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“Towards an even healthier mediterranean diet”
Nutrition, Metabolism & Cardiovascular Diseases (2013) 23, 1163e1166
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/nmcd
VIEWPOINT
Towards an even healthier mediterranean diet ´ b,c R. Estruch a,b,*, J. Salas-Salvado a
Department of Internal Medicine, Hospital Clinic, Institut d’Investigacio´, August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain b CIBER Obn, Physiopathology of Obesity and Nutrition, Institute of Health “Carlos III”, Government of Spain, Santiago de Compostela, Spain c Human Nutrition Unit, School of Medicine, Institut d’Investigacio´ Sanita`ria, Pere Virgili (IISPV), University Rovira i Virgili, Reus, Spain Received 24 July 2013; received in revised form 16 September 2013; accepted 23 September 2013 Available online 11 October 2013
KEYWORDS Mediterranean diet; Nutrition; Cardiovascular disease; Cardiovascular risk factors
Abstract Dietary guidelines to promote good health are usually based on foods, nutrients, and dietary patterns predictive of chronic disease risk in epidemiologic studies. However, sound nutritional recommendations for cardiovascular prevention should be based on the results of large randomized clinical trials with “hard” end-points as the main outcome. Such evidence has been obtained for the Mediterranean diet from the PREDIMED (Prevencio´n con Dieta Mediterra´nea) trial and the Lyon Heart Study. The traditional Mediterranean diet was that found in olive growing areas of Crete, Greece, and Southern Italy in the late 1950s. Their major characteristics include: a) a high consumption of cereals, legumes, nuts, vegetables, and fruits; b) a relatively high-fat consumption, mostly provided by olive oil; c) moderate to high fish consumption; d) poultry and dairy products consumed in moderate to small amounts; e) low consumption of red meats, and meat products; and f) moderate alcohol intake, usually in the form of red wine. However, these protective effects of the traditional Mediterranean diet may be even greater if we upgrade the health effects of this dietary pattern changing the common olive oil used for extra-virgin olive oil, increasing the consumption of nuts, fatty fish and whole grain cereals, reducing sodium intake, and maintaining a moderate consumption of wine with meals. ª 2013 Elsevier B.V. All rights reserved.
* Corresponding author. Department of Internal Medicine, Hospital Clı´nic, Villarroel, 170, 08036 Barcelona, Spain. Tel./fax: þ34 932279365. E-mail address: [email protected] (R. Estruch). 0939-4753/$ - see front matter ª 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.numecd.2013.09.003
1164 Dietary guidelines to promote good health are based on foods, nutrients, and dietary patterns predictive of chronic disease risk in epidemiologic studies. A systematic review of the evidence supporting the causal link between dietary factors and coronary heart disease (CHD) ranked the Mediterranean diet (Mediet) as the most likely dietary model to provide protection against CHD [1]. In prospective cohort studies, increasing adherence to Mediet has been consistently beneficial in the prevention of CHD, as well as allcause mortality [2,3]. A secondary prevention trial, the Lyon Diet Heart Study, showed remarkable reductions in CHD event rates and cardiovascular mortality in patients who survived a myocardial infarction and were allocated to a Mediet enriched with alpha-linolenic acid compared with a control diet [4]. Recently, the results of a large intervention trial evaluating the effects of a Mediet in the primary prevention of cardiovascular disease, the PREDIMED (PREvencion con DIeta MEDiterranea) study, were published [5]. In this study, high-unsaturated fat Mediets supplemented with extra-virgin olive oil or nuts reduced the incidence of an aggregate of cardiovascular disease events by 30%, compared to a control diet (Fig. 1). Interestingly, the Mediets recommended in the PREDIMED trial conferred a substantial benefit with regard to classical and emergent cardiovascular risk factors after only 3 months [6]. The Table 1 enclosed summarizes the main dietary recommendations to the participants included in the arms of the PREDIMED trial. Mediet intervention recommendations were based on the traditional dietary pattern found in olive growing areas of Crete, Greece, and Southern Italy in the late 1950s. The major characteristics of this diet are: a) a
Hazard Ratios (95% CI)* EVOO : 0.70 (0.53-0.91); P = 0.009 Nuts : 0.70 (0.53-0.94); P = 0.016
Figure 1 KaplaneMeier estimates of incidence of all major cardiovascular events (acute myocardial infarction, stroke or cardiovascular death) in the three intervention groups: Mediterranean diet þ Extra-virgin olive oil (green line), Mediterranean diet þ nuts (red line) and control group (black line). *Hazard ratios stratified by center (Cox model with robust variance estimators) CV denotes cardiovascular; EVOO, extravirgin olive oil. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
R. Estruch, J. Salas-Salvado ´ high consumption of cereals, legumes, nuts, vegetables, and fruits; b) a relatively high-fat consumption, mostly provided by olive oil; c) moderate to high fish consumption; d) poultry and dairy products consumed in moderate to small amounts; e) low consumption of red meats, and meat products; and f) moderate alcohol intake, usually in the form of red wine [7]. However, some changes have been included in the new versions of the traditional Mediet to improve its healthy effects [7]. Olive oil continues to be the predominant fat. The presumed antiatherogenic properties of olive oil have been attributed to its high oleic acid content, but in recent years converging evidence indicates that polyphenols, present mainly in virgin and extra virgin olive oil, contribute to the benefits of its consumption [8]. Since the atherogenic effects of oleic acid seems to be really weak in the recent literature [9], nowadays researchers believe that most of healthy effects of extra virgin olive oil are due to its polyphenolic content. Lower quality olive oils (refined olive oil) lose antioxidant and anti-inflammatory capacities because they are deprived of polyphenols. In fact, phenolics have shown strong antioxidant and anti-inflammatory activities in experimental and human studies. Moreover, consumption of phenolic-rich virgin live oil linearly reduced the cholesterol/HDL ratio and oxidized LDL levels [10]. Mediet is also rich in fatty fish. This fact may explain the rapid emergence of the differences in cardiovascular events observed among groups in the PREDIMED trial [5] (Fig. 1). Since traditional Mediet was rich in fish only in the coast areas, regular fatty fish intake should be regarded as another tool to make healthier the classical Mediet. Traditional Mediet is rich in low-glycemic index and lowglycemic load foods, such as whole grains and other fiber-rich products. High consumption of whole grains has also been associated with lower risk of diabetes mellitus, CHD and cancer [11]. Conversely, refined grain may increase the risk of diabetes, obesity, CHD, and other chronic diseases [12]. In a sub-study of the PREDIMED trial that analyzed 2213 highrisk participants, subjects in the highest quartile of white bread consumption, but not those who consume whole grain bread, showed a significant increase in body weight and waist perimeter [13]. Thus, nutritional recommendations should include changing refined cereal products for whole grain cereals even in the Mediet. Another important, albeit frequently ignored, issue in the Mediet definition is sodium intake. High sodium intake has been associated with high blood pressure and salt-preserved foods were associated with greater risk of stomach cancer, CHD and total mortality [14]. In the PREDIMED trial, sodium intake decreased significantly throughout the study (mean of 0.6e0.9 g/day of salt) from a moderate baseline intake (5e6 g/d of salt) in both Mediet groups. However, these figures continue to be higher than the tolerable upper intake level of sodium according to the USDA recommendations. Thus, sodium intake should also be included in the additional recommendations to follow a healthy diet such as Mediet. Finally, another specific component of the Mediet is wine, consumed in moderation, mainly with meals. There are several campaigns against alcohol beverages, including wine and beer, due to their toxic effects if consumed in high amounts. However, there is ample scientific evidence that regular light-to-moderate alcohol consumption is
Towards an even healthier mediterranean diet Table 1
1165
Summary of dietary recommendations to participants in the Mediterranean and control diet groups [4].
Mediterranean diet
Low-fat diet (control)
Recommended 1. 2. 3. 4. 5. 6. 7. 8. 9.
a
Olive oil Tree nuts and peanutsb Fresh fruits Vegetables Fish (specially fatty fish), seafood Legumes “Sofrito”c White meat instead of red meat Wine with meals (optionally, only for habitual drinkers)
Goal
Recommended
Goal
4 tbsp/d 3 serv./wk 3 serv./d 2 serv./d 3 serv./wk 3 serv./wk 2 serv./wk Preferable 7 glasses/wk
1. 2. 3. 4. 5.
3 3 3 2 3
Low-fat dairy products Bread, potatoes, pasta, rice Fresh fruits Vegetables Lean fish and seafood
serv./d serv./d serv./d serv./wk serv./wk
Discouraged
Goal
Discouraged
Goal
1. 2. 3. 4.
<1 <3 <1 <1
1. 2. 3. 4. 5. 6. 7. 8.
2 tbsp/d 1 serv./wk 1 serv./wk 1 serv./wk Always remove 1 serv./wk 1 serv./wk 2 serv./wk
Soda drinks Commercial bakery, sweets, pastriesd Spread fats Red and processed meats
drink/d serv./wk serv./d serv./d
Vegetable oils (including olive oil) Commercial bakery, sweets, pastriesd Nuts and fried snacks Red and processed fatty meats Visible fat in meats and soupse Fatty fish, seafood canned in oil Spread fats “Sofrito”c
a Including oil used for frying or salads, or consumed from meals eaten out of home. In the group allocated to Mediterranean diet with extra-virgin olive oil, the goal was to consume 50 g per day (4 tbsp z 40 g/d) of the polyphenol-rich olive oil supplied, instead of the ordinary refined variety, which is poor in polyphenols. b In participants allocated to the Mediterranean diet with nuts the recommended consumption was one daily serving (30 g, distributed as 15 g walnuts, 7.5 g almonds and 7.5 g hazelnuts). c “Sofrito” is a sauce made with tomato and onion, and/or garlic, slowly simmered with olive oil. d Commercial bakery, sweets or pastries (not homemade), including cakes, cookies, biscuits or custard. e Remove visible fat (or the skin) of chicken, duck, pork, lamb or veal meats before cooking and the fat of soups, broths, and cooked meat dishes before consumption.
associated with a lower risk of CHD and all-cause mortality, as opposed to binge drinking. It has been proposed that, among the different alcoholic beverages, red wine might be more cardioprotective than spirits [15]. Red wine contains alcohol and non-alcoholic compounds, mainly polyphenols. The results of clinical studies comparing the effects of red wine (alcohol plus polyphenols), dealcoholized red wine (polyphenols alone), and spirits (alcohol alone) show that part of the cardiovascular benefit of alcoholic beverages is due to their alcoholic content (ethanol), but other effects should be attributed to non-alcoholic components, mainly polyphenols [15]. In conclusion, sound nutritional recommendations for cardiovascular prevention should be based on the results of large randomized clinical trials with “hard” end-points as the main outcome. Such evidence has been obtained for the Mediet from the PREDIMED trial [3] and the Lyon Heart Study [4]. However, these protective effects of the traditional Mediet may be even greater if we upgrade the health effects of this dietary pattern, changing the common olive oil used for extra-virgin olive oil, increasing the consumption of nuts, fatty fish and whole grain cereals, reducing sodium intake, and maintaining a moderate consumption of wine with meals.
Acknowledgments CIBERobn is an initiative of ISCIII, Spain.
References [1] Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3:e442. [2] Serra-Majem L, Roman B, Estruch R. Scientific evidence of interventions using the Mediterranean diet: a systematic review. Nutr Rev 2006;64:S27e47. [3] Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr 2010;92:1189e96. [4] Estruch R, Ros E, Salas-Salvado ´ J, Covas MI, Corella D, Aro ´s F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279e90. [5] deLorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 1999;99:779e85. [6] Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado J, Ruiz-Gutierrez V, Covas MI, et al. for the PREDIMED Study Investigators. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med 2006; 145:1e11. [7] Bach-Faig A, Berry EM, Lairon D, Reguant J, Trichopoulou A, Dernini S, et al. Mediterranean diet pyramid today. Science and cultural updates. Public Health Nutr 2011;14:2274e84. [8] Lo ´pez-Miranda J, Pe ´rez-Jime ´nez F, Ros E, De Caterina R, Badimo ´n L, Covas MI, et al. Olive oil and health: summary of the II International Conference on Olive Oil and Health
1166
[9]
[10]
[11]
[12]
consensus report, Jae ´n and Co ´rdoba (Spain) 2008. Nutr Metab Cardiovasc Dis 2010;20:284e94. Jakobsen MU, O’Reilly EJ, Heitmann BL, Pereira MA, Ba ¨lter K, Fraser GE, et al. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr 2009;89:1425e32. Covas MI, Nyysso ¨nen K, Poulsen HE, Kaikkonen J, Zunft HJ, Kiesewetter H, et al. The effect of polyphenols in olive oil on heart disease risk factors: a randomized trial. Ann Intern Med 2006;14:333e41. Haas P, Machado MJ, Anton AA, Silva AS, De Francisco A. Effectiveness of whole grain consumption in the prevention of colorectal cancer: metaanalysis of cohort studies. Int J Food Sci Nutr 2009;21:1e13. Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T, Mitchell P, et al. Glycemic index, glycemic load, and chronic
R. Estruch, J. Salas-Salvado ´ disease riskea meta-analysis of observational studies. Am J Clin Nutr 2008;87:627e37. [13] Bautista-Castan ˜o I, Sa ´nchez-Villegas A, Estruch R, Martı´nezGonza ´lez MA, Corella D, Salas-Salvado ´ J, et al. Changes in bread consumption and 4-year changes in adiposity in Spanish subjects at high cardiovascular risk. Br J Nutr 2013;110: 337e46. [14] Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362:590e9. [15] Chiva-Blanch G, Arranz S, Lamuela-Raventos RM, Estruch R. Effects of wine, alcohol and polyphenols on cardiovascular disease risk factors: evidences from human studies. Alcohol Alcohol 2013;48:270e7.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/nmcd
VIEWPOINT
Towards an even healthier mediterranean diet ´ b,c R. Estruch a,b,*, J. Salas-Salvado a
Department of Internal Medicine, Hospital Clinic, Institut d’Investigacio´, August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain b CIBER Obn, Physiopathology of Obesity and Nutrition, Institute of Health “Carlos III”, Government of Spain, Santiago de Compostela, Spain c Human Nutrition Unit, School of Medicine, Institut d’Investigacio´ Sanita`ria, Pere Virgili (IISPV), University Rovira i Virgili, Reus, Spain Received 24 July 2013; received in revised form 16 September 2013; accepted 23 September 2013 Available online 11 October 2013
KEYWORDS Mediterranean diet; Nutrition; Cardiovascular disease; Cardiovascular risk factors
Abstract Dietary guidelines to promote good health are usually based on foods, nutrients, and dietary patterns predictive of chronic disease risk in epidemiologic studies. However, sound nutritional recommendations for cardiovascular prevention should be based on the results of large randomized clinical trials with “hard” end-points as the main outcome. Such evidence has been obtained for the Mediterranean diet from the PREDIMED (Prevencio´n con Dieta Mediterra´nea) trial and the Lyon Heart Study. The traditional Mediterranean diet was that found in olive growing areas of Crete, Greece, and Southern Italy in the late 1950s. Their major characteristics include: a) a high consumption of cereals, legumes, nuts, vegetables, and fruits; b) a relatively high-fat consumption, mostly provided by olive oil; c) moderate to high fish consumption; d) poultry and dairy products consumed in moderate to small amounts; e) low consumption of red meats, and meat products; and f) moderate alcohol intake, usually in the form of red wine. However, these protective effects of the traditional Mediterranean diet may be even greater if we upgrade the health effects of this dietary pattern changing the common olive oil used for extra-virgin olive oil, increasing the consumption of nuts, fatty fish and whole grain cereals, reducing sodium intake, and maintaining a moderate consumption of wine with meals. ª 2013 Elsevier B.V. All rights reserved.
* Corresponding author. Department of Internal Medicine, Hospital Clı´nic, Villarroel, 170, 08036 Barcelona, Spain. Tel./fax: þ34 932279365. E-mail address: [email protected] (R. Estruch). 0939-4753/$ - see front matter ª 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.numecd.2013.09.003
1164 Dietary guidelines to promote good health are based on foods, nutrients, and dietary patterns predictive of chronic disease risk in epidemiologic studies. A systematic review of the evidence supporting the causal link between dietary factors and coronary heart disease (CHD) ranked the Mediterranean diet (Mediet) as the most likely dietary model to provide protection against CHD [1]. In prospective cohort studies, increasing adherence to Mediet has been consistently beneficial in the prevention of CHD, as well as allcause mortality [2,3]. A secondary prevention trial, the Lyon Diet Heart Study, showed remarkable reductions in CHD event rates and cardiovascular mortality in patients who survived a myocardial infarction and were allocated to a Mediet enriched with alpha-linolenic acid compared with a control diet [4]. Recently, the results of a large intervention trial evaluating the effects of a Mediet in the primary prevention of cardiovascular disease, the PREDIMED (PREvencion con DIeta MEDiterranea) study, were published [5]. In this study, high-unsaturated fat Mediets supplemented with extra-virgin olive oil or nuts reduced the incidence of an aggregate of cardiovascular disease events by 30%, compared to a control diet (Fig. 1). Interestingly, the Mediets recommended in the PREDIMED trial conferred a substantial benefit with regard to classical and emergent cardiovascular risk factors after only 3 months [6]. The Table 1 enclosed summarizes the main dietary recommendations to the participants included in the arms of the PREDIMED trial. Mediet intervention recommendations were based on the traditional dietary pattern found in olive growing areas of Crete, Greece, and Southern Italy in the late 1950s. The major characteristics of this diet are: a) a
Hazard Ratios (95% CI)* EVOO : 0.70 (0.53-0.91); P = 0.009 Nuts : 0.70 (0.53-0.94); P = 0.016
Figure 1 KaplaneMeier estimates of incidence of all major cardiovascular events (acute myocardial infarction, stroke or cardiovascular death) in the three intervention groups: Mediterranean diet þ Extra-virgin olive oil (green line), Mediterranean diet þ nuts (red line) and control group (black line). *Hazard ratios stratified by center (Cox model with robust variance estimators) CV denotes cardiovascular; EVOO, extravirgin olive oil. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
R. Estruch, J. Salas-Salvado ´ high consumption of cereals, legumes, nuts, vegetables, and fruits; b) a relatively high-fat consumption, mostly provided by olive oil; c) moderate to high fish consumption; d) poultry and dairy products consumed in moderate to small amounts; e) low consumption of red meats, and meat products; and f) moderate alcohol intake, usually in the form of red wine [7]. However, some changes have been included in the new versions of the traditional Mediet to improve its healthy effects [7]. Olive oil continues to be the predominant fat. The presumed antiatherogenic properties of olive oil have been attributed to its high oleic acid content, but in recent years converging evidence indicates that polyphenols, present mainly in virgin and extra virgin olive oil, contribute to the benefits of its consumption [8]. Since the atherogenic effects of oleic acid seems to be really weak in the recent literature [9], nowadays researchers believe that most of healthy effects of extra virgin olive oil are due to its polyphenolic content. Lower quality olive oils (refined olive oil) lose antioxidant and anti-inflammatory capacities because they are deprived of polyphenols. In fact, phenolics have shown strong antioxidant and anti-inflammatory activities in experimental and human studies. Moreover, consumption of phenolic-rich virgin live oil linearly reduced the cholesterol/HDL ratio and oxidized LDL levels [10]. Mediet is also rich in fatty fish. This fact may explain the rapid emergence of the differences in cardiovascular events observed among groups in the PREDIMED trial [5] (Fig. 1). Since traditional Mediet was rich in fish only in the coast areas, regular fatty fish intake should be regarded as another tool to make healthier the classical Mediet. Traditional Mediet is rich in low-glycemic index and lowglycemic load foods, such as whole grains and other fiber-rich products. High consumption of whole grains has also been associated with lower risk of diabetes mellitus, CHD and cancer [11]. Conversely, refined grain may increase the risk of diabetes, obesity, CHD, and other chronic diseases [12]. In a sub-study of the PREDIMED trial that analyzed 2213 highrisk participants, subjects in the highest quartile of white bread consumption, but not those who consume whole grain bread, showed a significant increase in body weight and waist perimeter [13]. Thus, nutritional recommendations should include changing refined cereal products for whole grain cereals even in the Mediet. Another important, albeit frequently ignored, issue in the Mediet definition is sodium intake. High sodium intake has been associated with high blood pressure and salt-preserved foods were associated with greater risk of stomach cancer, CHD and total mortality [14]. In the PREDIMED trial, sodium intake decreased significantly throughout the study (mean of 0.6e0.9 g/day of salt) from a moderate baseline intake (5e6 g/d of salt) in both Mediet groups. However, these figures continue to be higher than the tolerable upper intake level of sodium according to the USDA recommendations. Thus, sodium intake should also be included in the additional recommendations to follow a healthy diet such as Mediet. Finally, another specific component of the Mediet is wine, consumed in moderation, mainly with meals. There are several campaigns against alcohol beverages, including wine and beer, due to their toxic effects if consumed in high amounts. However, there is ample scientific evidence that regular light-to-moderate alcohol consumption is
Towards an even healthier mediterranean diet Table 1
1165
Summary of dietary recommendations to participants in the Mediterranean and control diet groups [4].
Mediterranean diet
Low-fat diet (control)
Recommended 1. 2. 3. 4. 5. 6. 7. 8. 9.
a
Olive oil Tree nuts and peanutsb Fresh fruits Vegetables Fish (specially fatty fish), seafood Legumes “Sofrito”c White meat instead of red meat Wine with meals (optionally, only for habitual drinkers)
Goal
Recommended
Goal
4 tbsp/d 3 serv./wk 3 serv./d 2 serv./d 3 serv./wk 3 serv./wk 2 serv./wk Preferable 7 glasses/wk
1. 2. 3. 4. 5.
3 3 3 2 3
Low-fat dairy products Bread, potatoes, pasta, rice Fresh fruits Vegetables Lean fish and seafood
serv./d serv./d serv./d serv./wk serv./wk
Discouraged
Goal
Discouraged
Goal
1. 2. 3. 4.
<1 <3 <1 <1
1. 2. 3. 4. 5. 6. 7. 8.
2 tbsp/d 1 serv./wk 1 serv./wk 1 serv./wk Always remove 1 serv./wk 1 serv./wk 2 serv./wk
Soda drinks Commercial bakery, sweets, pastriesd Spread fats Red and processed meats
drink/d serv./wk serv./d serv./d
Vegetable oils (including olive oil) Commercial bakery, sweets, pastriesd Nuts and fried snacks Red and processed fatty meats Visible fat in meats and soupse Fatty fish, seafood canned in oil Spread fats “Sofrito”c
a Including oil used for frying or salads, or consumed from meals eaten out of home. In the group allocated to Mediterranean diet with extra-virgin olive oil, the goal was to consume 50 g per day (4 tbsp z 40 g/d) of the polyphenol-rich olive oil supplied, instead of the ordinary refined variety, which is poor in polyphenols. b In participants allocated to the Mediterranean diet with nuts the recommended consumption was one daily serving (30 g, distributed as 15 g walnuts, 7.5 g almonds and 7.5 g hazelnuts). c “Sofrito” is a sauce made with tomato and onion, and/or garlic, slowly simmered with olive oil. d Commercial bakery, sweets or pastries (not homemade), including cakes, cookies, biscuits or custard. e Remove visible fat (or the skin) of chicken, duck, pork, lamb or veal meats before cooking and the fat of soups, broths, and cooked meat dishes before consumption.
associated with a lower risk of CHD and all-cause mortality, as opposed to binge drinking. It has been proposed that, among the different alcoholic beverages, red wine might be more cardioprotective than spirits [15]. Red wine contains alcohol and non-alcoholic compounds, mainly polyphenols. The results of clinical studies comparing the effects of red wine (alcohol plus polyphenols), dealcoholized red wine (polyphenols alone), and spirits (alcohol alone) show that part of the cardiovascular benefit of alcoholic beverages is due to their alcoholic content (ethanol), but other effects should be attributed to non-alcoholic components, mainly polyphenols [15]. In conclusion, sound nutritional recommendations for cardiovascular prevention should be based on the results of large randomized clinical trials with “hard” end-points as the main outcome. Such evidence has been obtained for the Mediet from the PREDIMED trial [3] and the Lyon Heart Study [4]. However, these protective effects of the traditional Mediet may be even greater if we upgrade the health effects of this dietary pattern, changing the common olive oil used for extra-virgin olive oil, increasing the consumption of nuts, fatty fish and whole grain cereals, reducing sodium intake, and maintaining a moderate consumption of wine with meals.
Acknowledgments CIBERobn is an initiative of ISCIII, Spain.
References [1] Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3:e442. [2] Serra-Majem L, Roman B, Estruch R. Scientific evidence of interventions using the Mediterranean diet: a systematic review. Nutr Rev 2006;64:S27e47. [3] Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr 2010;92:1189e96. [4] Estruch R, Ros E, Salas-Salvado ´ J, Covas MI, Corella D, Aro ´s F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279e90. [5] deLorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 1999;99:779e85. [6] Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado J, Ruiz-Gutierrez V, Covas MI, et al. for the PREDIMED Study Investigators. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med 2006; 145:1e11. [7] Bach-Faig A, Berry EM, Lairon D, Reguant J, Trichopoulou A, Dernini S, et al. Mediterranean diet pyramid today. Science and cultural updates. Public Health Nutr 2011;14:2274e84. [8] Lo ´pez-Miranda J, Pe ´rez-Jime ´nez F, Ros E, De Caterina R, Badimo ´n L, Covas MI, et al. Olive oil and health: summary of the II International Conference on Olive Oil and Health
1166
[9]
[10]
[11]
[12]
consensus report, Jae ´n and Co ´rdoba (Spain) 2008. Nutr Metab Cardiovasc Dis 2010;20:284e94. Jakobsen MU, O’Reilly EJ, Heitmann BL, Pereira MA, Ba ¨lter K, Fraser GE, et al. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr 2009;89:1425e32. Covas MI, Nyysso ¨nen K, Poulsen HE, Kaikkonen J, Zunft HJ, Kiesewetter H, et al. The effect of polyphenols in olive oil on heart disease risk factors: a randomized trial. Ann Intern Med 2006;14:333e41. Haas P, Machado MJ, Anton AA, Silva AS, De Francisco A. Effectiveness of whole grain consumption in the prevention of colorectal cancer: metaanalysis of cohort studies. Int J Food Sci Nutr 2009;21:1e13. Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T, Mitchell P, et al. Glycemic index, glycemic load, and chronic
R. Estruch, J. Salas-Salvado ´ disease riskea meta-analysis of observational studies. Am J Clin Nutr 2008;87:627e37. [13] Bautista-Castan ˜o I, Sa ´nchez-Villegas A, Estruch R, Martı´nezGonza ´lez MA, Corella D, Salas-Salvado ´ J, et al. Changes in bread consumption and 4-year changes in adiposity in Spanish subjects at high cardiovascular risk. Br J Nutr 2013;110: 337e46. [14] Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010;362:590e9. [15] Chiva-Blanch G, Arranz S, Lamuela-Raventos RM, Estruch R. Effects of wine, alcohol and polyphenols on cardiovascular disease risk factors: evidences from human studies. Alcohol Alcohol 2013;48:270e7.