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MEDITERRANEAN DIET. The Mediterranean diet is defined variously. It sometimes refers simply to the dietary patterns and social mores surrounding eating in the countries bordering the Mediterranean Sea. In nutritional parlance the meaning is somewhat more confined. It applies to the traditional diet of European countries on the Mediterranean as characterized by foods and by patterns of nutrient intake.

Italy, Greece, France, and Spain are particularly associated with the diet because they were involved in the several ecological studies of dietary patterns, lifestyles, and coronary artery heart disease in the 1950s and 1960s led by Ancel Keys of the University of Minnesota (Keys, 1970, 1995; Keys et al., 1954). These landmark studies associated the relatively high dietary fat intake in those countries with a much lower prevalence of coronary artery disease than in the United States or northern Europe. Since dietary fat was thought to be the major culprit in coronary artery disease, this seemed remarkable at the time. Later discoveries linked saturated fat and cholesterol rather than total fat to heart disease risk. Olive oil, high in monounsaturated fat, and fish, high in polyunsaturated fat, which constituted the majority of the fat in the Mediterranean diet, were associated with lower risk. Other aspects of the food and nutrient profiles and lifestyles (for example, more physical activity, less smoking, etc.) may have contributed to low disease risk as well.

Reasons for Interest

Originally, interest in the Mediterranean diet was based on that association with decreased risk of coronary artery disease. The traditional Mediterranean diet included liberal amounts of fruits, vegetables, legumes, grains, and wine; high amounts of monounsaturated fats; moderate consumption of alcohol; liberal amounts of fish; and low amounts of meat and milk products. The diet was accompanied by a lifestyle that involved a good deal of obligatory physical activity, no smoking, and a relaxed attitude toward life. The actual diets were usually moderate in energy for physical activities. They were also relatively low in saturated fats and sugars and relatively high in most of the fat-and water-soluble nutrients and phytochemicals.

In the late twentieth century nutritional scientists attempted to examine whether or not the Mediterranean diet is associated with decreased risks of other diseases. Where traditional diets conforming to the Mediterranean pattern are eaten, health benefits seem to be present. In addition, the increased American interest in fine dining, ethnic cuisine, and food habits contributed to the popularity of the Mediterranean diet.

Evolution of the Mediterranean Diet Concept

Keys popularized the Mediterranean diet in the early 1970s, and other nutritionists, culinary experts, and commodity groups subsequently advocated it. In the early 1990s, Oldways, a group dedicated to preserving traditional eating patterns, joined members of the Harvard School of Public Health in conducting a series of conferences and other activities to popularize the Mediterranean pattern. This group published a healthy-eating Mediterranean pyramid based on the dietary traditions of the region.

Mediterranean Diet Pyramid

The Mediterranean diet pyramid is available at the website. W. C. Willett, and colleagues described it at length in "Mediterranean Diet Pyramid," published in the American Journal of Clinical Nutrition in 1995. The pyramid puts bread, other grain products, and potatoes at the base. The second tier is vegetables, including beans, other legumes, and nuts, and fruits. Third is a shallow tier for olive oil, and next is a cheese and yogurt tier. All of these foods should be consumed daily.

Near the top of the pyramid are small blocks for foods consumed a few times a week, including fish, poultry, eggs, and sweets. At the peak of the pyramid are foods consumed only a few times a month, including red meats, fats, oils, and sweets. The pyramid is accompanied by a wineglass to indicate "wine in moderation" and a running stick figure with the headline "regular physical activity" (Wilson, 1998).

Acceptable Alternative or Dietary Imperative?

Is consumption of a Mediterranean diet mandatory for good health? The notion of a single Mediterranean cuisine has been criticized on the grounds that no single such diet exists and that to contend one does promotes stereotypes and fails to account for the dynamic nature of dietary changes. Also, diets in the Mediterranean region and elsewhere in Europe change rapidly and no longer reflect those of yesteryear. Many healthful dietary patterns are associated with diets designed to reduce chronic disease risks. It is not necessary to consume diets similar to those traditionally eaten in the Mediterranean to stay healthy, but the Mediterranean diet is one alternative that provides an appropriate and healthful nutrient pattern.

Does the inclusion of Mediterranean-type foods make contemporary American diets healthier? This depends on a number of factors, chiefly how they are used. While decreased risk is associated with traditional Mediterranean diets, the patterns in these countries have changed a great deal since the early 1950s. They may not always provide all of the health advantages their traditional counterparts did, especially if food is eaten in excess. The specific health benefits of individual foods rather than the entire Mediterranean pattern are also unclear. Although most of the traditional foods are delicious and nutritious, other foods with similar nutrient compositions would seem to be equally effective. Therefore simply adding one or more "Mediterranean" foods to American diets does not necessarily provide positive health effects. The overall pattern in moderation has been linked to positive health outcomes.

During the late twentieth century, awareness of the considerable culinary and aesthetic advantages of the Mediterranean diet grew. Many staples of traditional Mediterranean diets have become popular and are widely available in the United States and other Western countries.

The plant-based Mediterranean diets of the early and mid-twentieth century were environmentally sound and responsible in the locales in which they flourished. Whether they are exportable and feasible on a large scale in other climates in non-Mediterranean countries is a matter of debate.

Traditional food habits typical of countries bordering the Mediterranean Sea in the mid-1950s have health and nutritional advantages. Guides for eating in the Mediterranean manner are readily available, but following their advice is not mandatory for good health.

See also Africa: North Africa; Ancient Mediterranean Religions; Greece, Ancient; Greece and Crete; Italy; Rome and the Roman Empire.

Johanna Dwyer