To provide an overview of research relevant to the Mediterranean diet.

Personal perspectives.

International.

Populations in Europe, North America, Asia.

Approximately 50 years ago, Keys and colleagues described strikingly low rates of coronary heart disease in the Mediterranean region, where fat intake was relatively high but largely from olive oil. Subsequent controlled feeding studies have shown that compared to carbohydrate, both monounsaturated and polyunsaturated fats reduce LDL and triglycerides and increase HDL cholesterol. Importantly, these beneficial metabolic effects are greater in the presence of underlying insulin resistance. In a detailed analysis within the Nurses' Health Study, trans fat from partially hydrogenated vegetable oils (absent in traditional Mediterranean diets) was most strongly related to risk of heart disease, and both polyunsaturated and monounsaturated fat were inversely associated with risk. Epidemiologic evidence has also supported beneficial effects of higher intakes of fruits and vegetables, whole grains, fish, and daily consumption of moderate amounts of alcohol. Together with regular physical activity and not smoking, our analyses suggest that over 80% of coronary heart disease, 70% of stroke, and 90% of type 2 diabetes can be avoided by healthy food choices that are consistent with the traditional Mediterranean diet.

Both epidemiologic and metabolic studies suggest that individuals can benefit greatly by adopting elements of Mediterranean diets.

To put the debate on the Mediterranean diet in context by highlighting historical and prospective changes in the level and composition of food consumption in the world and key Mediterranean countries.

Data from FAO's food balance sheets are used to illustrate historical evolution. Projections to 2030 are presented from FAO's recent and ongoing work on exploring world food and agriculture futures.

International.

Many developing countries are undergoing diet transitions bringing them closer to the diets prevalent in the richer countries, i.e. with more energy-dense foods. There follows an increase in the incidence of diet-related non-communicable diseases, which are superimposed on the health problems related to undernutrition that still afflict them. In parallel, many low-income countries are making little progress towards raising food consumption levels necessary for good nutrition and food security. Wider adoption of food consumption patterns akin to those of the Mediterranean diet hold promise of contributing to mitigate adverse effects of such diet transitions. However, the evolution of food consumption in the Mediterranean countries themselves is not encouraging, as these countries have also followed the trend towards higher shares of energy-dense foods. Possible policy responses to these problems include measures to raise awareness of the benefits of healthier diets and/or to change relative food prices in favour of such diets (by taxing fattening foods) or, at the extreme, making individuals who follow ‘bad’ diets, and thus are prone to associated diseases, bear a higher part of the consequent costs borne by the public health systems (tax fat people).

To discuss present knowledge about Mediterranean diet and cardiovascular diseases.

Review of existing literature.

Epidemiological studies as well as randomised dietary trials suggest that Mediterranean diet may be important in relation to the pathogenesis (and prevention) of CHD. For instance, a striking protective effect of an ALA-rich Mediterranean diet was reported in the Lyon Diet Heart Study with a 50 to 70% reduction of the risk of recurrence after 4 years of follow-up in CHD patients. According to our current knowledge, dietary ALA should represent about 0.6 to 1% of total daily energy or about 2 g per day in patients following a Mediterranean diet, whereas the average intake in linoleic acid should not exceed 7 g per day. Supplementation with very-long-chain omega-3 fatty acids (about 1 g per day) in patients following a Mediterranean type of diet was shown to decrease the risk of cardiac death by 30% and of sudden cardiac death by 45% in the GISSI trial.

In the context of a diet rich in oleic acid, poor in saturated fats and low in omega-6 fatty acids (a dietary pattern characterising the traditional Mediterranean diet), even small doses of omega-3 fatty acids (about 1 g EPA + DHA the form of fish oil capsules or 2 g α-linolenic acid in canola oil and margarine) might be very protective. These data underline the importance of the accompanying diet in any dietary strategy using fatty acid complements.

To describe the main finding produced so far by the EPIC project, which aims to improve the scientific knowledge of nutritional factors involved in cancer.

Prospective cohort study in 23 centres from 10 European countries. Dietary assessment method varied by countries: in some cases a diet history by personal interview was carried out, while in most countries a self-administered semi-quantitative food-frequency questionnaire was used; in one case the questionnaire was combined with a food record. Information on a wide range of lifestyle factors and anthropometric measurements were also collected for most participants.

The cohort includes 521 468 men and women mostly aged between 39 and 69 years, whereas blood samples are available for 387 889 subjects.

To date 24 185 cancer cases have been identified in the follow-up of the cohort. The publications produced by each centre can be consulted on the EPIC website (http://www.iarc.fr/epic/). Among initial findings concerning the associations between cancer and dietary factors, one of the most important results is a protective effect of high fibre intake and fish consumption against colorectal cancer, while high red and processed meat intake increase the risk. Regarding lung cancer the first analyses found a protective effect of fruit intake but no association with vegetable consumption. No association was observed between vegetables and fruit intake and the risk of prostate cancer or breast cancer. Finally, data from Cambridge point to an interesting result regarding breast cancer: no association was observed with saturated fat intake measured by food-frequency questionnaire, but according to the food diary a daily intake of 35 g doubles the risk of breast cancer compared to women with daily intake of 10 g or less.

Cohort study (the SUN project) to identify dietary determinants of hypertension, diabetes, obesity and coronary heart disease (CHD), among other conditions.

The SUN project is a Mediterranean dynamic prospective follow-up (cohort) study assessing participants every 2 years. The recruitment started in 2000 and it is permanently open (this is a dynamic cohort). A preliminary case–control study of myocardial infarction was also conducted, selecting incident cases of myocardial infarction and matched hospital controls.

The SUN study is conducted in Spain with university graduates, most of them being former students of the University of Navarra. The case–control study was conducted in three tertiary hospitals in the city of Pamplona (Spain).

The case–control study included 171 cases and 171 controls. We have currently enrolled more than 17 500 participants in the SUN cohort. Approximately 7500 of them were enrolled less than 2 years ago, and have not received yet the invitation to complete the 2-year follow-up assessment. The follow-up rate for the first 10 000 participants approaches 90%.

The case–control study found inverse associations between olive oil (or adherence to a Mediterranean food pattern) and myocardial infarction. In the SUN cohort, after 28.5 months of follow-up a higher adherence to a Mediterranean food pattern rich in olive oil was associated with a reduced risk of hypertension, though the results were statistically significant only among men.

The SUN study and the accompanying case–control study support the benefits of a Mediterranean diet and olive oil against CHD and hypertension.

To fulfil a comprehensive approach to consumption, which is necessary to characterise food habits and their relationship to diseases, using a diet quality index (DQI) developed for a Mediterranean region (Med-DQI).

A cross-sectional nutritional survey provided the data for the construction of the DQI.

A representative sample made up of 964 subjects from a French Mediterranean area, Hérault département.

Foods such as olive oil, fish and cereals were used instead of nutrients to build up scores which constructed the Med-DQI. Biochemical analysis identified biomarkers used to validate the Med-DQI. Correspondence factorial analysis illustrated the characteristics of subjects with different scores given by the Med-DQI.

The subjects could be satisfactorily classified by the Med-DQI. The oldest age, less educated, overweight, manual workers, living in a rural area and male classes showed a better Med-DQI. For women, they were also from the oldest age class, but some of them were from the upper social class, with an ideal BMI and lived by the Mediterranean shore. A composite biomarker index, based on plasma carotene and vitamin E levels and the percentage of EPA and DHA in erythrocytes membranes, can identify subjects with good and poor Med-DQI.

Med-DQI G is a good instrument to identify groups at risk with regard to nutritional quality. Subjects with α+β-carotene levels > 1 mg/l, vitamin E > 30 mg/l, EPA > 0.65% and DHA > 4% of fatty acids in erythrocytes are likely to have a good diet.

The Healthy Eating Index (HEI), designed to assess adherence to the Dietary Guidelines for Americans and the Food Guide Pyramid, was previously associated with only a small reduction in major chronic disease risk in US adult men and women. We assessed whether an alternate index would better predict risk.

Dietary intake reported by men and women from two prospective cohorts was scored according to an a priori designed Alternate Healthy Eating Index (AHEI). In contrast with the original HEI, the AHEI distinguished quality within food groups and acknowledged health benefits of unsaturated oils. The score was then used to predict development of CVD, cancer or other causes of death in the same population previously tested.

67 271 women from the Nurses' Health Study and 38 615 men from the Health Professionals' Follow-up Study.

Men and women with AHEI scores in the top vs. bottom quintile had a significant 20% and 11% reduction in overall major chronic disease, respectively. Reductions were stronger for CVD risk in men (RR = 0.61, 95% CI 0.49–0.75) and women (RR = 0.72, 95% CI 0.60–0.86). The score did not predict cancer risk.

The AHEI was twice as strong at predicting major chronic disease and CVD risk compared to the original HEI, suggesting that major chronic disease risk can be further reduced with more comprehensive and detailed dietary guidance.

The aim of the present paper is to describe the development of the National Plan of Action for Food and Nutrition (NPAFN) for Turkey.

Access to a safe and healthy variety of food, a fundamental human right, was stressed by the International Conference on Nutrition and by the World Food Summit. In the International Conference on Nutrition in December 1992, one major commitment was the preparation of NPAFN. The NPAFN for Turkey was designed according to this commitment.

Turkey.

To this end, under the coordination of the State Planning Organization, a Working Committee Report for National Food and Nutrition Strategy of Turkey was prepared and published, with the participation of different sectors. The goal of the prepared National Food and Nutrition Strategy for Turkey is to protect and promote health through and healthy nutrition and reduce the burden of diseases, while contributing to socio-economic development and a sustainable food security.

In Turkey the NPAFN was developed and implementation has initiated. Nearly for all the actions, related projects are being developed.

Breast cancer mortality and incidence rates in the Canary Islands, and particularly in Gran Canaria, are higher than those in the rest of Spain.

A case–control study was designed to assess the role of differential fatty acid intakes and olive oil consumption on breast cancer risk in the Canary Islands. The study was conducted between 1999 and 2001, including a total of 755 women: 291 incident cases with confirmed breast cancer and 464 controls randomly selected from the Canary Island Nutrition Survey (ENCA). A semi-quantitative food-frequency questionnaire was completed and potential confounders were adjusted using unconditional logistic regression.

Compared to the first quintile of intake, the highest quintile of monounsaturated fat intake was significantly related to a lower risk of breast cancer (odds ratio = 0.52; 95% CI 0.30–0.92). Regarding olive oil, the odds ratio for women in the three upper quintiles of consumption (≥8.8 g/day) was 0.27 (95% CI 0.17–0.42).

Our results support the protective role of olive oil consumption on breast cancer among Canaries women.