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The Mediterranean Diet: Science and Practice The Mediterranean diet: science and practice The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Willett, Walter C. 2006. “The Mediterranean Diet: Science and Practice.” Public Health Nutrition 9 (1a): 105–10. https:// doi.org/10.1079/phn2005931. Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:41426840 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA Public Health Nutrition: 9(1A), 105–110 DOI: 10.1079/PHN2005931 The Mediterranean diet: science and practice Walter C Willett* Department of Nutrition, Harvard School of Public Health, Huntington Avenue, Boston, MA 02115, USA Abstract Objective: To provide an overview of research relevant to the Mediterranean diet. Design: Personal perspectives. Setting: International. Subject: Populations in Europe, North America, Asia. Results: 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 Keywords healthy food choices that are consistent with the traditional Mediterranean diet. Mediterranean Conclusion: Both epidemiologic and metabolic studies suggest that individuals can Diet benefit greatly by adopting elements of Mediterranean diets. Nutrition Until very recently in history, Homo sapiens was approximately 10-fold difference in rates was observed, dependent on foods that were available in its local which was well documented by applying standardised environment. The fact that populations have survived and diagnostic criteria. This was probably the most fundamen- developed in vastly different climates and ecological tally important contribution of the study as this naturally contexts, with correspondingly variable dietary patterns, is raised the question as to why these differences existed. For a testimony to the remarkable biological and cultural each of the 14 populations that were studied, dietary data resilience of humans. Although different populations were collected in a sample of participants, and it was living in an extremely wide range of environments found that saturated fat was strongly correlated with managed to survive through reproductive age, these incidence and mortality rates of CHD. At the same time, environments and their corresponding dietary patterns Keys and other nutritionists were conducting a series of were not necessarily equal in their ability to support carefully controlled short-term feeding studies to deter- long-term health and well-being. The transplantation of mine the effects of specific types of fat on serum total plant species across continents and the development of cholesterol levels, which had recently been shown to transportation and food preservation technologies have predict CHD incidence in the Framingham cohort and dramatically increased the options of human populations other prospective studies2. The results of these controlled in selecting foods to eat. It is thus natural that the feeding studies were summarised in two competing implications of these options for health have become of equations by Keys and by Hegsted1,3. In both equations, great interest. changes in cholesterol were positively related to increases The clinical observations by Dr Grande Covian and in saturated fat, and inversely related to polyunsaturated others in Southern Europe that rates of coronary heart fat intake. Together, the Seven Countries Study and the disease (CHD) were extremely low in this region led to feeding studies had profound effects upon dietary development in the 1960s of the now-famous Seven recommendations in the 1960s and 1970s, whereby the Countries Study, coordinated by Ancel Keys1. Among the USA and other countries moved to replace saturated fat 14 populations followed within the seven countries an with polyunsaturated fat. Indeed, during the next 25 years *Corresponding author: Email [email protected] q The Author 2006 106 WC Willett polyunsaturated fat in the USA, the UK, Australia, and the total amount of calories was similar. Interestingly, the many other countries approximately doubled, and CHD drive to promote fat-free products corresponded with the rates declined by about 50%2. This dietary change was explosion of obesity in the USA and Northern Europe. quite fortuitous because the effects of saturated fat and The campaign to reduce fat intake may have contributed polyunsaturated fat on serum cholesterol are not to the rise in obesity because many nutritionists were sufficiently strong to explain either the 10-fold difference telling the public that only calories from fat would make in CHD rates or the 50% reduction in CHD following people fat, which could have helped promote the large recommendations to increase polyunsaturated fat intake. increase in consumption of carbohydrate that occurred Keys himself noted that the differences in CHD rates were during this period, as people were led to believe that fat- probably due in part to other factors besides saturated fat free products were conducive to weight loss. Soberingly, because the magnitude of these differences, even though during the late 1980s the rate of decline in CHD mortality the correlation was strong, was too great to be explained slowed and both CHD incidence and mortality due to by saturated fat intake alone. Considerable discussion has stroke began to plateau in the USA9,10. surrounded the contribution of various factors to the Until the 1980s, the investigation of dietary factors that decline in CHD, but the large increase in polyunsaturated might influence heart disease had almost entirely focused fat intake is likely to have explained much of this, on their impact on total blood cholesterol level. At that probably mediated by antithrombotic, antiarrhythmic, and time it was realised that high-density lipoprotein (HDL) insulin-sensitising effects beyond its effects on serum total was an even better predictor of CHD than was total cholesterol4. cholesterol, although the direction of this relation was In the late 1980s a major shift in dietary recommen- inverse. Similarly, high triglyceride levels were related to dations occurred in Western countries, departing from the heart disease in a positive direction. In a seminal message to increase polyunsaturated fat and reduce controlled feeding study, Drs Mensink and Katan11 saturated fat to the idea that all types of fat in the diet compared a diet in which 10% of energy from saturated should be reduced. The origin of this policy is somewhat fat was replaced either with olive oil or with complex hard to determine, but many nutritionists apparently carbohydrates. Thus, the olive oil was nutritionally much believed that individuals would find it too difficult to like a Mediterranean-type diet, and the complex carbo- understand the differences in types of fat and that it was hydrate diet was similar to that being advocated by the easier just to tell them to reduce all fat, even though the American Heart Association and other organisations. In goal was to reduce saturated fat. This policy appears to this feeding study total cholesterol levels dropped have had no empirical basis, as it could well be easier to similarly in both groups, but on the high carbohydrate substitute one type of fat for another rather than to reduce diet HDL was depressed and triglycerides rose. Thus, all fat in the diet. Also, nutritionists during that period else being equal, one would have predicted a lower rate of appeared to have forgotten other findings of the Seven CHD with the higher fat/olive oil diet. This finding has Countries Study. Importantly, total fat was not significantly been reproduced repeatedly, and has become an related to CHD rates because countries with both the important element in understanding the health benefits lowest and the highest rates of CHD had similar intakes of of the Mediterranean diet. total fat as a percentage of total energy intake. The obvious Subsequently, Mensink and Katan12 conducted a difference was, of course, that the nature of the fat was controlled feeding study comparing 10% of energy from completely different; in the north of Europe this was saturated fat with 10% of energy from trans unsaturated primarily dairy fat and lard, whereas in Crete (the lowest fatty acids (trans fat) produced by partial hydrogenation of risk area) and
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