Mediterranean diet decreases risk for CVD events in women

Randolph Martin, MD

This study confirms what other studies have shown previously and confirms the reason that the Mediterranean diet was just selected as the No. 1 best diet by U.S. News and World Report. It is based upon a diet of the countries around the Mediterranean basin. It historically has been a very healthy diet, but even more importantly, a healthy lifestyle because if you look at the food pyramid of the Mediterranean diet, the base of it includes exercise and socialization, all things that are very important in the Mediterranean society.

There have been two classic studies. The Lyon Diet Heart Study (Kris-Etherton P, et al. Circulation. 2001;103:1823–1825.) was done in the late 1990s in 605 French men who had MI. They compared a Mediterranean diet to the American Heart Association’s low-fat, high-carbohydrate controlled diet and found that men randomly assigned to the Mediterranean diet had a 50% to 70% lower risk for recurrent MI. That was very strong.

The second and equally important with findings much similar to this current study was the PREDIMED study (Estruch R, et al. N Engl J Med. 2013;doi:10.1056/nejmoa1200303.) of almost 7,500 people from Spain who all had risk factors for heart disease. They may have been overweight, smoking or had diabetes. It was interesting in that they took people on a Mediterranean diet with a lot of extra virgin olive oil or a Mediterranean diet with a lot of extra walnuts, almonds and hazelnuts vs. those who would be on a low-fat diet and followed them. That study was stopped after 5 years because the results were so dramatic in that there was a 30% decrease in the risk for heart disease and MI. In fact, people even lost weight.

This study that was just published in JAMA was not a dietary controlled study, but it did have very interesting and similar findings as the previous two studies. There were almost 26,000 women who were 45 years or older, and they were put on a trial to compare aspirin vs. vitamin E regarding in the outcome of heart disease and other events. They filled out dietary questionnaires and had bloodwork done. From those questionnaires, the authors of the current study could determine those who followed a Mediterranean diet extensively, or what they called the highest Mediterranean diet, vs. those with a very low following. It showed about a 25% reduction in the risk for heart attacks and strokes. It is very similar.

People have to fill out a dietary questionnaire, so it is not as if you are feeding them a controlled diet as was in the PREDIMED study. All of them have shown unequivocally that there are reductions in CV events, MI, strokes and dying from CVD that are pretty dramatic. There are other effects that have been seen like a decrease in body weight, cancer mortality and diabetes over time.

My major takeaway is that this confirms what we have known previously, that if you are rigorous in following the Mediterranean diet, whether you are male or female, it decreases your risk for CV events.

More importantly, for clinical practice, a Mediterranean diet is really more like a Mediterranean lifestyle: This is a way to eat for life and it is a way to also incorporate things we know are good for you, which is regular exercise — it could be gardening, it could be walking — and to continue to be socially engaged in your environment with friends and family or people in your religious institution.

In my years of practice, I have tried to get patients to follow a Mediterranean diet because it is a very healthy diet, one that is palatable and it restricts processed foods, excessive red meat and prohibits red meat and restricts sugar, but does not restrict alcohol in moderation.

It is hard for most people to start a Mediterranean diet. What you have to do is to give patients the evidence and then give them a simple pathway to follow this. There are so many diets out there and so many books on diets, but it is really about incorporating a healthy way to eat and a healthy way to live. That is why the base of the Mediterranean diet pyramid is exercise and socialization. That is very important in any diet. What is important is to explain to patients what the Mediterranean diet is and give them information or where they can find more information. It is staying away from processed and refined carbohydrates, excessive processed meats, looking at the common sense things that we’ve known for a long time like eating lots of fruit on a daily basis, lots of vegetables, especially those with color like beans, peas and nuts, having fish if you like it three times per week and beginning to think about the way that whole grains and fresh fruits and vegetables are healthy for you.

It is probably a more achievable diet than a pure vegan or vegetarian diet. While those have proven to be good, they are tough for people. The Mediterranean diet has historical background, it has scientific background and it incorporates how you eat into how you live. That is going to be extremely important.

The researchers also showed in one of their figures the things that everyone has shown before, that when you are on a Mediterranean diet, you decrease the inflammation in your body. Inflammation is the culprit in promoting CVD and even some cancers. You decrease the resistance in insulin, which is one of the common ways that people develop type 2 diabetes. You decrease your BP and the way you handle blood sugar. It has a lot of metabolic healthy effects.

If you can get patients to understand its importance and begin eating this way and living this way, it is probably one of the most striking things you can do to improve your overall health and well-being.

We have a tremendous amount of research that says that this is an excellent way for people to eat and incorporate it into their lifestyle. I am not convinced that we need more research on this because there is too much historical proof on this.