The Mediterranean Diet, its Components, and Cardiovascular Disease

“numerous RCTs with the principal sources for these data are the Diet and reinfarction trial (DART), Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI)-Prevention, and Japan EPA Lipid Intervention Study JELIS studies (30-33).”

“Interestingly, a more recent meta-analysis pointed out benefits of nuts (85) on weight loss.”

“Mechanisms for the benefit of whole grains on cardiovascular disease are numerous (76), but the whole-body benefits of increased fiber from whole grains appear to be related to reduced inflammation, reactive oxidation, lipid profiles, and blood pressure (77) (Figure 2).”

“copious, yet congruent, observational and RCT data exist with one RCT evaluating surrogate markers of cardiovascular disease prevention showing that the Mediterranean diet reduces the risk of repeat cardiovascular events (8).”

“Observational and ecological studies such as the original Seven Countries Study have shown positive benefits of the Mediterranean diet in terms of cardioprotection, surrogate markers for cardiovascular disease, as well as overall morbidity and mortality.(27,28) Subsequently, a large meta-analysis of over 50,000 patien…”

“Observational studies show that benefits extend to improved glucose metabolism,(89,90) reduction in weight,(91) and antioxidant capabilities.(92) Alternatively, high-fiber whole grain diets could inhibit absorption of fats, simple carbohydrates, or toxins.”

“Estimates of lifestyle modifications such as the Mediterranean diet as a whole (106), fruits and vegetables (59, 61, 62), smoking cessation (103), moderate alcohol (105), omega-3 fatty acids (110), and improved physical activity (102) have substantial benefits for CVD prevention not seen with commonly used standard me…”

“Estimates of lifestyle modifications such as the Mediterranean diet as a whole (106), fruits and vegetables (59, 61, 62), smoking cessation (103), moderate alcohol (105), omega-3 fatty acids (110), and improved physical activity (102) have substantial benefits for CVD prevention not seen with commonly used standard me…”

“acid intake increased lipid levels, including high-density lipoprotein.(66) Scant evidence establishes the effect of monounsaturated fats alone on cardiovascular disease mortality, yet a large meta-analysis suggests an inverse correlation between blood pressure and monounsaturated fats intake.”

“67 preventative risk reduction on heart disease.(43) One early evaluation of observational studies showed that substituting walnuts, peanuts, almonds, or other nuts for a serving of carbohydrates or saturated fats reduced blood lipids as well as the risk for cardiovascular disease by 30% and 45%, respectively.”

“Estimates of lifestyle modifications such as the Mediterranean diet as a whole (106), fruits and vegetables (59, 61, 62), smoking cessation (103), moderate alcohol (105), omega-3 fatty acids (110), and improved physical activity (102) have substantial benefits for CVD prevention not seen with commonly used standard me…”

“Subsequently, a large meta-analysis of over 50,000 patients showed that the Mediterranean diet significantly reduced the risk of metabolic syndrome and protected against risk factors such as waist circumference, lipids, glucose, and blood pressure (15) in primary prevention (Figure 2).”

“Estimates of lifestyle modifications such as the Mediterranean diet as a whole (106), fruits and vegetables (59, 61, 62), smoking cessation (103), moderate alcohol (105), omega-3 fatty acids (110), and improved physical activity (102) have substantial benefits for CVD prevention not seen with commonly used standard me…”

“Observational and ecological studies such as the original Seven Countries Study have shown positive benefits of the Mediterranean diet in terms of cardioprotection, surrogate markers for cardiovascular disease, as well as overall morbidity and mortality.(27,28) Subsequently, a large meta-analysis of over 50,000 patien…”

“One early evaluation of observational studies showed that substituting walnuts, peanuts, almonds, or other nuts for a serving of carbohydrates or saturated fats reduced blood lipids as well as the risk for cardiovascular disease by 30% and 45%, respectively.(93,94) Furthermore, a recent 2009 meta-analysis showed a sig…”

“A multitude of meta-analyses have shown a potential cardiovascular disease morbidity and mortality benefit for mainly secondary prevention with increased fish intake (19-28).”

“Recent meta-analyses of observational studies support the intake of higher amounts of fish (40-60 grams/day or 1-2 times/week) in high-risk populations (27, 34, 35).”

“Another large (over 200,000 patients) meta-analysis of observational studies showed a 17% reduction in cardiovascular disease events with three to five servings of fruits and vegetables daily as the primary endpoint (60), data that were reaffirmed two years later (61).”

“Mechanisms underlying the beneficial effects of fish on cardiovascular disease include improved lipid profiles (38) and reduced blood pressure (39, 40), presumably through reduced inflammation, oxidation, and coagulation (41, 42) (Figure 2).”

“The primary advantage of the Mediterranean diet appears to lie in its synergy among various cardioprotective nutrients and foods.(110) Indeed, the diet and, to a lesser degree, its components, have been found to reduce cardiovascular disease risk by mechanisms including reduction of surrogates of cardiovascular diseas…”

“No significant differences in cardiovascular disease surrogate markers were observed after 4 months, although the study might have been underpowered to detect them in such a short period of time, despite a similar design to the positive trials involving whole grains and cardiovascular disease.82 A single meta-analysis…”

“Estimates of lifestyle modifications such as the Mediterranean diet as a whole (106), fruits and vegetables (59, 61, 62), smoking cessation (103), moderate alcohol (105), omega-3 fatty acids (110), and improved physical activity (102) have substantial benefits for CVD prevention not seen with commonly used standard me…”

“Mechanisms underlying the beneficial effects of fish on cardiovascular disease include improved lipid profiles(52) and reduced blood pressure,(53,54) presumably through reduced inflammation, oxidation, and coagulation (Figure 2).(55,56) Thus, diets with moderate fish intake seem to confer”

“Mechanisms underlying the beneficial effects of fish on cardiovascular disease include improved lipid profiles(52) and reduced blood pressure,(53,54) presumably through reduced inflammation, oxidation, and coagulation (Figure 2).(55,56) Thus, diets with moderate fish intake seem to confer”

“These data were then confirmed that same year by a larger cohort of health professionals that showed no association between increased fish consumption (from 1-2 to 5-6 servings/week) and reduced cardiovascular disease mortality.(51) As these are observational studies, selection bias and recall bias must be taken into…”

“A single meta-analysis evaluating the merit of whole grains showed a collective benefit in a series of prospective cohort studies, with a 21% reduction in cardiovascular disease events and mortality (72).”

“postmenopausal women,(106) consistent with prior metaanalyses mentioned above.(104) However, subsequent meta-analyses have been less convincing about cardiovascular disease benefit, particularly with regard to surrogate endpoints.”

“Mechanisms underlying the beneficial effects of fish on cardiovascular disease include improved lipid profiles (38) and reduced blood pressure (39, 40), presumably through reduced inflammation, oxidation, and coagulation (41, 42) (Figure 2).”

“The Mediterranean diet appears to show beneficial effects regarding the metabolic syndrome (12) and diabetes (11) compared to lowfat diets, especially when enriched with either nuts or olive oil (12).”

“Initial observational studies showed legume and soy intake to be beneficial toward preventing cardiovascular disease (87) as NHANES data showed an 11% reduction in cardiovascular disease in women who consumed legumes four or more times weekly over those who consumed legumes one, or fewer, times weekly.”

“numerous RCTs with the principal sources for these data are the Diet and reinfarction trial (DART), Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI)-Prevention, and Japan EPA Lipid Intervention Study JELIS studies (30-33).”

“While solid evidence establishes the antioxidant properties of fruit and vegetables (65) and the health benefits of increased flavonol intake (66), alternative mechanisms have been proposed (67) and could include the effects of nitric oxide (NO) species or concomitant weight loss associated with diets high in fruits a…”

“While solid evidence establishes the antioxidant properties of fruit and vegetables (65) and the health benefits of increased flavonol intake (66), alternative mechanisms have been proposed (67) and could include the effects of nitric oxide (NO) species or concomitant weight loss associated with diets high in fruits a…”

“The diet does not single out specific food items or limit calories, but rather emphasizes an abundance of plant foods, olive oil as the principal source of fat, limited dairy products, consumption of moderate amounts of fish, poultry, and wine, low amounts of red meat, and fresh fruit dailye consistent with current Am…”

“A multitude of meta-analyses have shown a potential cardiovascular disease morbidity and mortality benefit for mainly secondary prevention with increased fish intake (19-28).”

“Another meta-analysis of 2650 patients showed that the Mediterranean diet provided a more robust reduction in cardiovascular disease risk factors and inflammatory markers.(30) In fact, theMediterranean diet is comparable with other interventions such as aspirin, statins, physical activity, and even antihypertensives s…”

“A multitude of meta-analyses have shown a potential cardiovascular disease morbidity and mortality benefit for mainly secondary prevention with increased fish intake (19-28).”

“A smaller RCT showed beneficial effects on BMI and waist circumference in the group randomized to hypocaloric whole grains as opposed to hypocaloric refined grains.(80) Moreover, the group obtaining all carbohydrates from whole grains for 12 weeks had significant improvements in C-reactive protein levels and cholester…”

“Furthermore, a recent 2009 meta-analysis showed a significant reduction in LDL cholesterol, inflammatory and oxidants mediators with increased walnut consumption (84), but no evidence established meaningful reductions in other risk factors or cardiovascular disease mortality.”

“Small RCTs in low-moderate risk patients show little (90) to no change in lipid levels (91, 92).”

“Observational studies show that benefits extend to improved glucose metabolism (78, 79), reduction in weight (80), and antioxidant capabilities (81).”

“lipid profiles.(81) In a recent RCT, over 300 overweight individuals were randomized to control, intermediate whole grain, or high whole grain diets for 4 months in substitution for their normal carbohydrate intake.”

“While solid evidence establishes the antioxidant properties of fruit and vegetables (65) and the health benefits of increased flavonol intake (66), alternative mechanisms have been proposed (67) and could include the effects of nitric oxide (NO) species or concomitant weight loss associated with diets high in fruits a…”

“Now, the cardioprotective effects of olive oil are thought to be attributed to the presence of its phenolic compounds obtained from the water-soluble fraction and include mostly the low-molecular-weight molecule hydroxytyrosol and also oleuropein, which are both potent antioxidants, free radical scavengers, and enzyme…”

“Similar observational data have been reported out of Japan99 and China.100 RCT data rarely address hard cardiovascular disease endpoints, and the grouped data show only marginal benefits with regard to lipid levels, blood pressure, or endothelial function.”

“Another large (over 200,000 patients) meta-analysis of observational studies showed a 17% reduction in cardiovascular disease events with 3-5 servings of fruits and vegetables daily as the primary endpoint,(73) data that were reaffirmed 2 years later.(4) Recently, population-based evidence from the European Prospectiv…”

“One of the largest cohort trials examining fish intake and cardiovascular disease, the Physician’s Health Study published in 1995, utilized prospective cohort data to argue against an association between fish consumption and cardiovascular disease benefit.(50) These data were then confirmed that same year by a larger…”

“A multitude of meta-analyses have shown a potential cardiovascular disease morbidity and mortality benefit for mainly secondary prevention with increased fish intake (19-28).”

“Mechanisms for the benefit of whole grains on cardiovascular disease are numerous (76), but the whole-body benefits of increased fiber from whole grains appear to be related to reduced inflammation, reactive oxidation, lipid profiles, and blood pressure (77) (Figure 2).”

“Recent meta-analyses of observational studies support the intake of higher amounts of fish (40-60 grams/day or 1-2 times/week) in high-risk populations.(41,48,49) Although less convincing, primary prevention data are favorable as long as patients carefully balance fish intake to 2-3 times/week to minimize the risk of…”

“Finally, observational data show improved all-cause and cardiovascular disease mortality in women with type 2 diabetes who consume whole grains.(86) Mechanisms for the benefit of whole grains on cardiovascular disease are numerous,(87) but the whole-body benefits of increased fiber from whole grains appear to be relat…”

“No significant differences in cardiovascular disease surrogate markers were observed after 4 months, although the study might have been underpowered to detect them in such a short period of time, despite a similar design to the positive trials involving whole grains and cardiovascular disease.(82) A single meta-analys…”

“Observational studies show that benefits extend to improved glucose metabolism (78, 79), reduction in weight (80), and antioxidant capabilities (81).”

“Small RCTs in low-moderate risk patients show little (90) to no change in lipid levels (91, 92).”

“Two randomized, blinded crossover trials have assessed the antioxidant effect of dietary supplementation of extra virgin olive oil in humans: EUROLIVE(61) and the Virgin Olive Oil Study (VOLOS).(62) The Italian VOLOS trial(62) studied the inflammatory protective potential of olive oil in 22 mildly dyslipidemic patient…”

“RCTs have shown a benefit on blood pressure in patients with moderate hypertension.(105) And a recent RCT shows no benefit of soy on NO bioavailability or BP in moderately hypertensive,”

“One early evaluation of observational studies showed that substituting walnuts, peanuts, almonds, or other nuts for a serving of carbohydrates or saturated fats reduced blood lipids as well as the risk for cardiovascular disease by 30% and 45%, respectively.(93,94) Furthermore, a recent 2009 meta-analysis showed a sig…”

“Finally, the prospective Chicago Western Electric Study showed a slight benefit on blood pressure compared with intake of red meat over a 7-year period of time.(72) This body of work demonstrates that increased red meat consumption produced a net blood pressure elevation in middle-aged men compared with an increased f…”

“A recent randomized crossover trial in a small group of healthy patients demonstrated that not only does the Mediterranean Diet (rich with olive oil) improve endothelial function and reduce systemic inflammation, but it also improves endothelial progenitor cell numbers, which the authors report as a marker of increase…”

“Further RCT evidence supports the use of a Mediterranean diet to reduce genetic predisposition for risk factors, not cardiovascular disease morbidity or mortality and their complications, in a high-risk population (9).”

“A larger sample of RCTs studies showed no benefit from soy supplementation on normotensive patients (97) and an earlier meta-analysis mirrored these findings (98).”

“The AHA guidelines indicate that diets high in fiber such as whole grains, oats, and barley, reduce cardiovascular disease morbidity and mortality through lipid lowering, and recommend a total dietary fiber intake of 25-30 g per day from whole foods.(79) While the ESC does not have specific guidelines or recommendatio…”

“A 2004 crosssectional analysis of a prospective cohort study (the SUN study) showed that fruit and vegetable consumption is inversely associated with blood pressure in a Mediterranean population with a high vegetable-fat intake (56).”

“Additionally, the AHA has strongly recommended the intake of a variety of phytochemicals, of which fruits and vegetables have large quantities, for the prevention of cardiovascular disease (54).”

“A multitude of meta-analyses have shown a potential cardiovascular disease morbidity and mortality benefit for mainly secondary prevention with increased fish intake (19-28).”

“Recent data from our laboratory indicate a beneficial effect of olive oil supplementation on endothelial function in low- to moderate-risk patients.(65) Early meta-analyses primarily evaluating the effects of fatty acids on surrogate markers for cardiovascular disease, such as cholesterol, indicated that monounsaturat…”

“Scant evidence establishes the effect of monounsaturated fats alone on cardiovascular disease mortality, yet a large meta-analysis suggests an inverse correlation between blood pressure and monounsaturated fats intake.(67) Finally, there are RCT data(21) that the Mediterranean diet supplemented with olive oil proffers…”

“Observational studies show that benefits extend to improved glucose metabolism (78, 79), reduction in weight (80), and antioxidant capabilities (81).”

“A larger sample of RCTs studies showed no benefit from soy supplementation on normotensive patients,(108) and an earlier meta-analysis mirrored these findings.(109) Thus, despite an abundance of observational data, and recent, well-designed RCTs and subsequent meta-analyses, we find little direct evidence that legume…”

“Estimates of lifestyle modifications such as the Mediterranean diet as a whole,12 fruits and vegetables,3-5 smoking cessation,9 moderate alcohol,11 omega-3 fatty acids,16 and improved physical activity8 have substantial benefits for CVD prevention not seen with commonly used standard medical therapies such as statins,…”

“Estimates of lifestyle modifications such as the Mediterranean diet as a whole,(12) fruits and vegetables,(3-5) smoking cessation,(9) moderate alcohol,(11) omega-3 fatty acids,(16) and improved physical activity(8) have substantial benefits for CVD prevention not seen with commonly used standard medical therapies such…”

“Small RCTs in low- to moderate-risk patients show little(101) to no change in lipid levels.(102,103) Yet one meta-analysis shows a 5% reduction in LDL levels in patients who were randomized to high legume intake,(104) however, this reduction was not noted to have an effect on hard cardiovascular disease endpoints.”

“A multitude of meta-analyses have shown a potential cardiovascular disease morbidity and mortality benefit for mainly secondary prevention with increased fish intake (19-28).”

“A multitude of meta-analyses have shown a potential cardiovascular disease morbidity and mortality benefit for mainly secondary prevention with increased fish intake (19-28).”

“A 2001 RCT showed that increased fruits and vegetables portended no significant change in lipid or blood pressure profiles, although a strong trend existed for both.(74) A subsequent RCT showed a statistically significant effect of fruit and vegetable consumption on both plasma antioxidant concentrations and blood pre…”

“And a recent RCT shows no benefit of soy on NO bioavailability or BP in moderately hypertensive, post-menopausal women (95), consistent with prior meta-analyses mentioned above (93).”

“0-mm Hg decrease in systolic blood pressure among women who consumed a higher amount of fruits, vegetables, or vitamin C, with no difference in men.(69) A 2004 cross-sectional analysis of a prospective cohort study (the SUN study)(70) showed that fruit and vegetable consumption is inversely associated with blood press…”