The Mediterranean Way of Eating

Front matter

Evidence for Chronic Disease Prevention and Weight Management

John J.B. Anderson and Marilyn C. Sparling

CRC inp)

Chapter 1 What Is a Mediterranean Diet? Common Components in

Diverse Dietary Patterns Promote Health and Long Life... 3 Introduction isai na neni K Ea E A R R E 3 Mediterranean Foods and Their Components Contribute to Healthy Diets successes ne aarne are A SS EE EE N E EEK 7 Life Expectancy across the Millennia... eee eeeeeesseeeeeeees 9 UMM ALY osise sesdtetesescese stayed saseslasnstasdscaadaasesussebasescebessibesdass 10 Introduction es. iiine nania a i aiins 13 Western: Region. icsse naa a a A etn 16 Adriatic Region ees narninireneeenae aeaea E eni 19 Eastern: Rêgioi sinih issidein oeae sien aiae nasie 19 Adverse Effects of Fast Foods... cccecesesseeseeeseeseceseeseeeseessenseeatenes 27 SUMMATY neaiski E a E 27 Chapter 3 Critical Nutrients in Foods of Mediterranean Nations... 29 Introduction snina a E a s 29 vii viii

Chapter 4

Contents Energy from Macronutrients ...0...0... ccc eeceeseeseceeeeceeseeeeeeaseneeeaeenes 30 Types of Macronutrients 0... eee eee eeeeseeseceseeseeeseceeseaseneeeaeeaes 31 Carbohydrates suc2s2.s2sssecs iessecceatigoas eteeseceeseapseescaseegcadastesteceeeesd 31 Fats sveitiievec decent sectdleahc hee hel hteee ave eee aS ae 32 Proteins eeren r TA EER E T A O S 33 AIC ONG Mge a E AE 33 Essential Amino Acids «0.00... cesceeeseeesceeenecesceeececeseeeeeeceaeeeeeeesaee 34 Nonessential Amino Acids 20.0... eeeeesceeeseceseeeececeeeeeeeceaeeeeneeeaee 34 Saturated Patty ACidSs. s.c.5..s5.204 incase eneren ein E IESE 35 Monounsaturated Fatty Acids... cee eeeeseeseeseceeceseeneeeaeenes 35 Polyunsaturated Fatty Acids oo... elec eeeeseeseeeeceeeeeeseeeaeenes 36 Metabolic Conversions of PFAs and the Ratio of Omega-6s tO: OMe Pa-3S IID ICE soos sins vedere eera Uedeevs ducer E R reteset 37 Oxidative Stress of Dietary Fats... eee eseeseeseeeseeeeeeseeees 38 Cholesterol: A Nonessential Nutrient But a Critical Molecule IN; LIPOPLOlSINS:2..s2asesse hes vee cs Ses ves ads ese hese eats 39 Micronutrients’. niea pi a coibetacunndcaatiies deena nied sat A E 39 Water-Soluble Vitamins... cecceesecesesseeceseeeeeeceeeeeeeceaeeesneeeaeeee 39 Macromimeral Sires neket arctan kite oh deka 41 Microminerals nnen enni r a i Ee E E RE EREKE 42 Water eeren teres e eN EEE A E E E AEE E E 42 Diétáry Fiber oire cas aee aaa N eves dese AA AE E EEA ET OEA LEi 42 Antioxidant Molecules: A Few Vitamins and Many PhytochemicalSiienrai nnan n R desea tocieas 43 SUMMAFY irronneen 45 IntrodýCti OM wisi iii aa eaea casi EE aE E EEEE IEE TREE 47 Diabetes: Mellitüs sic csspceacectsceul eehesesshaedeesbewaved vangecs AR T RNE 50 Relationships among Obesity, Insulin Resistance, Inflammation, and Type 2:1abetes i.e. stiecnests E E oasis tee A R AE 52 Effective Dietary Patterns for Losing Weight and Reducing Risk of Ty pe:2 Diabetes omis e ee ar eT EEA E R E aai 53 Magnesium eioen eap open ede erkeni aa EA E R E 54 Dietary Fiber osiin nna an R A R 54 Glycemic ndek ocer esate tn ede Mie N 55 SUMMAT Y aar o os duds E a E SVERTE E E ETETEA EL E TETERE 58

Chapter 5

Chapter 6

TMtrOUU Ct OM teieni donan des tian de ei AE i A E 59 Major Diet-Related Risk Factors for Heart and Other Cardiovascular Diseases inson ensen a an aE EEr KEE 62 Preventive Measures for Cardiovascular Diseases and Metabolic Syndrome san eeu heli E E a waa Miia 64 Intact versus Isolated Dietary Fiber... eee eeeeseeeeceeeseeeeeeees 65 SUMITALY 55st deat: joven testbes a vkcevid Wecssveread wa E E E 67 Introducti ON e eaa aE EE aii panini 69 DiëétReláted:Çaåcer Seninem rs ea et ae o R E n N a 69 Excessive Energy, Fat, and Diet-Related Cancers... eee 71 Insufficient Intakes of Micronutrients and Antioxidants and Diet-Related' Cancers: m E E E E EET 72 Phytochemicals and Diet-Related Cancer... ee eeeeeeeeseeeee 76 Arterial Calcification eer i e e EEES 79 Chronic Kidney Disease... cece eeceseeseeseeeseeseeeseeseeessenseeatenes 79 Immune Defense en ee e E E RE EA E EAA 81 Decline in Bone Mass and Osteoporosis... eeeeseeeeseeeeeeeeee 81 Summary fois vececsen Hoes te a ee sate ns ails ths Fh svenene vss E EE E EN 81

SECTION II Protective Health Effects of the Chapter 7

Mediterranean-Style Dietary Pattern

Introduction to the Health Benefits of Mediterranean-Style

Dietary Patterns is. 2.02 ek ieee Retin dR Rae i eee 85 Introduction ienne a abo ce eceleduesies Moke Ta 85 Balanced Caloric Intakes. s.c:tsiss. essapessceessetsssssestsesssaosaseeeadessacotvsesseis 85 Consumption of Nutrients in Appropriate Amounts... eee 86

Chapter 8

Chapter 9

Chapter 10

Chapter 11

High Consumption of Monounsaturated Fat and Low

Consumption of Saturated Fat... ce eeeeesceeeseceeeceneeeeeeeeeeeseeeeseeee 89 TithO dictions. a Uist teases odeatank Biss ates aati eee eek 89 Fatty Acid Types in Fats and Oils 0.0... eeceeseceeereeeseeeeneeeseenes 89 OAO T EE E A nies al eet ana Ae inion 91 Bottom DT a A sees is E A A E E AET 95 Introduction 52: sfis EEE E Se eee hoa aed aeins shes oe oe 97 Te GUMS, enoia a a E E E ede ER E 100 Applying the Evidence on Fruits, Vegetables, and Legumes to Dark-Green Leafy Vegetables «00.0... cece eseeseceeceeeeeeeeeeees 103 Salad Dressings ninine os a E E a EA 104 Potatoes aaa a hes eee eter Rees 104 Sweet POtatOes adiecs 3. he T Goto aver ees 105 Cooking TIPS.: iisi esoterika iranere ieaiaia aea Seerias 105 OTS AN AE E eds Bein Hee EE EE ES 106 Convenience niaan a a ee ees 107 Pesticides semo a a e e eels ae BE BER 107 Bottom: Lane AEE T A AEREE 107 Jiale hi reln T1 t EEEE EEEE EERE E E a ETE 109 Applying the Evidence on Whole Grains to Reduce Risk of Obesity and Type 2 Diabetes... iriiri ipsis 111 Applying the Evidence on Whole Grains to Reduce Risk of Understanding Identification, Processing, and Labeling of Grains.... 114 The Milling Process + ::s::3scei wcsesedstessas sthesseetcandees eva caeviaawadecenvey 116 SODIUM. secs a a a tere eee ea 117 Bottom Lamers zesicc. i505 A E ET AA NA 119 Moderate Consumption of Nuts and Seeds... eee eeeeeeeeees 121 TrtrOGuctiOn nnne ea E e e e ale veoebcanedsssduaendoes 121 Applying the Evidence on Nuts and Seeds to Reduce Risk of Chromic: Disedses isni ie e a E a AT 122 Peanuts masaren n ra a a NEE 124

Chapter 12

Chapter 13

Chapter 14 xi

ECOG E 126 Hypotheses for the Beneficial Effects of Nuts and Seeds in

Reéditicing CVD) RISK scorie a RERE 126 Recommended Number of Servings and Serving Sizes for Nuts

and See dS a a a a Mac A E E EAE EAE 127 Bottom Eine sene eaa E E E detec ee 127 Moderate Consumption of Fish and Seafood... eee 129 Introduction iaae Seas Sieh tte ei alee 129 Applying the Evidence on Fish to Reduce Risk of Chronic

Diseases iien a n E deessprenaa chanted ies 130 Contaminants in Fish 0... eee na i a a A RN i 132 Sustainability and the Environmental Impact of Consuming Fish ... 132 Cooking Fish sscan ocna p sdeexsetecsasebundedbcosategeauiass 133 Fish Oil from Food and Supplements... eee eeeeeeeeseeeeeeseeeees 133 Recommended Servings and Serving Sizes of Fish and Seafood.... 135 Bottom: line: siete: Sy cicdacee eet en Aged nie iced 135

Low Consumption of Meats and Low-to-Moderate

Consumption of Poultry and Eggs oo... eee ee eeeeseeeeeeeeeeeeseeeees 137 Introductions: i522 na tis tea E r EE EER igeed 137 Applying the Evidence on Meats to Reduce Risk of Chronic

Disease Super ee e aaen A ea ea aE EEE OEE O T AA 138 Applying the Evidence on Poultry and Eggs to Reduce Risk of Chronic: Diseases nero rere n e r dees damages Saves ieee 142 Recommendations for Number of Servings and Serving Sizes of Meat, Poultry, and Eggs oo... eee eesecseeeeecseceseeseeeseceecesesseeeaeesaes 145 Bottoni me? sno o oee Fenda e a a a cases svedead copenved E 145

Low Consumption of Milk and Moderate Consumption of

Checseand Yount onnan re e a cones eeeetesseateid 147 Tntrodücto Ninenin e a E ER ER 147 Applying the Evidence on Dairy Products to Reduce Risk of

Obesity and Type 2 Diabetes... eee eeecseceeeseeeseeseeeseeneees 148 Applying the Evidence on Dairy Products to Reduce Risk of Recommendations on Number of Servings and Serving Sizes of Dairy: Products issen taeren iee EN EA R S 150 xii Contents Chapter 15 Moderate Consumption of AICOMOL] 00.0... eeeeeeeeeeceeeeeeeeeeeeeeeeaees 153 IntrodüctióN s -2i..fccsscossescsdessseess coccacstiscsdisestajessesedbacasasesucadeseasasesees ce 153 Applying the Evidence on Alcohol to Reduce Risk of Type 2 Diabetes sesiecssocts ssa. ieeutiasdeasvecassas dies seeveas vay daguagseehees cast oecuceesSesaxteteavaas 154 Applying the Evidence on Alcohol to Reduce Risk of Potential Advantages of Red Wine Consumption Compared to Other Types of Alcohols ssiccsscsssscestessce. cetapessdeaseeechsdvesuads n 156 Bottom: Limes si. 53, fesse pices wees Gite ended adie ieee 157 Chapter 16 High Consumption of Herbs, Spices, and Garlic... eee eee 159 Mitr OMU CHO iseina esin ois ian ias iai a an cassette 159 Additional Information on Selected Herbs and Spices with Bottom, Linenn iera a R a, 162 SECTION IIl Eating the Mediterranean Way Introdúcese eaei tints, E RE 165 Transferring the Mediterranean Dietary Pattern to Non- Maintaining a Mediterranean-Style Diet... eee eect eters 167 Increasing the Health Benefits of a Vegetarian or Vegan Diet when Following a Mediterranean Eating Pattern... 169 Choosing Foods When Eating Out That Fit a Mediterranean- Style: Diets. ss ccsssesseecestecsacs dessettocesceeeebspesevashaphscacestaudeasseastevasegsevestagesse 170 Taking Steps to Begin Moving toward a Mediterranean-Style Diet.... 172 SUMMATY eia E aA E a E a s A E a 173 Chapter 18 Eat Like a Mediterranean: Enjoy Your Food, Be Healthy, and

Féel Good h a AE hn iets ees 175

JEAKA ROOL] ASN EE E EE E S 175

The Total Diet and the Slower Lifestyle... eee eeeeeeeeeees 175

Health Benefits of the Mediterranean Pattern of Eating: Focus

on the Dietary Components That Contribute to Health... 176

Health Benefits of the Mediterranean Pattern of Eating: Focus

Type.2 Diabetes: Mellitus iiics 180

Statistics on Chronic Disease Reductions in Consumers of a

Eo AAA A T E E T A ean ee Changes in Fating Patterns: Moving Slowly toward Traditional Mediterranean Dietse e e a E E EO E E Healthy Values to Aim for by Mediterranean Diet Consumers .…….... Summary- ae a eh Ie ead E A Oa

Chapter 1: What Is a Mediterranean Diet? Common Components Chapter 2: Dietary Patterns of the Mediterranean Nations: Then And NOW nenia a sitesi ET E EE E R Chapter 3: Critical Nutrients in Foods of Mediterranean Nations... Chapter 4: Obesity and Type 2 Diabetes Mellitus...

Chapter 5: Cardiovascular Diseases and the Metabolic Syndrome ... Arterial Calcifcations..:isc:..sc.sesiacescashsiaces testes esdessesescatbeedsatescapeese Cances oiai thesis E E ra E AR EE AE Immune Defense: sisinio a A RA Skeletal Declitiews: sonipes E E E E ir Chapter 7: Introduction to the Health Benefits of Chapter 8: High Consumption of Monounsaturated Fat and Low Chapter 9: High Consumption of Fruits, Vegetables, and Legumes... Chapter 10: High Consumption of Whole Grains... eee Chapter 13: Low Consumption of Meats and Low-to-Moderate Consumption of Poultry and Eggs o... eee eeee eee eeeeseeeeeeseeeseeseees Chapter 14: Low Consumption of Milk and Moderate Chapter 17: Moving toward a Mediterranean-Style Diet in Your Own Dike seuss tin ivisin ia nin alsin gel tind dese neice Chapter 18: Eat Like a Mediterranean: Enjoy Your Food, Be Healthy, and Feel Good... ieee eeccesseeeeseeeseesecnseceensesseeeaeesees xiv Contents

Split Pea and Lentil Soup oo... eee eeeeseceeeeaeeeseeseenseeasenes 211

Smoked Salmon Sandwich Spread... eee eeeeceereeeeeeeees 213

Greek-Style Appetizer Pizzas... eee ec ceeeceeseeeeeseeeseteeeseeseees 214

Cold Salad S tek ei el wes nee a EE TAREE 214

Wild Rice and Barley Salad 0... eee eeceecneeeeeneeteeees 216

Beans, Tomato, and Feta Cheese Salad... cececececeseseeeeeee 216

Vegetable: Dishes (HOt) sis astraer E EEEE ET EEA 217

Greek Pasta with Tunae: eesotsa i KaR R E 218

Appendix D: Websitesine ieira nn n (eee tect nd 223 Appendix E: Glossary of Terms Used in Text... ccc eceeceeeceecneeseeneeneeneees 225

Foreword

Good nutrition is based on a pattern of eating nutritious foods in appropriate amounts—not too much or too little. This book on Mediterranean diet patterns leads the way toward the establishment of healthy eating habits and the promotion of sound lifestyle behaviors that minimize the chronic diseases so common in the Western world.

For example, heart disease and stroke combined are now the leading cause of death and disability worldwide, claiming more than 17 million lives per year. Those who survive an event frequently suffer with crippling disabilities and symptoms. Alarming increases in obesity and diabetes are an important factor contributing to this growing global burden of cardiovascular disease. Experts agree that improving diets is an effective first step toward preventing heart disease and stroke as well as preventing obesity, diabetes, and certain forms of cancer. In a landmark decision, the United Nations, working through the World Health Organization, has set a goal to reduce by 25% the premature mortality caused by these disorders by the year 2025. To achieve this goal heightened interest worldwide now focuses on how a healthy diet can contribute to improved quality of life, reduction of disease, and longevity.

For years epidemiologists and others have been interested in a Mediterranean diet and how its foods, and their nutrients, might relate to the observed longevity and healthy outcomes of certain populations in Mediterranean countries. Results from a series of important trials now support the benefits of a Mediterranean pattern of eating to prevent and reduce the prevalence of heart attacks and stroke. The Lyon (France) Heart Study showed that individuals of a high-risk population who had survived a cardiovascular event did better when they adhered to a Mediterranean-style diet. Recently the PREDIMED trial (Primary Prevention of Cardiovascular Disease with a Mediterranean Diet) confirmed that a Mediterranean diet, supplemented with extra-virgin olive oil or certain nuts, effectively reduced the occurrence of a first cardiovascular event. A systematic review of dietary factors and coronary heart disease has ranked a Mediterranean way of eating as most likely to provide protection against coronary heart disease because of satisfaction and adherence to the diet. In the face of abundant evidence supporting the benefits of adhering to a Mediterranean diet it remains essential to understand the concepts and eating patterns required for its implementation.

This book provides the tools and core elements needed to understand and adopt a healthy way of eating that can reduce the risk of suffering the devastating consequences of a heart attack or stroke. Knowledge is fundamental to any successful change in lifestyle if it is put into practice. The authors have written a thoughtful, comprehensive text which will be an asset to anyone with a serious interest in developing a healthy lifestyle and changing their eating habits. Years of experience and

XV xvi Foreword research combined with data from the most recent trials have been distilled into a readable, understandable primer, which provides the reader with valuable information. I highly recommend this thoughtful review of a Mediterranean diet and urge all to make a healthy diet and lifestyle their fundamental personal choice and lifelong commitment.

School of Medicine, UNC, Chapel Hill

and

Former President, American Heart Association Immediate Past President, World Heart Federation