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Natalie Jane Maglich

N00919055

HUN 3800

Literature Review

Professor Yu

October 28, 2016

Mediterranean Diet and Cardiovascular Disease

Title:
Can the Mediterranean Diet Delay the Onset of Heart Disease in Adults Compared to an
American Diet?
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Introduction

Cardiovascular disease, also known as heart and blood disease includes numerous

problems, many of which are related to atherosclerosis. Atherosclerosis is a condition in the body

where plaque builds up in the walls of the arteries, constricts blood flow, and makes it difficult

for blood to flow through. If blood clots form this can cause a serious life-threatening problem

such as a heart attack or stroke2. On average almost 2,200 Americans die of cardiovascular

disease each day, this is equivalent to one death every 40 second. In addition, hypertension in the

U.S. has risen to almost 33% of all Americans1. These numbers have reached a record high in the

past years, and will continue to rise because of the poor Western diet that Americans are

consuming. Scientists and doctors have studied and conducted research on lowering the risk of

cardiovascular disease because of how prevalent it has become. Scientists have found a positive

correlation between the effects of a Mediterranean diet and its beneficial properties, which fight

against Cardiovascular Disease.

Historical Studies of the Mediterranean Diet and Cardiovascular Disease

Prior to the 1960s, inhabitants of Crete and other parts of Greece accounted for the

lowest rates of cardiovascular disease in the world. Ancel Keys, a nutrition research pioneer and

his colleagues led an ecological study on this occurrence. The Seven Country study ran from

1958 to 1983, and focused on lifestyle and diet patterns of 16 different populations. After the

study was completed Key came up with his lipid hypothesis: that the rate of coronary disease in

populations and individuals was related to fat composition of their diet and their serum

cholesterol levels. The study did not measure variables such as low obesity rates, high-physical

activity, or genetics, which could have skewed the results. Therefore, scientist cannot conclude

that diet alone created these positive health effects. Key suggested that this study introduce the
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concept of how a Mediterranean diet combined with exercise could delay the onset of heart

disease. The Mediterranean diet is based off of the traditional diet of those who lived off of the

Mediterranean Sea. Their diets were high in fruits and vegetables, nuts, unrefined grains,

legumes, fish and olive oil as a fat source4. In addition, using herbs and spices instead of salt for

flavor, limiting red meat to no more than a few times a month, eating fish and poultry twice a

week, and drinking red wine in moderation3. The studies presented in this literature review

summarize the findings on whether the Mediterranean diet combined with exercise could delay

the onset of heart disease in Americans.

Mediterranean Diet, Cardiovascular Disease and Risk Factors

A Mediterranean Diet has had significant promise in reducing the risk of cardiovascular

disease. The New England Journal of Medicine conducted a research study on primary

prevention of cardiovascular disease with a Mediterranean diet. The trial was conducted in

Spain, they randomly assigned participants who were at a high cardiovascular risk, but with no

cardiovascular disease to one of three diets: a Mediterranean diet supplemented with extra-virgin

olive oil, a Mediterranean diet supplemented with mixed nuts, and a control diet (which they

advised to reduce dietary fat). In total, 7447 persons were enrolled with an age range of 55 to 80

years old. The subjects in the Mediterranean diet and control group all received individual

training from dieticians and group dietary training. The median follow-up period was 4.8 years.

There was a total of 288 primary-outcome events which include 96 in the group assigned to the

Mediterranean diet with extra-virgin olive oil, 83 in the group assigned to Mediterranean diet

with nuts, and 109 in the control group. In this trial, the subjects diets that were supplemented

with either extra-virgin olive oil or nuts resulted in a risk reduction of approximately three major

cardiovascular diseases, for a relative risk reduction of 30% among high-risk patients5. The
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results of this study support the benefits of the Mediterranean diet and cardiovascular risk

reduction. Another study completed in Sicily, Italy further supports the statement of the

protective role the Mediterranean diet has on several cardiovascular risk factors. The aim of this

study was to asses the association between the adherence to the Mediterranean diet and

cardiovascular risk factors: obesity, diabetes, and hypertension. The survey included 3090

subjects where their food intake was evaluated through a validated food frequency questionnaire

and their adherence to the diet was assessed using MedDietScore. Blood pressure, BMI, and

waist circumference were measured before, as well as a questionnaire, which included questions

about demographics, dietary and lifestyle habits of the participants. The results states that those

who had a higher adherence to the Mediterranean diet were less likely to be obese, hypertensive,

and diabetic. They found an association between a higher adherence to the Mediterranean diet

and a lower likelihood of being hypertensive. On the contrary, the analysis on blood pressure

demonstrated a weak association between the Mediterranean diet with this variable, because

those who had high blood pressure were less likely to follow the dietary pattern. It can also be

considered that variables such as age, physical activity, and smoking may play a stronger role for

this risk factor. They also found that a greater adherence to the Mediterranean diet was correlated

with a lower likelihood of obesity. Following the Mediterranean diet has also showed beneficial

results on decreased insulin resistance. The protective role of a diet rich in virgin olive oil on

insulin resistance is dependent upon the amount of polyunsaturated fatty acids, which had results

beneficial to those who had diabetes. These results could potentially help patients with diabetes

to improve insulin sensitivity. The finding from this study may have been affected by re-call

bias, but the findings are valuable indications that adherence to the Mediterranean diet could

have beneficial effects on cardiovascular disease risk factors7.

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Mediterranean Diet and Obese Patients

Obesity is directly related to cardiovascular disease, and is one of the main causes of

morbidity. Obesity has become a worldwide epidemic, and their needs to be long-term

interventions to decrease this trend. A study completed by the European Journal of Clinical

Nutrition researched the effect of a moderately hypoenergetic Mediterranean diet and exercise

program on body cell mass and cardiovascular disease risk factors in obese women. The study

includes adult obese women between the ages of 25-70 years of age, who were placed on a

Mediterranean diet. The participants received written instructions about the quantity and quality

of foods, and were required to weigh their food daily before consumption. Every 2 weeks the

subjects received a new list of foods to increase variety in their diet, and were also provided with

cooking instructions. The study also required them to engage in supervised exercise training such

as bicycling and running two days per week for 60 minutes. At the end of the study, 47 out of the

60 participants completed the entire study. At two and four months, body weight, BMI, and fat

mass had decreased significantly. In addition, there was also a decrease in serum total cholesterol

concentrations and serum triglyceride concentration. LDL-C concentrations were lowered, and

respectively HDL-C concentrations were increased at four months. Overall, this study has

shown that body cell mass and cardiovascular disease risk factors can be improved with this diet

and exercise program. Limitations to this study include the absence of a control group, the

relatively small sample size, and controlling the dietary intake of the participants who were free-

living. Besides these limitations in this study, it is still a good insight on how a hypoenergetic

Mediterranean diet can be effective in maintaining body cell mass, and improving cardiovascular

disease risk factors in obese women11.

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Another study completed by Bach, Buckland, and Serra-Majem completed a review of

observational and intervention studies between the correlation of obesity and Mediterranean

Diet. This literature involves 21 epidemiological studies that investigated the relationship

between the Mediterranean diet and weight loss. These studies included seven cross-sectional,

three cohort, and 11 intervention studies. The studies were carried out between the years of 2000

and 2007 in eight different countries. The health statuses of the subjects were grouped into three

groups: (i) healthy individual without chronic disease, (ii) obese individuals, and (iii) individuals

with chronic disease, such as cardiovascular disease. Out of the 21 studies, 13 found adherence

to the Mediterranean diet was more beneficial to weight loss in obese patients, and eight studies

found that there was no significant association between the two. None of the studies reported that

a Mediterranean diet considerably increased obesity. Just over half of the studies reported

adherence to the Mediterranean diet was associated with less overweight individuals and

promoted weight loss. In the cohort study they had found that in men who followed the

Mediterranean diet were 29% less likely to become obese. In addition, the cross-sectional studies

they saw up to 51% less probability of being overweight. Even though the data in this study is

inconsistent it stills shows promise between the beneficial properties of the Mediterranean diet

and obesity. Obesity can also be understood as a risk factor for cardiovascular disease. Following

a Mediterranean diet lifestyle could significantly reduce weight in obese individuals resulting in

a less likely chance of them developing cardiovascular disease or atherosclerosis. In obese

individuals the Mediterranean diet could be an intervention for reducing the risk factors of

cardiovascular disease8.
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Mediterranean Diet and Elderly Patients

The purpose of this study completed in the Province of Ikaria Island from 2009

was to learn about the impact of long-term adherence to the Mediterranean diet on serum uric

acid levels in elderly individuals, without known cardiovascular disease. Hyperuricaemia

concentrations above 450mol/L in males and 360mol/liter in females have been associated

with increased oxidative stress, and some studies have shown it to be linked to cardiovascular

morbidity and mortality. Serum UA concentrations have been linked to four major processes:

dietary purine intake, endogenous purine metabolism, urinary urate excretion and intestinal

uricolysis. Among other factors, diet has been a leading developmental factor of hyperuricaemia.

This cross-sectional study took 257 males and 281 females, all inhabitants of the island. A diet

score that assesses adherence to the Mediterranean diet was applied to each participant. After

four months measures were taken for all participants and the results were as follows. Overall

they found the MedDietScore was inversely proportional to UA levels, the better they adhered to

the diet the lower the UA levels were. However when the analysis was stratified by gender, the

MedDietScore was only inversely proportional in males. This can be attributed to the already

low levels of UA in women, which may weaken the impact of dietary changes on their levels.

Although the effects of the Mediterranean diet on hyperuricemia have not been studied

thoroughly, this study shows promise that lowering UA levels may decrease the onset of

cardiovascular disease in elderly patients. Further studies may be done to assess the

Mediterranean diet and UA levels, and the differences in men and women12.

Another research study looks at a compilation of studies that provide the possible

beneficial properties of the Mediterranean Diet and coronary heart disease in the elderly.

Investigators from Lyon Heart Study examined 605 patients from age 55-80 years old with
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previous myocardial infarction and they found that the benefits of the Mediterranean diet were

extended to a secondary prevention of cardiovascular disease. They found that those who

followed the diet had a 50-70% lower risk of a recurrent heart disease, compared to those who

followed a diet recommended by the American Heart Association. Another study done by

CARDIO2000 investigators studied a sample of 848 middle-aged and older patients with

previous cardiovascular problems. This study found a 23% reduction in the risk of developing a

first event of acute coronary syndrome. In an ATTICA study of 3042 adult men and women from

Greece, investigators observed participants with high blood pressure were less likely to consume

the Mediterranean diet compared to those with normal blood pressure. The consumption of a

Mediterranean diet was associated with a 26% lower relative risk of being hypertensive. A

prospective study completed in 2003 found an inverse relationship between adherence to the

Mediterranean diet and death from coronary heart disease. This was significant among adults 55

and older, but not among young participants. Lastly, Kouris-Blazos and colleagues completed a

study of 141 Anglo Celts and 189 Greek Australians who were all older than 70 years. They

concluded that a diet that followed the Mediterranean diet principles was associated with a

longer life expectancy. In these studies they have found that adherence with this diet in elderly

patients helps decrease the risk of additional cardiovascular problems. Elderly patients are

already at a higher risk for recurrent heart diseases, so intervention for hypertensive elderly

patients and with previous myocardial infarctions will be beneficial9.

Application to Nutritional Field

The rise in cardiovascular disease among the American people makes this topic directly

applicable to the nutritional field. One of the many problems Americans are facing is consuming

a Western diet high in refined sugars and low in healthy fats. This is why Americans have such a
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high rate of cardiovascular disease. Using this information a Registered Dietician (RD) could

directly affect individuals who are at high risk for cardiovascular disease. A RD could potentially

work in a hospital on a cardiovascular floor helping patients transition their diet to live a healthy

lifestyle. These measures could help in recovery and decrease the probability of individuals

having another life threatening event. In addition, an RD could work on the preventative side, for

example, work with patients who have high cholesterol levels or who are hypertensive. This

could significantly decrease the likelihood of them developing cardiovascular disease and could

help with weight loss and lead to a healthier lifestyle.

Conclusion

In conclusion, the major findings reviewed above agree with the statement that adherence

to the Mediterranean diet can significantly delay the onset of heart disease and decrease the risk

factors for it compared to an American diet. The Mediterranean diet has been dated back to the

1960s from people of Crete who show a longer life expectancy and decrease in cardiovascular

disease. With this information, scientists have done further studies on how this diet can prevent

the onset of cardiovascular disease in patients who are at high risk for developing it. They also

found that with adherence to the Mediterranean diet it has potential to decrease obesity,

hypertension, and insulin sensitivity. These findings are applicable to doctors studying

cardiovascular disease, obesity, and diabetes because of the beneficial properties that this diet

has shown. Moving forward, areas for future studies could look into the different types of fat that

cause this diet to work so well. They could also look into how the diet affects men, women and

ethnic populations differently. The major findings of this review all support that the

Mediterranean Diet has potential to delay the onset of Heart disease in adults compared to an

American diet.
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Resources
1. What is Cardiovascular disease?

http://www.heart.org/HEARTORG/Caregiver/Resources/WhatisCardiovascularDisease/

What-is-Cardiovascular- Disease_UCM_301852_Article.jsp#.V_

HIEJMrJsM. Accessed October 3, 2016.

2. Mozoffarian D, Benjamin EJ, GO AS, et al. Heart disease and stroke Statistics-2016

update. AHA Statistical Update. January 2015:350.doi:10.1161/CIR.

Http://circ.ahajournals.org/content/early/2015/12/16.Accessed October

3. Robson D. Positive effects of the Mediterranean Diet and the Prevention and

Management of Cardiovascular Disease: A Literature Review . Excellence in Student

Research. 2014;20:200-205.

4. Staff MC. Nutrition and healthy eating Mediterranean diet: A heart-healthy eating

plan.Mayoclinic. May 2016. http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-

healthy-eating/in-depth/mediterranean-diet/art-20047801. Accessed October 3, 2016.

5. Estruch R. Effects of Mediterranean diet on the primary prevention of cardiovascular

disease. The New England Journal of Medicine. 2013;368:1279-1290.

doi:10.1186/isrctn35739639.
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6. Grosso G, Pajak A, Mistretta A, et al. Protective role of the Mediterranean diet on

several cardiovascular risk factors: Evidence from Sicily, southern Italy. Nutrition,

Metabolism and Cardiovascular Diseases. 2014;24(4):370-377.

doi:10.1016/j.numecd.2013.09.020.

7. Andreoli A, Lauro S, Daniele ND, Sorge R, Celi M, Volpe SL. Effect of a moderately

hypoenergetic Mediterranean diet and exercise program on body cell mass and

cardiovascular risk factors in obese women. European Journal of Clinical Nutrition Eur J

Clin Nutr. 2007;62(7):892-897. doi:10.1038/sj.ejcn.1602800.

8. Buckland G, Bach A, Serra-Majem L. Obesity and the Mediterranean diet: a

systematic review of observational and intervention studies. Obesity Reviews.

2008;9(6):582-593. doi:10.1111/j.1467-789x.2008.00503.x.

9. Chrysohoou C, Skoumas J, Pitsavos C, et al. Long-term adherence to the Mediterranean diet

reduces the prevalence of hyperuricaemia in elderly individuals, without known

cardiovascular disease: The Ikaria study. Maturitas. 2011;70(1):58-64.

doi:10.1016/j.maturitas.2011.06.003.

10. Dontas AS, Zerefos NS, Panagiotakos DB, Valis DA. Mediterranean diet and

prevention of coronary heart disease in the elderly. Mediterranean diet and prevention of

coronary heart disease in the elderly. 2007;2(1):109-115. doi:10.2147/ciia.2007.2.1.109.

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