such as beta-carotene and vitamins C and E, which ‘mop up’ harmful free radicals – molecules that can cause oxidation of LDL or bad cholesterol, which potentially speeds up the process of the narrowing of arteries.

Furthermore, many fruit and veggies are good sources of naturally occurring plant chemicals such as flavonoids, which act as powerful antioxidants.

Tomatoes in particular have come under scrutiny because they feature so heavily in Mediterranean dishes. These are a good source of the antioxidant lycopene, which may be important for a healthy heart, as well as reducing the risk of some cancers.

Better still, cooking tomatoes helps the body to absorb lycopene more easily, with the result that tomato-based pasta dishes and pizzas are good choices.

For good health, it’s important to eat five servings of different fruit and veg every day.

Bread, rice, pasta and couscous

It’s unlikely the Atkins diet ever caught on in Mediterranean countries, as starchy foods tend to form the basis of most meals! Interestingly, recent research has shown that pasta is good for a weight loss diet.

Starchy foods have the benefit of being filling and contain good amounts of nutrients and naturally-occurring disease-fighting chemicals called phytochemicals, particularly if wholegrain varieties are chosen, such as wholewheat pasta, granary bread and brown rice. Unfortunately, when grains are refined, for example to make white flour or white rice, the outer bran and germ layers of the grain are stripped away – also removing the fibre, nutrients and phytochemicals, which are concentrated in these areas.

In particular, wholegrain starchy foods help to keep the heart healthy – research suggests that people who eat at least three servings of wholegrains each day are less likely to suffer from heart disease, and type 2 diabetes and certain types of cancer.

Other research suggests wholegrains may play a role in treating and preventing obesity because they are more filing than their refined counterparts. Indeed, a study of American nurses found that those who ate a diet high in fibre and wholegrains were least likely to be overweight.

Olive oil

Olive oil is used liberally in many Mediterranean dishes and is also poured onto salads, mixed with pasta and used with bread instead of butter. As a result, Mediterranean diets tend to be higher in monounsaturates and lower in saturates and trans fats than typical diets in the UK.

Eating fewer saturates and trans fats and boosting intakes of monounsaturates is particularly important when it comes to keeping the heart healthy. This is because saturates and trans fats increase levels of LDL or bad cholesterol – the type that can be chemically changed (a process called oxidation) and taken up by the cells in the artery walls, causing them to become narrower.

In contrast, monounsaturates lower LDL or ‘bad’ cholesterol but help to maintain levels of HDL or ‘good’ cholesterol, the type that carries excess cholesterol away from the arteries to the liver, where the body gets rid of it.

Fish

Fresh fish is usually in abundance in most Mediterranean countries due to the proximity to the sea – and there are usually plenty of varieties to choose from including white fish such as monkfish, octopus, squid and snapper, shellfish like crab, mussels, prawns, crayfish and lobster and oily fish like sardines, mackerel, anchovies and fresh tuna.

This is good news as all fish is packed with protein and contains plenty of vitamins and minerals. White fish and shellfish are also low in fat making them a great choice for slimmers.

But the true heart heroes from the ocean tend to be oily fish.

Despite recent reports to the contrary, most health experts still believe omega-3 fats, a type of polyunsaturated fat found in oily fish, have an important part to play in keeping the heart healthy. As well as reducing the stickiness of blood, making it less likely to clot, omega-3s help to keep the heart beating regularly and protect the small arteries, which carry blood to the heart, from damage. They also help to lower levels of another type of fat found in the blood called triglycerides, high levels of which are linked with heart disease.

For good health, the Food Standards Agency recommends we should eat at least two servings of fish each week, one of which should be an oily fish.

Nuts

Forget crisps, biscuits and chocolate. In Mediterranean countries, unsalted nuts are far more likely to be eaten as a snack. But that’s not all.

Nuts are often included in savoury dishes and deserts – think pine nuts in homemade pesto, walnuts in bread and pistachio ice cream! Like olive oil, nuts are a good source of monounsaturates. Plus they’re packed with fibre and protein and contain a range of vitamins and minerals. When it comes to heart health, several large-scale studies have shown that people who eat nuts are less likely to suffer with coronary artery disease.

Better still, research also shows that people who follow diets containing moderate amounts of nuts are more likely to maintain their weight after dieting than people who don’t eat nuts. This is thought to be because slimmers find it easier to stick to diets that contain moderate amounts of fat, rather than diets that drastically restrict fat.

Red wine

Binge drinking is far less common in Mediterranean countries than in the UK. Instead, most people drink small amounts of alcohol with meals.

As red wine is frequently consumed in the Med, much research has been carried out looking at the specific heart benefits of this alcoholic drink. In particular, red wine contains antioxidants called flavonoids, which may prevent the build-up of fatty deposits within the wall of the arteries.

However, while some research has suggested red wine is the most beneficial alcoholic tipple for heart health, this is still not conclusive. Indeed, it’s thought that small amounts of any alcohol – that’s no more than one or two units of alcohol a day – are associated with a lower risk of heart disease. Sadly though, these beneficial effects are only seen in men over the age of 40 and postmenopausal women! In particular, alcohol raises HDL or ‘good’ cholesterol and may reduce the stickiness of the blood.

In contrast, people who persistently exceed sensible drinking limits – that’s a maximum of three units a day for women and four units a day for men – are more likely to suffer from risk factors associated with heart disease such as high blood pressure. Binge drinking can also cause abnormal heart rhythms and regular heavy drinking may lead to an enlargement of the heart.

Alcohol contains calories but little else in the way of nutrients so drinking large amounts can lead to obesity, which in itself is a risk factor for heart disease!

As a result, most health experts agree that eating a healthy diet, stopping smoking and being more active are likely to have a far greater benefit to heart health than drinking small amounts of alcohol. And if you do drink, stick to the recommended maximum limits.

Garlic and herbs

Garlic and herbs are used in abundance in Mediterranean dishes and undoubtedly help food to taste fabulous.

In particular, it’s been suggested that adding garlic to food may help to keep the heart healthy. However, according to the British Heart Foundation, there’s currently not enough evidence to suggest that it can protect us from heart disease. Nevertheless, together with fresh herbs, garlic is a great way to flavour food without the need to add salt – and cutting down on salt can help to lower blood pressure, which is a risk factor for heart disease.

Dairy products

In general, full-fat dairy products like whole milk and cheese tend to be eaten in smaller amounts in Mediterranean countries, helping to keep intakes of saturates down, which in turn is associated with a reduced risk of heart disease.

Furthermore, traditional cheeses like feta or goats cheese tend to be lower in fat than traditional hard cheeses like Cheddar or Red Leicester. Nevertheless, they’re often just as high in salt, if not higher. For example, 100g of feta cheese contains 3.6g salt compared to 1.7g salt in 100g of Cheddar. Furthermore, yogurt tends to be eaten more frequently, for example, in the form of tzatziki, as a desert mixed with honey and fruit, or stirred into savoury dishes to add a creamy texture.

Red meat

Red meat tends to be eaten in smaller amounts in Mediterranean countries and this is thought to contribute to the lower rates of heart disease. Indeed, some studies have shown a slight increase in the risk of cardiovascular disease in meat eaters compared with those who don’t eat meat. However, just as many other studies have shown that eating lean red meat doesn’t increase cholesterol and may even reduce levels of ‘bad’ or LDL cholesterol, possibly because lean red meat contains monounsaturates, omega-3 fats, B vitamins and selenium, all of which help to keep the heart healthy. As a result, the British Nutrition Foundation says it’s fine to eat lean red meat as part of a diet for a healthy heart.

Are the health benefits simply due to diet?

Even as far back as the 1950’s, Professor Ancel Keys – one of the first scientists to link the Mediterranean diet with low rates of heart disease – recognised that lifestyle factors as well as diet probably play a role in keeping the heart healthy.

In Mediterranean regions, people tend to be more physically active – they walk rather than using a car and often have more physically demanding jobs. The pace of life is also often more leisurely and family ties are frequently strong with a greater emphasis put on families cooking and eating together and taking their time over meals – a far cry from microwaved ready meals eaten hurriedly on your own in front of the TV!

How does the Mediterranean diet differ to a typical UK diet?

In many respects, the diet doesn’t differ greatly from the healthy eating guidelines recommended by health experts in the UK, where the emphasis is on eating more fruit, vegetables and high-fibre, starchy foods and fewer processed foods and those rich in saturates and trans fats.

The main difference relates to the overall fat content of the diet. In general, people eating a traditional Mediterranean style diet get more of their calories from fat – often up to 40 percent. But they tend to eat less saturated fat. In fact, intakes of saturates are well within our dietary guidelines. Instead, more than half of the calories in a Mediterranean diet come from monounsaturated fats.

However, because the fat content of Mediterranean diets is higher, diets are also often higher in calories and this is thought to be contributing to the rapidly expanding rates of obesity in Mediterranean countries. In fact, statistics from the International Obesity Task Force reveal that there are more overweight and obese adults in Greece than there are in the UK, while Spain is following hotly on the heels of the UK, where 66 percent of men and 60 percent of women are either overweight or obese.

So will a Mediterranean diet help me lose weight?

Not necessarily!

Mediterranean dishes are often packed with calories due to the large amounts of oil used and may, in fact, be higher in calories than a standard UK diet. Dressing on salads, olive oil drizzled over food before serving, fried foods, pasta mixed with olive oil and oily pasta sauces soon tot up the calories. Plus all that bread served in addition to pasta or rice simply adds more calories. Red wine is also packed with calories – a small 150ml glass still contains 100 calories. Bottom line: if you want to follow a Med-style diet, you’ll still need to stick to your daily calorie allowance as recommended by Weight Loss Resources if you want to shift those pounds. And ultimately, that will probably mean going easy on the olive oil, bread and red wine!

Having said this, a small American study has shown that following a calorie-restricted Med-style diet may actually help you to keep the weight off once you’ve lost those pounds. In the study, 61 overweight adults followed either a standard low-fat diet or a Med-style diet – both containing the same number of calories. After six months, both groups had lost the same amount of weight but a big difference was seen in how well they kept the weight off. After a year, many of the people who followed the Med-style diet had stuck with the diet and maintained their weight loss, whereas those who followed the low-fat diet found it difficult to stick to and regained all those lost pounds, plus a few more!

Are there any negatives?

As well as being potentially high in calories, many Mediterranean dishes also contain a lot of salt and then more salt is often added at the table.

It’s easy to get into the habit of gradually drinking more and more red wine – before you know it, one small glass has become half a bottle every night and that’s a lot of calories – and more than the maximum amount recommended for good health.

Low intakes of dairy products may mean that calcium intakes are low and this can increase the risk of osteoporosis (weakened bones) in later life. Furthermore, research shows that the calcium in low-fat dairy products can aid weight loss, particularly fat around the midriff – so skipping dairy means you’re also potentially skipping a slimming benefit.

Similarly, low intakes of red meat and eggs can make it hard for women to meet their requirements for iron, a mineral that keeps the blood healthy and prevents a condition called anaemia. This is a worry as currently, a quarter of females aged 19 to 64 years in the UK have iron intakes below the minimum amount needed to stay healthy.

Dietitian’s verdict

The Mediterranean diet is as much about a way of life as it is about the food that’s eaten. This means food is seen as a pleasure rather than a pain – every part of the process from shopping for ingredients and preparing them to cooking delicious meals and enjoying them with your family is considered to be enjoyable.

It’s hard to find fault with a diet that promotes fresh, natural foods and more fruit, veg and filling, high-fibre foods. It’s also nice to see an eating plan that isn’t based on lots of unpleasant restrictions. This is good news as most people find it easier to stick to a more moderate eating plan.

I would suggest using the basic rules of a Med-style diet for everyday eating – for example, choosing foods rich in monounsaturates over saturates, eating more fruit and veg, basing meals on starchy foods, and eating more fish and beans and fewer processed foods. But you’ll still need to count those calories if you want to lose weight – and ultimately, that will mean watching portion sizes, not going mad with olive oil, enjoying small amounts of red wine and having either pasta or bread – but not both!

In the meantime, why not start to incorporate the Med way of life into your own daily routine? Okay, you might not be able to take a daily siesta, but you can start to get more creative in the kitchen, encourage the family to eat together around the table and now summer is here, even enjoy meals outside.