Why is it that most people who know the nutrition literature recommend people adopt the Mediterranean Diet?  That includes the vast majority of nutritionists, physicians in the field of Culinary Medicine, and even US News ranks this as the number one diet. This podcast we interview Dr. Timothy Harlan, whose program provides certification for physicians desiring a sub-specialty in Culinary Medicine. I was fortunate enough to have him as a guest this week, and he was the one who signed my certification for Culinary Medicine.

Most people understand that are certain foods that will reduce your risk of heart disease, stroke, and cancer over the next five years.  That doesn’t mean stop those diseases from happening, but you can greatly reduce the risk. Now you can keep track and score how you do on a daily basis – it is called The Mediterranean Diet Score.

The Mediterranean Diet Score is below.  Each of the nine categories is worth a point. If you make the daily serving size (or eat less meat and less dairy and less alcohol) you get a point Every day you can look at what you ate and see if you got a point on this.  If you increase your score by 2 points you can reduce your risk of death from heart attacks and cancer by up to 25%. Every category is one point.

Below are the categories and the science behind each one. This isn’t a fad diet, this is a simple way that you can add food to your daily routine and reduce your risk of death from certain diseases over the next five years. This is based on tens of thousands of patients studied over many years. Imagine eating better, losing weight, and decreasing your risk of medical problems?

Eat 9 oz of Vegetables a Day

When we measure foods, we measure them in their raw state. So how to get in all of these vegetables? The easiest way is to add them to the things you eat now. If you add cut up vegetables to spaghetti sauce. Consider that if you bake 12 oz of broccoli it will end up being about 3 ounces but you get credit for more. The key is to take the foods that you love and modify them.

You could have a large salad filled with some of these at lunch, and you could make a point to add more vegetables as snacks throughout the day. Plus there are plenty of ways to get in those vegetables at night.  If you aren’t eating enough vegetables, don’t worry – this is something we add to your diet.  Adding more will provide you with lots of micronutrients that will help you decrease your risk of heart disease and cancer.  It also will improve your odds of surviving cancer, heart disease, help manage diabetes better.

Increasing vegetables is the most important part of this score. So what is a serving size? One carrot is about 80 grams,  3 oz, or one serving size according to some studies. That would mean five large carrots a day. Adding a carrot to mid morning, one mid afternoon means you have made a start. Combine that with some healthy vegetables for dinner and a great salad for lunch and you now have filled the most important category.

Why more vegetables are important:

There are many nutrients thought to be responsible for the effects of vegetables: higher rates of potassium, carotenoids, fiber, and magnesium. In many studies those people who increase consumption of fruits and vegetables from less than 3 servings a day to more than 5 servings a day had a 17% reduction in heart disease over an 11 year period of time (He FJ, et al. “Increased consumption of fruit and vegetables is related to a reduced risk of coronary heart disease: meta-analysis of cohort studies.” J Hum Hypertens 2007 Sept;21(9) 717-28).

Some people don’t like variety, and studies were clear that it is the increase in numbers of fruits and vegetables and not variety that led to a lower risk of heart disease and cancers. (Bhupathiraju, Shilpa N et al. “Quantity and Variety in Fruit and Vegetable Intake and Risk of Coronary Heart Disease.” The American Journal of Clinical Nutrition 98.6 (2013): 1514–1523. PMC. Web. 23 Feb. 2017.)

Legumes

Roasted chickpeas – a legume, great for a snack or a meal. Beans, peas, peanuts, soy,  chickpeas (my favorite), and Okra. It is easy and inexpensive to add lentils to tacos, spaghetti. They decrease the amount of meat you need, which means decreasing calories. No one will notice, but they will be eating better.

Why legumes are important:

A healthy source of fiber and protein. A recent study with 19 years of follow up showed that legume consumption 4 times a week or more compared to 1 or less was associated with a 22% lower risk of coronary heart disease and an 11% lower risk of coronary vascular disease. (Brazzano L, He J, Ogden L, et al. Legume consumption and risk of coronary heart disease in US men and women: NHANES I Epidemiologic Follow-up Study. Arch Intern Med. 2001;161(21):2573-2578).

Yes, this means peanut butter isn’t the evil that some think it is. That also means that if you have a peanut butter sandwich on whole wheat bread you have two points.

Fruits and Nuts

Contrary to popular belief, fruits and nuts are good for you. In fact, fruit should be considered for dessert. One medium apple is about six ounces.  Have a medium apple for breakfast and add some nuts to your mid afternoon snack and you have just added one point to your Mediterranean Diet Score.

Why nuts are important:

When looking at the Mediterranean Diet with added nuts, those individuals had a reduction in “blood pressure, lipid profiles, lipoprotein particles, inflammation, oxidative stress, and carotid atherosclerosis, as well as on the expression of proatherogenic genes involved in vascular events and thrombosis.” (Ros, Emilio et al. “Mediterranean Diet and Cardiovascular Health: Teachings of the PREDIMED Study.” Advances in Nutrition 5.3 (2014): 330S–336S. PMC. Web. 22 Feb. 2017.) In addition, when looking at seven different studies, one serving of nuts per day showed a reduction of 4 per cent risk of all causes of mortality in that time period, and 27% risk reduction of cardiovascular disease (Grosso G1, et al. Nut consumption on all-cause, cardiovascular, and cancer mortality risk: a systemic review and meta-analysis of epidemiologic studies. Am J Clin Nutr 2015 Apr, 101(4) 783-93.)

Why fruit is important:

Even when it comes to fruits, an increased serving of fruits have been shown to decrease risks of heart disease, strokes, and cancer. Increasing fruits in the diet decrease the risk of heart disease by 4% with each serving over 8 years of follow up. The most astounding was when you combine with fruits and vegetables and have 8 servings a day (one serving was 80 grams or 3/4 of a cup) there was a 22% lower risk of fatal heart disease (Crowe FL, et al. “Fruit and vegetable intake and mortality from ischeaemic heart disease: results from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Heart study.” Eur Heart J. 2011 May; 32 (10): 1235-43). That seems like a lot until you realize that one large apple is about 80 grams.  So imagine if you were told you could reduce your risk of heart disease by eating 8 apples a day? In this case, we would want to have three apples and five carrots.

Adding more fruits to your diet, and vegetables, is the easiest way to reduce your risk of a fatal heart attack in the next five years. They are inexpensive, they have a lot of nutrients you need.  Cheaper than medication, satisfying for a long time, and healthy.

Fish

When it comes to fish, fatty fish like salmon is an important part of any diet.  Some would say that fish is the “flesh of choice.” But it is the fatty acids in fish, particularly the omega-3 fatty acids, that are a key component, something that is very difficult to get from nuts or vegetables.  While some don’t like the “fishy” taste of salmon, often it is because they are not getting fresh fish.  Salmon How I Like It describes my journey with salmon from having a lot as a kid to hating it to falling in love with it again, and how to buy it. What doesn’t work is simply adding fish oil, or other omega-3 supplements to your diet. They have not been shown to decrease your risk of heart disease.

On the Mediterranean Diet scale you get 1 point for fish. But, this is one of those rolling three day averages.  So if you have 3-4 ounces of salmon on Monday you can claim a point for Monday, Tuesday, and Wednesday. Or add some tuna to a weekly lunch.

Why fish is important

Fish not only reduces the risk of heart failure, it also reduces the risk of all cause mortality. The higher the fish consumption the better.  In a study of the Mediterranean Diet, the increase of fish in the diet is one of the most important to reduce all causes of death. (Sala‐Vila, Aleix et al. “Dietary α‐Linolenic Acid, Marine ω‐3 Fatty Acids, and Mortality in a Population With High Fish Consumption: Findings From the PREvención Con DIeta MEDiterránea (PREDIMED) Study.” Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease 5.1 (2016): e002543. PMC. Web. 22 Feb. 2017.)

Whole Grains

This is more like the bread they had in 1492 – bread that you had to worry about spoiling- not the white doughy bread of today.
This is a category that drives many people a bit nutty – and I mean that in a wheat berry way. Many fad diets have said that grains are bad, and too many books relate grains to brains and other issues.  From Adkins onward the fad has been “no whites.” But here we are talking about whole grains, not the highly processed grains that are out there.  So lets look at some of the common ones like bread, and what this would mean: First, use whole wheat bread instead of standard bread. Now, that might be a challenge because there are a lot of labels that say whole wheat bread, but you have to look at the ingredient label. Most “whole wheat” breads are not made with whole wheat, and label regulations state that “whole wheat flour” must be at least 51% whole wheat.

It turns out that popcorn is a whole grain – yes, corn is a grain – it is a whole grain and one of the whole grains you can get that can be made without butter, and you can add things to it that will make it taste pretty good.

Why Whole Grains Are Healthy:

These are not the highly processed grains you find in many breads, crackers, pastries, cookies, and cereals. These are whole grains that have been shown to provide a decrease in all causes of mortality.  Grains that are whole are healthy. In a summary of 45 different peer-reviewed studies, adding whole grains in as little as 90 grams(90 g is equivalent to three servings—for example, two slices of bread and one bowl of cereal or one and a half pieces of pita bread made from whole grains) showed a reduction in death including coronary heart disease, stroke, cardiovascular disease overall, total cancer, and all cause mortality as well as less common causes of death such as from respiratory disease, diabetes, infectious disease, and all non-cardiovascular, non-cancer causes.(Aune, Dagfinn et al. “Whole Grain Consumption and Risk of Cardiovascular Disease, Cancer, and All Cause and Cause Specific Mortality: Systematic Review and Dose-Response Meta-Analysis of Prospective Studies.” The BMJ 353 (2016): i2716. PMC. Web. 22 Feb. 2017.)

Quality Oils and Fats:

The best olive oils come from the US
There is something special about olive oil. While the saturated fat/unsaturated fat controversy that is being played out in the popular press – the truth is that olive oil has some properties that is good for you. And in real science, as opposed to those who want to put butter in their coffee, people who had more olive oil in their diet did better. Using olive oil as a main source of fat works well.

Why quality fats are important:

There is no doubt that olive oil is an important part of the Mediterranean Diet. Olive oils contain anti-inflammatory ingredients that protect the heart. Cooking with olive oil is sometimes difficult because of the “low smoke point” but many do. Grapeseed oil is good to cook with. What was critical was the decrease in cooking with saturated fats and instead using better sources of fat.  In spite of the popular press liking coconut oils, there is a lot of evidence that olive oil is the key to better health.For each 2 teaspoons increase in extra-virgin olive oil consumption, cardiovascular disease and mortality risk decreased by 10% and 7%, respectively.Guasch-Ferré, Marta et al. “Olive Oil Intake and Risk of Cardiovascular Disease and Mortality in the PREDIMED Study.” BMC Medicine 12 (2014): 78. PMC. Web. 22 Feb. 2017.).

Dairy

The Mediterranean diet emphasizes fermented dairy products, yogurt and cheese. Two major issues: yogurt in the Mediterranean areas is unlike yogurt found in the United States. Most yogurt in the United States, even those that are labeled as “Greek” yogurt have large amounts of added sugar. To get a point for dairy on the Mediterranean Diet Score it is best to use plain yogurt and add your own fruit (blueberries, strawberries) to it. That way you get points for the fruit you add.  As with many products it is always best to read the label of the yogurt to see if it has added sugar to it. My favorite brand of plain yogurt comes from Iceland, Siggi’s and you can purchase it at Safeway stores, as well as AJ’s. One other way is to make your own yogurt in an instant pot.

Other fermented products include cheese. Cheese is calorie dense, and like yogurt, it has limited amounts to get a point. My favorite cheese is still the Norwegian goat cheese that I grew up with as a child.

The key with dairy is that there is an upper limit. In this case about 3/4 to 1 cup per day. This allows some modest cheese and perhaps a bit of yogurt. In the Mediterranean they don’t have a lot of dairy. Some cheese is added as flavor. In the United States the Dairy Industry would have you believe you should be drinking a lot of milk and eating a lot of cheese. Limiting these, as they do in the Mediterranean Diet, provides you with cheese for some satisfaction but not so much that it increases caloric load. You will get plenty of calcium through your vegetables.

Still it is a point on the Mediterranean Diet Score and more points are not a bad thing. The key is that if you are having yogurt that has a lot of added sugar you will defeat yourself, and your mid-section. The studies were clear that yogurt and low fat milk had a reduced risk of metabolic syndrome but higher consumption of cheese did increase the risk of metabolic syndrome. (Babio N, et al. Consumption of Yogurt, Low-Fat Milk, and Other Low-Fat Dairy Products Is Associated with Lower Risk of Metabolic Syndrome Incidence in an Elderly. Mediterranean Population.J Nutr. 2015 Oct;145(10):2308-16. for link click here.)

Red Meats

There is no doubt that I am a lover of red meat. I really am. Lamb is probably my favorite, followed closely by steak. Those who live in the Mediterranean area didn’t eat that much red meat. The limit is 4 ounces per day. Not that this is a difficult thing to do, but to be fair, it is a point on the system. Four ounces of red meat can be quite satisfying.

If you slice the meat and display it out, as I did here – you get your four ounces. In the back is a lot of vegetables – in fact enough for a point on the Mediterranean Diet Score.

The difficulty is that many people like more red meat. This isn’t a debate about steak or red meat or its great benefit – this is about the score. Could you do this for dinner and be satisfied – yes. The studies thus far have shown that red meat consumption does not seem to be associated with shorter survival, but processed meats do (Bellavia A, et al. Differences in survival associated with processed and with nonprocessed red meat consumption. Am J Clin Nutr. 2014 Sept; 100(3):924-9 for link click here)

Alcohol

In this case the Mediterranean Diet Score typically uses red wine. For men this is two glasses of a five ounce pour per day, and one for women. Like my colleague, Dr Tim Harlan says – you cannot save this up for the weekend.

There are a lot of benefits from red wine – including anti-oxidants such as resveratrol, catechin, epicatechin, proanthocyanidins. Sadly resveratrol has been a part of one of the bigger frauds in weight loss schemes. If you heard the commercials touting “RM3” – it is a combination of one ingredient that doesn’t work for weight loss and resveratrol.

So a bit of wine is good for you – not a lot, just a bit. Drinking small amounts of red wine have been shown to decrease the risk of heart disease over non-drinkers. But more is not better. (Di Castelnuovo A, et al. Meta-analysis of wine and beer consumption in relation to vascular risk. Circulation. 2002 Jun 18; 105(24):2836-44 – link click here)

Do you want to score your own self on a weekly basis? Dr. Harlan has a PDF sheet that you can use to score your self on a weekly basis.

References

Mitrou, PN, Kipnis, V, Thiebaut, AC, et. al. (2007). Mediterranean dietary pattern and prediction of all-cause mortality in a US population: results from the NIH-AARP Diet and Health Study, Archives of Internal Medicine.

Walton, A. (2016). Mediterranean Diet May Help Prevent Death After Heart Disease, Forbes.com

Estruch, R, Ros, E, Salas-Salvado, J, et. al. (2013). Primary Prevention of Cardiovascular Disease with a Mediterranean Diet, The New England Journal of Medicine. (Reanalyzed and republished here)

Stewart, R, Wallentin, L, Benatar, J (2016). Dietary patterns and the risk of major adverse cardiovascular events in a global study of high-risk patients with stable coronary heart disease, European Heart Journal.

Smith, G. Can a Mediterranean diet lower my risk of Alzheimer’s?, Mayo Clinic.

http://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/alzheimers-disease/faq-20058062

Mediterranean Diet, MedlinePlus. https://medlineplus.gov/ency/patientinstructions/000110.htm