Observational Study Results

Since the publication of the Seven Countries study, others have examined the association between the consumption of Mediterranean dietary pattern and risk of CHD. Notably, the characterization of the diet has required development of a Mediterranean-diet score that incorporates salient characteristics of this diet.29 A scale of 0-9 was created and indicates the degree of adherence to the traditional Mediterranean diet.

Table 2.1 Characteristics of the 1960 Crete, a.k.a "Mediterranean diet," compared with the average diet consumed by the United States men (age 40-59 years) and diets tested within the setting of randomized clinical trails

Mediterranean-like diets

Table 2.1 Characteristics of the 1960 Crete, a.k.a "Mediterranean diet," compared with the average diet consumed by the United States men (age 40-59 years) and diets tested within the setting of randomized clinical trails

Mediterranean-like diets

Typical US

Lyon Diet

Indo-

diet men age

Heart Study

Mediterranean

OMNI/

OMNI/

40-59 (1997-

clinical trial

Diet Heart

DASH/Prudent

Carbohydrate

OMNI/Protein

Unsaturated fat

Dietary pattern

1999) (Zhou31)

Crete I96012

(de Lorgeril8) Study25)

American2

diet3)

diet3

diet3

Source of diet

24 h dietary

Food record

Unspecified

7-day detailed

Analyses of

Analyses of

Analyses of

Analyses of

information

recall

diet

food diary

composited

composited

composited

composited

survey

meals and

meals and

meals and

meals and

from menus

from menus

from menus

from menus

Fat (%kcal)

33.3

41.9

30.4

26.3

25.6

27

27

37

Saturated (%kcal)

10.8

8.9

8

8.2

7

6

6

6

Polyunsaturated

7.0

4.4

4.6

8.1

6.8

8

8

10

(% kcal)

Monounsaturated

12.4

26.8

17.

10

9.9

13

13

21

(% kcal)

Protein {% kcal)

15.6

12.5

16.2

14.2

17.9

15

25

15

% protein from plant

32

35

36

48

36

Carbohydrates

48.4

43

53.4

59.5

56.5

58

48

48

(% kcal)

Fiber (g/1,000 kcal)

8.2

15.2

9.6

23.9

14.8

14.3

14.3

14.3

Cholesterol

133

74.5

104

62

72

71

71

71

(mg/1,000 kcal)

Alcohol {% kcal)

2.7

2.7

5.8

<2

<2

Table 2.1 (continued)

Mediterranean-like diets

Table 2.1 (continued)

Mediterranean-like diets

Typical US

Lyon Diet

diet men age

Heart Study

Indo-

40-59

clinical trial

Mediterranean

DASH/

OMNI/

OMNI/

(1997-1999)

(de Lorgeril

Diet Heart

Prudent

Carbohydrate

OMNI/Protein

Unsaturated fat

Dietary pattern

(Zhou 2000)

Crete I96012

1994)

Study25)

American2

diet3)

diet3

diet3

Description

High in fruits.

Emphasizes

Emphasizes

Emphasizes

Similar to

Approximately

Emphasized

vegetables.

bread, root

low total

fruits.

DASH

50% of

Monounsaturated

bread.

vegetables.

fat

vegetables.

except for

protein from

fat-included olive

cereals.

green

(<30%),

and low-

slightly

plants

oil, canola, safflower

potatoes.

vegetables.

saturated

fat dairy

reduced

(legumes.

oils, and a variety of

beans, nuts.

fish, poul

fat (<10%)

products;

protein

grains, nuts.

nuts and seeds to

and seeds;

try, and is

and

includes

and seeds)

meet targeted fatty

includes

reduced in

cholesterol

whole

acid distribution

olive oil.

red meat.

(<300 mg/

grains.

dairy prod

Butter and

day.) In

poultry.

7s

ucts, fish.

cream

addition.

fish, and

poultry.

replaced

empha

nuts; and

wine, and

with marga

sizes fruits.

is reduced

g

eggs; and

rine rich in

vegetables.

in red meat

n*

is reduced

Alpha-lino-

nuts.

and sweets

in red meat

lenic acid

whole grains, and oils rich in linolenic

M

acid

OQ n

Table 2.2 Dietary features characteristic of the traditional Mediterranean diet29 High intake of vegetables, legumes, fruits, nuts, and whole-grain non-refined cereals High intake of olive oil Low intake of saturated fats Moderately high intake of fish

Low to moderate intake of dairy products (mostly yogurt and cheese) Low intake of meat and poultry

Regular but moderate intake of alcohol (primarily wine with meals)

A value of 0 or 1 was assigned to each of nine components with the use of sex-specific median as a cut-off. For beneficial components (vegetables, legumes, fruits and nuts, cereal, high monounsaturated fat intake, and fish), persons whose consumption was below the median were assigned a value of 0, and persons whose consumption was above the median were assigned a value of 1. For components presumed to be detrimental (meat, poultry, and dairy products), persons whose consumption was below the median were assigned a value of 1, and persons whose consumption was at or above the median were assigned a value of 0. For alcohol, a value of 1 was assigned for those who consumed between 5 and 25 g/day and 0 to those with more or less consumption.

In a prospective study of 22,043 adults in Greece followed for 44 months, there was a reduction in total mortality (adjusted hazards ratio (HR) = 0.75, 95% confidence interval (CI), 0.64-0.87) and in death due to CHD (HR = 0.67, 95% CI, 0.59-0.98) associated with a two point increment in the Mediterranean diet score.29 A subgroup analysis of those with prevalent CVD at baseline, showed that adherence to the diet by two units was associated with a 27% lower total mortality (HR = 0.73, 95% CI, 0.58-0.93) and 31% lower risk of cardiac deaths (HR = 0.69, 95% CI, 0.52-0.93).28 Hence, the diet was associated with a reduced risk of CVD in both those with and without prevalent disease. This Greek population was part of the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort study that reported results for the entire cohort of 74,607 men and women from 10 European countries. In the entire cohort, using a similar scoring technique, each 2 point increment in the diet score was associated with a reduction of 8% in total mortality (95% CI, 3-12%).30

The Healthy Ageing Longitudinal study in Europe (HALE), examined singly the effects of consumption of the Mediterranean diet, and in combination with being physically active, moderate alcohol use, and nonsmoking on 10 year all-cause and CHD mortality in 2,339 men and women ages 70-90 from 11 European countries.13 Adherence to the Mediterranean diet was associated with a significant reduction in all-cause mortality (HR = 0.77, 95% CI, 0.68-0.88). Adherence to the Mediterranean diet combined with additional diet and lifestyle factors lowered the all-cause mortality rate (HR = 0.35, 95% CI, 0.28-0.44). In total, lack of adherence to this low risk pattern was associated with a population attributable risk of 60% for all deaths, 64% for deaths from coronary heart disease, and 61% from cardiovascular diseases.

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