The Mediterranean Diet and Cardiovascular Health: A Critical Review
Open accessAbstract
The Mediterranean diet (MedDiet), abundant in minimally processed plant-based foods, rich in monounsaturated fat from olive oil, but lower in saturated fat, meats, and dairy products, seems an ideal nutritional model for cardiovascular health. Methodological aspects of Mediterranean intervention trials, limitations in the quality of some meta-analyses, and other issues may have raised recent controversies. It remains unclear whether such limitations are important enough as to attenuate the postulated cardiovascular benefits of the MedDiet. We aimed to critically review current evidence on the role of the MedDiet in cardiovascular health. We systematically searched observational prospective cohorts and randomized controlled trials which explicitly reported to assess the effect of the MedDiet on hard cardiovascular end points. We critically assessed all the original cohorts and randomized controlled trials included in the 5 most comprehensive meta-analyses published between 2014 and 2018 and additional prospective studies not included in these meta-analyses, totaling 45 reports of prospective studies (including 4 randomized controlled trials and 32 independent observational cohorts). We addressed the existing controversies on methodology and other issues. Some departures from individual randomization in a subsample of the landmark Spanish trial (PREDIMED [Prevención con Dieta Mediterránea]) did not represent any clinically meaningful attenuation in the strength of its findings and the results of PREDIMED were robust in a wide range of sensitivity analyses. The criteria for causality were met and potential sources of controversies did not represent any reason to compromise the main findings of the available observational studies and randomized controlled trials. The available evidence is large, strong, and consistent. Better conformity with the traditional MedDiet is associated with better cardiovascular health outcomes, including clinically meaningful reductions in rates of coronary heart disease, ischemic stroke, and total cardiovascular disease.
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Examples of heart-healthy diets are the Mediterranean, DASH, and MIND diets.
“Examples of heart-healthy diets are the Mediterranean, DASH (Dietary Approaches to Stop Hypertension) and MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diets.135-137”
From 2023 Alzheimer's disease facts and figures (2023) · cites this paper as [135]
The Conclusions (page not provided) describe the Mediterranean diet as approaching the gold standard for cardiovascular health. The paper supports that example, but the passages retrieved for DASH and MIND do not establish either as a heart-healthy diet. (LLM, conf=0.86)
Experimental — accuracy not yet measuredIn the same systematic review, the Mediterranean diet provided benefits for cardiovascular health.
“provided bene fi ts for cardiovascular health (76,77).”
In a systematic review of trials of >6 months' duration, compared with a low-fat diet, the Mediterranean diet demonstrated greater reductions in body weight and HbA1c levels.
“In a systematic review of trials of > 6 months ' duration, compared with a low-fat diet, the Mediterranean diet demonstrated greater reductions in body weight and HbA1c levels”
From Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) (2022) · cites this paper as [76]
The Abstract and “Further Experimental Evidence Beyond the PREDIMED and Lyon Trials” discuss cardiovascular outcomes, not weight or HbA1c reductions. Searches for HbA1c, body weight, and low-fat-diet comparisons found no passage reporting those two outcomes in a systematic review of trials lasting more than six months. (LLM, conf=0.76)
Experimental — accuracy not yet measuredIn the same systematic review, the Mediterranean diet delayed the requirement for diabetes medication.
“delayed the requirement for diabetes medication”
From Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) (2022) · cites this paper as [76]
The Abstract and Conclusions discuss cardiovascular outcomes, not when diabetes medication becomes necessary. A search for diabetes and medication found no passage reporting a delay in starting diabetes treatment; the medication mention in “Is the MedDiet a Concept Based on Vested Commercial Interests of Olive Oil and Nut Companies?” concerns pharmaceutical-industry bias. (LLM, conf=0.74)
Experimental — accuracy not yet measured
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- [85]85. Martínez-González MA, García-López M, Bes-Rastrollo M, Toledo E, Martínez-Lapiscina EH, Delgado-Rodriguez M, Vazquez Z, Benito S, Beunza JJ. Mediterranean diet and the incidence of cardiovascular disease: a Spanish cohort. Nutr Metab Cardiovasc Dis. 2011;21:237-44.
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2023 Alzheimer's disease facts and figures
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Mediterranean Diet and Its Association with Cardiovascular Disease Risk Factors: A Scoping Review
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Diets to promote healthy brain ageing
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Gut Microbiota and Type 1 Diabetes Mellitus: The Effect of Mediterranean Diet
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Risk-Based Approach for the Prediction and Prevention of Heart Failure
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Nutritional Approaches for the Management of Metabolic Acidosis in Chronic Kidney Disease
Noce, A., Marrone, G., Jones, G. W., Lauro, M. D., Zaitseva, A. P., Ramadori, L., Celotto, R., Mitterhofer, A. P., & Daniele, N. D. (2021) · Nutrients · doi:10.3390/nu13082534 · Cited by 56 · see citing works
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Self-citationAssociations of Urban Built Environment with Cardiovascular Risks and Mortality: a Systematic Review
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Diet and Aging: The Role of Polyphenol-Rich Diets in Slow Down the Shortening of Telomeres: A Review
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- Authors
- Martínez-González, M. A., Gea, A., & Ruiz-Canela, M.
- Affiliations
- From the Department of Preventive Medicine and Public Health, IdiSNA, Navarra Institute for Health Research, University of Navarra, Pamplona, Spain (M.A.M.-G., A.G., M.R.-C.)
- Instituto de Salud Carlos III (ES)
- ORCID
- Gea, Alfredo
- Venue
- Circulation Research
- Published
- 2019-03
- Volume
- 124
- Issue
- 5
- Pages
- 779-798
- ISSN
- 0009-7330 (ISSN-L)
- 1524-4571
- OpenAlex
- W2917793655
- Semantic Scholar
- 0490ad755099677273d0356336ce3b4b40f7f8bc
- Cited by
- 878
- References
- 175
- Citations by year
- 2026: 103 · 2025: 149 · 2024: 143 · 2023: 120 · 2022: 136 · 2021: 121 · 2020: 80 · 2019: 25 · 2012: 1
- FWCI
- 14.79
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Circulation Research (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Instituto de Salud Carlos III
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
- Health Sciences › Nursing › Nutrition and Dietetics › Fatty Acid Research and Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Keywords
- Mediterranean diet, cardiovascular health, PREDIMED trial, coronary artery disease, ischemic stroke, olive oil, monounsaturated fatty acids, dietary intervention, randomized controlled trials, prospective cohort
- MeSH terms
- Diet, Healthy, Cardiovascular Diseases, Female, Humans, Male, Nutritional Status, Nutritive Value, Risk Factors, Meta-Analysis as Topic, Randomized Controlled Trials as Topic, Risk Assessment, Evidence-Based Medicine, Diet, Mediterranean, Risk Reduction Behavior, Recommended Dietary Allowances, Observational Studies as Topic, Protective Factors
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