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FROM THE ACADEMY Question of the Month I Have a Client Who Wants to Follow the Mediterranean DietWhere Do I Start? T HE TERM MEDITERRANEAN diet can be used to describe the eating pattern of at least 16 countries that border the Med- iterranean Sea, which presents some difculty in characterizing a Mediterra- nean diet. Research on the health ben- ets of a Mediterranean eating pattern date back to the 1950s with the Seven Countries Study that established the Mediterranean diet as a heart-healthy eating pattern based on the traditional foods and cooking styles of this part of the world. 1 Oldways created the Mediterranean Diet Pyramid and in- cludes the following among the dening characteristics this pattern: An abundance of food from plant sources, including fruits and vegetables, potatoes, breads and grains, beans, nuts, and seeds. Olive oil as the principal fat, with total fat ranging from less than 25% to over 35% of energy, with saturated fat no more than 7% to 8% of energy. Daily consumption of low to moderate amounts of cheese and yogurt. Twice-weekly consumption of low to moderate amounts of sh and poultry; up to 7 eggs per week (including those used in cooking and baking). Fresh fruit as the typical daily dessert. Moderate consumption of wine, normally with meals; about one to two glasses per day for men and one glass per day for women. From a contemporary public health perspective, wine should be considered optional and avoi- ded when consumption would put the individual or others at risk. Red meat a few times per month. Regular physical activity at a level that promotes a healthy weight, tness, and well-being. 2 Recently, a large, randomized clinical trial provided further evidence to support a Mediterranean diet to reduce the risk for cardiovascular disease. In- vestigators in Spain randomized 7,447 people at high risk for cardiovascular disease to one of three diets: A Mediter- ranean diet supplemented with extra- virgin olive oil (4 tablespoons per day); a Mediterranean diet supplemented with mixed nuts (30 grams per day of walnuts, hazelnuts, and almonds); or a control diet for which people were advised to lower their intake of dietary fat. Participants in the control group decreased their fat intake by 2%, result- ing in a diet with 37% of calories from fat (exceeding the <30% fat intake that denes a low-fat diet) vs 39% for both variations of the Mediterranean diet. The trial was stopped early by the data and safety monitoring board when an interim analysis indicated the two Med- iterranean diet groups when compared with the control group reduced their risk of cardiovascular events (myocardial infarction, stroke, or death from cardio- vascular disease) by 30%. 3 Other research suggests that adher- ence to a Mediterranean diet pattern has a positive effect on a range of medical conditions beyond mortality due to cardiovascular disease. In- creasing evidence suggests it could counter diseases associated with chronic inammation, including meta- bolic syndrome, atherosclerosis, cancer, diabetes, obesity, pulmonary diseases, and cognition disorders. 4 Widely re- ported research regarding the health benets of the Mediterranean diet is likely to inuence some people to adopt some form of a Mediterranean diet. For some, that may mean more olive oil; but according to the Academy position paper on dietary fatty acids, because the dietary pattern also em- phasizes vegetables and fruits, n-3 fatty aciderich foods, nuts, low-fat dairy, and moderate red wine intake, re- ported benets of a Mediterranean diet on CVD risk factors cannot be attrib- uted solely to the monounsaturated fatty acid content. 5 The Dietary Guidelines for Americans recommends the Mediterranean diet as well as the Dietary Approaches to Stop Hypertension (DASH) diet as eating plans that can help promote health and prevent disease. 6 Counseling the patient who wants to incorporate the Mediter- ranean diet into their lifestyle begins with collecting as much data as possible before the rst encounter, which can help assess how a patients current intake compares to the Mediterranean dietary pattern. This nutrient-dense diet is consistent with a food rstapproach and RDNs can combine this with an individualized approach that can help clients make the characteristics of the Mediterranean diet work for those motivated to make changes. References 1. Keys A. Seven Countries: A Multivariate Analysis of Death and Coronary Heart Dis- ease. Cambridge, MA: Harvard University Press; 1980. 2. Mediterranean Diet Pyramid. Oldways website. http://oldwayspt.org/resources/ heritage-pyramids/mediterranean-pyramid/ overview Accessed June 2, 2014. 3. Estruch R, Ros E, Salas-Salvadó J, et al. Pri- mary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013;368(14):1279-1290. 4. Gotsis E, Anagnostis P, Mariolis A, Vlachou A, Katsiki N, Karagiannis A.Health benets of the Mediterranean diet: An update of re- search over the last 5 years. [published online ahead of print April 27, 2014]. Angiology. http://dx.doi.org/10.1177/0003319714532169. 5. Dietary fatty acids. J Acad Nutr Diet. 2014;114(1):136-153. 6. US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition. Washington, DC: US Government Printing Ofce; 2010. This article was written by Eleese Cunningham, RDN, of the Academy of Nutrition and DieteticsKnowledge Center Team, Chicago, IL. Academy members can contact the Knowledge Center by sending an e-mail to [email protected] http://dx.doi.org/10.1016/j.jand.2014.06.004 1312 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS ª 2014 by the Academy of Nutrition and Dietetics.

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Page 1: I Have a Client Who Wants to Follow the Mediterranean Diet—Where Do I Start?

FROM THE ACADEMY

This article was written by EleeseCunningham, RDN, of the Academyof Nutrition and Dietetics’ KnowledgeCenter Team, Chicago, IL. Academymembers can contact the KnowledgeCenter by sending an e-mail [email protected]

h p://dx.doi.org/10.1016/j.jand.2014.06.004

1312 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Question of the Month

I Have a Client Who Wants to Follow theMediterranean Diet—Where Do I Start?

THE TERM MEDITERRANEANdiet can be used to describe theeating pattern of at least 16countries that border the Med-

iterranean Sea, which presents somedifficulty in characterizing a Mediterra-nean diet. Research on the health ben-efits of a Mediterranean eating patterndate back to the 1950s with the SevenCountries Study that established theMediterranean diet as a heart-healthyeating pattern based on the traditionalfoods and cooking styles of this partof the world.1 Oldways created theMediterranean Diet Pyramid and in-cludes the followingamong thedefiningcharacteristics this pattern:

� An abundance of food from plantsources, including fruits andvegetables, potatoes, breads andgrains, beans, nuts, and seeds.

� Olive oil as the principal fat, withtotal fat ranging from less than25% to over 35% of energy, withsaturated fat no more than 7% to8% of energy.

� Daily consumption of low tomoderate amounts of cheese andyogurt.

� Twice-weekly consumption oflow to moderate amounts of fishand poultry; up to 7 eggs perweek (including those used incooking and baking).

� Fresh fruit as the typical dailydessert.

� Moderate consumption of wine,normally with meals; about oneto two glasses per day for menand one glass per day for women.From a contemporary publichealth perspective, wine should

tt

be considered optional and avoi-ded when consumption wouldput the individual orothers at risk.

� Red meat a few times per month.� Regular physical activity at a

level that promotes a healthyweight, fitness, and well-being.2

Recently, a large, randomized clinicaltrial provided further evidence tosupport a Mediterranean diet to reducethe risk for cardiovascular disease. In-vestigators in Spain randomized 7,447people at high risk for cardiovasculardisease to one of three diets: A Mediter-ranean diet supplemented with extra-virgin olive oil (4 tablespoons per day);a Mediterranean diet supplementedwith mixed nuts (30 grams per day ofwalnuts, hazelnuts, and almonds); or acontrol diet for which people wereadvised to lower their intake of dietaryfat. Participants in the control groupdecreased their fat intake by 2%, result-ing in a diet with 37% of calories from fat(exceeding the <30% fat intake thatdefines a low-fat diet) vs 39% for bothvariations of the Mediterranean diet.The trial was stopped early by the dataand safety monitoring board when aninterim analysis indicated the two Med-iterranean diet groups when comparedwith the control group reduced their riskof cardiovascular events (myocardialinfarction, stroke, or death from cardio-vascular disease) by 30%.3

Other research suggests that adher-ence to a Mediterranean diet patternhas a positive effect on a range ofmedical conditions beyond mortalitydue to cardiovascular disease. In-creasing evidence suggests it couldcounter diseases associated withchronic inflammation, including meta-bolic syndrome, atherosclerosis, cancer,diabetes, obesity, pulmonary diseases,and cognition disorders.4 Widely re-ported research regarding the healthbenefits of the Mediterranean diet islikely to influence some people toadopt some form of a Mediterraneandiet. For some, that may mean more

ª 2

olive oil; but according to the Academyposition paper on dietary fatty acids,because the dietary pattern also em-phasizes vegetables and fruits, n-3 fattyaciderich foods, nuts, low-fat dairy,and moderate red wine intake, re-ported benefits of a Mediterranean dieton CVD risk factors cannot be attrib-uted solely to the monounsaturatedfatty acid content.5

The Dietary Guidelines for Americansrecommends the Mediterranean diet aswell as the Dietary Approaches to StopHypertension (DASH) diet as eatingplans that can help promote health andprevent disease.6 Counseling the patientwho wants to incorporate the Mediter-ranean diet into their lifestyle beginswith collecting as much data as possiblebefore the first encounter, which canhelp assess how a patient’s currentintake compares to the Mediterraneandietary pattern. This nutrient-dense dietis consistentwith a “foodfirst” approachand RDNs can combine this with anindividualized approach that can helpclients make the characteristics of theMediterranean diet work for thosemotivated to make changes.

References1. Keys A. Seven Countries: A Multivariate

Analysis of Death and Coronary Heart Dis-ease. Cambridge, MA: Harvard UniversityPress; 1980.

2. Mediterranean Diet Pyramid. Oldwayswebsite. http://oldwayspt.org/resources/heritage-pyramids/mediterranean-pyramid/overview Accessed June 2, 2014.

3. Estruch R, Ros E, Salas-Salvadó J, et al. Pri-mary prevention of cardiovascular diseasewith a Mediterranean diet. N Engl J Med.2013;368(14):1279-1290.

4. Gotsis E, Anagnostis P, Mariolis A, Vlachou A,Katsiki N, Karagiannis A.Health benefits ofthe Mediterranean diet: An update of re-searchover the last 5 years. [published onlineahead of print April 27, 2014]. Angiology.http://dx.doi.org/10.1177/0003319714532169.

5. Dietary fatty acids. J Acad Nutr Diet.2014;114(1):136-153.

6. US Department of Agriculture and USDepartment of Health and Human Services.Dietary Guidelines for Americans, 2010. 7thEdition. Washington, DC: US GovernmentPrinting Office; 2010.

014 by the Academy of Nutrition and Dietetics.