The Mediterranean Diet is a nutritional model based on the diet of people who live in the Mediterranean region of southern Europe and northern Africa. The diet encourages the consumption of large amounts of fruits and vegetables, olive oil and fish, while limiting red meat. It also suggests moderate alcohol consumption.

The Mediterranean Diet differs from the American Heart Association (AHA) recommended heart-healthy diet in that it allows a higher fat intake (up to 40 percent of calories coming from fat as opposed to the AHA recommended 25 to 35 percent). However, fat in the Mediterranean Diet almost always comes from olive oil and nuts – foods high in healthy monounsaturated fats and low in unhealthy saturated fats. Like the USDA recommended Dietary Guidelines for Americans, the Mediterranean Diet suggests eating large amounts of food containing antioxidants and omega-3 fatty acids, which have known health benefits.

The purported benefits of the Mediterranean Diet have been studied since the 1960s. Proponents maintain that adhering to the diet will reduce the risk of heart disease and cancer and help people live a quality life for longer. While the results have been encouraging, there is not enough evidence to confirm all the health benefits that are claimed of the Mediterranean Diet.

The Mediterranean Diet is a nutritional model that stresses limiting red meat and eating large amounts of fresh fruits and vegetables, olive oil and fish. It is based on the traditional diet of people who live in the regions of Europe and Africa that lie on the Mediterranean Sea (e.g., Greece, Italy, Spain, Morocco, Tunisia).

The Mediterranean diet was developed primarily from the diet of Cretans (people who live on the Greek island of Crete) and generally reflects the diet of much of southern Europe and northern Africa, although the different Mediterranean regions do have somewhat different diets. For example, in Morocco, pastries and couscous are eaten instead of the Italian bread and pasta and, in Turkey, beef and lamb are eaten more often than in southwestern Europe. However, what unites most of the countries of the Mediterranean is their production of olive oil and reliance on fish, fresh fruits and vegetables as a source of nutrition. In the 1950s, scientists discovered that the populations of these countries had a lower rate of heart disease and generally lived longer than most people in northern Europe and America.  

The Mediterranean Diet was produced by combining the various dietary elements of the different Mediterranean countries with modern nutritional information. The diet became popular in the 1990s after scientists found encouraging evidence in support of the claims regarding its benefits for people with a high risk of heart disease. It seems, according to research, that there is not one element of the Mediterranean diet that is more beneficial for the body than any other. Studies have shown that all the elements work in synergy with each other to provide many of the health benefits that its supporters claim.

In 1993, a number of health organizations produced a Mediterranean Diet pyramid to reflect the healthy choices that people who choose to follow the Mediterranean Diet can make. Unlike the United States Department of Agriculture's (USDA) food guide pyramid, the Mediterranean food pyramid does not give specifics on how much of each food should be consumed. Rather, it indicates the frequency that each food group should appear in an individual’s diet. It is divided into foods that should be consumed daily, weekly and monthly.

In the Mediterranean Diet, the following foods are consumed daily:

• Bread, pasta, rice, couscous, polenta, other whole grains and potatoes. Whole grain bread, pasta and rice are favored over bleached forms since whole grains contain more nutrients.
  
  
• Fruits, vegetables, beans, legumes and nuts. Between 7 and 9 servings of fruits and vegetables are eaten every day on the Mediterranean Diet. This is slightly higher than the USDA recommendation of 5 servings per day. The Mediterranean Diet stresses the importance of eating seasonally fresh and locally-produced fruits and vegetables, which often maximizes the health-promoting micronutrient and antioxidant content of these foods. In addition, nuts, seeds, beans and legumes are consumed on a daily basis. According to the Mediterranean Diet, the most nutritionally valuable nuts are those that come from trees (e.g., walnuts, pecans, almonds, hazelnuts).
  
  
• Olive oil and other plant oils. Olive oil is the defining characteristic of the Mediterranean Diet, since it is the one element common in the diets of most of those who live in the Mediterranean region. Proponents of the Mediterranean Diet suggest that most sources of saturated fats (e.g., butter, margarine, lard) should be replaced with olive oil, which is high in healthy monounsaturated fats and low in unhealthy saturated fats. Virgin and extra virgin olive oils are considered healthier because they are the least processed and provide the most antioxidant elements. These types of olive oil are also the most flavorful. In addition to olive oil, other plant oils such as canola oil are used. In the Mediterranean Diet, fats account for up to 40 percent of caloric intake, compared to just 25 percent to 35 percent as recommended by the American Heart Association.
  
  
• Cheese and yogurt. Low-fat cheese (e.g., mozzarella, feta) and low-fat yogurt are consumed daily. High-fat dairy products, such as whole milk and high-fat cheeses, are avoided.
  
  
• Alcohol. The Mediterranean Diet encourages drinking a moderate amount of alcohol, usually red wine, every day. The diet recommends no more than one alcoholic drink per day for women and no more than two alcoholic drinks per day for men. One drink is equal to:
  
  
• • 12 ounces (350 milliliters [ml]) of beer or wine cooler
    
    
  • 4 ounces (150 ml) of wine
    
    
  • 1.5 ounces (45 ml) of 80-proof liquor

It is important that people do not introduce alcohol into their diet for the supposed health benefits – many of the benefits of red wine can also be gained by drinking purple grape juice. It is important for people to discuss the risks and benefits of alcohol with a physician before changing their diet.

The following foods are consumed weekly in the Mediterranean Diet:

• Fish (three to five times per week).
  
  
• Poultry (one to three times per week). Fish is generally preferred over poultry.
  
  
• Eggs. Yolks (including those used in baking and cooking) are restricted to zero to  four per week. Egg whites are eaten freely.
  
  
• Sweets. In the Mediterranean Diet, fresh fruit is normally eaten after dinner instead of sugary, processed desserts. Those sweets that are eaten are often sweetened with honey rather than refined sugars.

Traditionally, red meat is rarely eaten in the Mediterranean Diet because of the abundance of fish and poultry in the region. The Mediterranean Diet pyramid advises that red meat should be eaten very rarely – only a few times per month.

The Mediterranean Diet differs slightly from the Dietary Guidelines for Americans, which was developed by the U.S. departments of Health and Human Services (HHS) and Agriculture (USDA). Some of these differences include:

• Fat. The Mediterranean Diet encourages fat intake through olive oil and nuts (a source of healthy monounsaturated fats), but not through butter or margarine (a source of unhealthy saturated fats). In the Guidelines, all fats are combined in one group (including heart-healthy monounsaturated fats), with recommended serving sizes to maintain a low-fat diet.
  
  
• Meat. The Guidelines make no distinction between red meat (high in saturated fat) and white meat and fish (high in protein and low in fat).
  
  
• Nuts and beans. The Guidelines combines meat, beans and nuts into one category. Portions of nuts and beans that are eaten contribute to the daily recommended meat intake.

Despite these differences, many of the recommendations of the Mediterranean Diet fall within the guidelines set by the USDA, which has endorsed the Mediterranean food pyramid (as well as the Asian and the Latin American food guide pyramids) as an alternative that can be followed alone or in conjunction with the traditional USDA food guide pyramid.

In general, the Mediterranean Diet follows the patterns of most dietitian-recommended diet plans. This is particularly true in its emphasis on fresh fruits and vegetables, whole grains, consumption of fish and the limiting of red meat. The Mediterranean diet is approved by the USDA for use by both adults and children, with extra water replacing wine in the children’s diet. 

The most substantial health benefit that the Mediterranean Diet offers is the large amounts of antioxidants provided by the foods in the diet. Antioxidants are substances found in fruits, vegetables and other foods that protect cells from being damaged by free radicals in a process called oxidative stress. Oxidative stress happens when free radicals steal electrons from healthy tissue. Antioxidants neutralize the free radicals that cause oxidative stress and this may reduce the signs of aging as well as the risk of heart disease, cancer and stroke.

There are many substances that have antioxidant properties. One of the most prevalent in the Mediterranean Diet are polyphenols. These substances are most notably found in the seeds and skin of grapes and are believed to be the component of red wine that accounts for its potentially healthy effects. Polyphenols have been shown to limit the build up of fatty deposits (lipids) in the blood vessels (atherosclerosis). This condition is one of the causes of heart failure and can also lead to heart attack, stroke and peripheral arterial disease. In addition, polyphenols are thought to protect the brain from the cell damage that may cause Alzheimer’s disease. Many of the benefits related to polyphenolic compounds may also be achieved through drinking purple grape juice.

Omega-3 fatty acids also provide the body with antioxidants. Omega-3 is type of unsaturated fat known to prevent the inflammation and stress on the body associated with oxidative stress. It has also been shown to reduce the viscosity of blood platelets, which reduces the possibility of blood clots. Omega-3 may also boost the immune system. Olive oil and certain fish, such as tuna (either fresh or water packed), salmon, swordfish and herring are good sources of omega-3.

In addition, olive oil may also provide the body with antioxidants. Studies have indicated that it may contain anti-inflammatory agents associated with antioxidants, which could help prevent cardiovascular disease and dementia. The U.S. Food and Drug Administration (FDA) announced in 2004 that olive oil is associated with certain health benefits, including a reduced risk of heart disease. Olive oil is also a source of vitamins A, B1, B2, C, D, E, K and iron.

Several elements of the Mediterranean Diet have also been shown to improve cholesterol levels in the body. Fruits and vegetables lower LDL cholesterol while moderate alcohol intake (defined as two drinks per day) has been shown to raise HDL cholesterol levels by about 12 percent, according to the American Heart Association (AHA). Also, replacing saturated fats with monounsaturated fats has been shown to reduce LDL (bad) cholesterol, while raising HDL (good) cholesterol. Saturated fat contributes to high levels of LDL cholesterol in the body and increases the risk of heart disease. Red meat is high in saturated fats, and so limiting this helps lower the risk of heart problems. The effect of the Mediterranean Diet on blood cholesterol levels may play a role in the reason this diet has been shown to decrease the risk of cardiovascular conditions despite its higher total fat intake.

However, although there are apparently a number of benefits to the Mediterranean Diet, consuming a high amount of healthy fat still means the body is getting a higher number of calories, which can lead to obesity (a growing problem in the Mediterranean region).

In addition, there has been some debate about the Mediterranean Diet’s advocacy of alcohol consumption. Although moderate amounts of alcohol may be beneficial, drinking too much alcohol has been linked to an increased risk of the same conditions that moderate drinking may help prevent, such as heart disease and cancer. It is also important to remember that the recommended alcohol intake is intended for those who already drink alcohol. Most medical organizations advise that people do not start drinking for the health benefits, especially since many of the health benefits associated with alcohol can also be gained by other means. People who wish to know about the risks and benefits of alcohol should consult their physician.

Despite these risks, there is evidence that a diet low in saturated fat and high in fruit, vegetables and fish has significant health benefits. It appears that no one element of the Mediterranean Diet is better for the body than any other. Rather, research has shown that it is each element working in synergy that seems to provide the health benefits that its supporters claim.

Even today, the Greeks, whose eating habits the diet is based on, live longer than most populations, including Americans, according to the World Health Organization. Studies have also shown that in the 1950s and 1960s, when the diet was first researched, Greeks were much less likely to die of a heart attack and cancer than Americans. However, there are other factors that play a role in the long life and overall health of those who live in the Mediterranean region. People from that area are generally more physically active than those in the United States, and have a more relaxed lifestyle with a greater support system. These elements individually have been shown to reduce stress and lead to a decrease in heart disease risk.

Several recent studies have found evidence supporting claims that the Mediterranean Diet can be good for a person’s health. On recent study found that this type of diet may cut the risk of progressive inflammatory lung disease (COPD) by 50 percent. Other researchers have reported evidence that consuming a Mediterranean Diet may reduce allergy and asthma symptoms, or may cut the risk of developing Alzheimer’s disease.

Each Mediterranean region features a different choice of ingredients and, in this sense, there is no one true Mediterranean Diet. However, central to the Mediterranean Diet is fresh fruit and vegetables, fish, and olive oil. The sample menu below demonstrates the range of dishes which are acceptable on the Mediterranean Diet:

• Breakfast
  
  
• French-style crepe with cinnamon glazed apples
• Garden vegetable hash browns
• Mediterranean vegetable omelet
  
  
• Lunch
  
  
• Chicken with penne pasta
• Broccoli with lentils in a lemon garlic sauce
• Herb-roasted potatoes with olive oil
  
  
• Dinner
  
  
• Salmon with a yogurt dill sauce
• Mixed fruit with pine nuts
• Oven-roasted squash with lima beans and olive oil & pesto
  
  
• Snacks
  
  
• Banana on a stick with peanuts
• Homemade pretzels
• Apple, cheese and crackers

Preparing questions in advance can help patients to have more meaningful discussions regarding their conditions. Patients may wish to ask their doctor or registered dietitian the following questions related to the Mediterranean Diet:

1. Is it safe for me to start following the Mediterranean Diet?
   
   
2. Should I talk to a dietitian? Can you recommend one?
   
   
3. Could the Mediterranean Diet help lower my cholesterol levels?
   
   
4. Could the Mediterranean Diet help lower my blood pressure?
   
   
5. If I have diabetes, can I still follow the Mediterranean Diet?
   
   
6. I’m worried about increasing my fat intake. Could there be any detrimental effects to consuming more monounsaturated fats?
   
   
7. Is it safe for me to drink a moderate amount of alcohol every day? How would you define “moderate” for me?
   
   
8. Will I get all the nutrients I need from the Mediterranean Diet?
   
   
9. Are there any elements of the Mediterranean Diet that should be adjusted for me?
   
   
10. Are there any other diet plans that may improve my health?
    
    
11. How do I structure a Mediterranean Diet to correspond with my weight management goals (lose, gain or maintain)?