The Mediterranean Way of Eating Evidence for Chronic Disease Prevention and Weight Management The Mediterranean Way of Eating Evidence for Chronic Disease Prevention and Weight Management John J.B. Anderson and Marilyn C. Sparling The Mediterranean Way of Eating Evidence for Chronic Disease Prevention and Weight Management John J.B. Anderson and Marilyn C. Sparling CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2014 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed on acid-free paper Version Date: 20140108 International Standard Book Number-13: 978-1-4822-3125-0 (Hardback) This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmit- ted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright. com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging‑in‑Publication Data Anderson, John J. B. (John Joseph Baxter), 1934- The Mediterranean way of eating : evidence for chronic disease prevention and weight management / John J.B. Anderson and Marilyn C. Sparling. pages cm “A CRC title.” Includes bibliographical references and index. ISBN 978-1-4822-3125-0 1. Nutrition. 2. Diet--Mediterranean Region. 3. Cooking, Mediterranean. I. Sparling, Marilyn C., 1940- II. Title. RA784.A5334 2014 641.59’1822--dc23 2013050914 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2014 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed on acid-free paper Version Date: 20140108 International Standard Book Number-13: 978-1-4822-3125-0 (Hardback) This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmit- ted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright. com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging‑in‑Publication Data Anderson, John J. B. (John Joseph Baxter), 1934- The Mediterranean way of eating : evidence for chronic disease prevention and weight management / John J.B. Anderson and Marilyn C. Sparling. pages cm “A CRC title.” Includes bibliographical references and index. ISBN 978-1-4822-3125-0 1. Nutrition. 2. Diet--Mediterranean Region. 3. Cooking, Mediterranean. I. Sparling, Marilyn C., 1940- II. Title. RA784.A5334 2014 641.59’1822--dc23 2013050914 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com The Open Access version of this book, available at www.taylorfrancis.com, has been made available under a Creative Commons Attribution-Non Commercial-No Derivatives 4.0 license. This book is dedicated to our spouses, Betsey Anderson and Joseph Sparling, who have been so supportive in our efforts to write this book. vii Contents Foreword................................................................................................................... xv Preface....................................................................................................................xvii Acknowledgments....................................................................................................xix About.the.Authors....................................................................................................xxi Abbreviations.and.Acronyms............................................................................... xxiii Section i Mediterranean Dietary Patterns Chapter 1 What.Is.a.Mediterranean.Diet?.Common.Components.in. Diverse.Dietary.Patterns.Promote.Health.and.Long.Life..................... 3 Introduction........................................................................................... 3 Factors.Contributing.to.Diverse.Mediterranean.Dietary.Patterns........ 4 Nutrient.Needs.of.Early.Mediterranean.Populations............................ 6 Mediterranean.Foods.and.Their.Components.Contribute.to. Healthy.Diets.........................................................................................7 Nutrient.Components.of.Healthy.Diets................................................. 8 Life.Expectancy.across.the.Millennia. ..................................................9 Summary............................................................................................. 10 Chapter 2 Dietary.Patterns.of.the.Mediterranean.Nations:.Then.and.Now........ 13 Introduction......................................................................................... 13 Regions.of.the.Mediterranean.and.Their.Traditional.Diets................ 13 Western.Region.............................................................................. 16 Adriatic.Region.............................................................................. 19 Eastern.Region............................................................................... 19 North.African.Region..................................................................... 23 Recent.Influences.of.Processed.Foods.and.Fast.Foods....................... 25 General.Threats.to.the.Traditional.Mediterranean.Lifestyle.............. 25 Adverse.Health.Effects.of.Extensive.Food.Processing....................... 26 Adverse.Effects.of.Fast.Foods. ............................................................ 27 Summary............................................................................................. 27 Chapter 3 Critical.Nutrients.in.Foods.of.Mediterranean.Nations. ....................... 29 Introduction......................................................................................... 29 Nutrient.and.Phytochemical.Components.of.Healthy.Diets............... 30 viii Contents Energy.from.Macronutrients............................................................... 30 Types.of.Macronutrients................................................................. 31 Carbohydrates............................................................................ 31 Fats. ............................................................................................ 32 Proteins...................................................................................... 33 Alcohol...................................................................................... 33 Protein.Also.Serves.as.a.Source.of.Amino.Acids.......................... 33 Essential.Amino.Acids..............................................................34 Nonessential.Amino.Acids........................................................34 Fat.as.a.Source.of.Saturated.and.Unsaturated.Fatty.Acids............ 34 Saturated.Fatty.Acids................................................................ 35 Monounsaturated.Fatty.Acids. ................................................... 35 Polyunsaturated.Fatty.Acids...................................................... 36 Metabolic.Conversions.of.PFAs.and.the.Ratio.of.Omega-6s. to.Omega-3s.in.Diet........................................................................ 37 Oxidative.Stress.of.Dietary.Fats. .................................................... 38 Cholesterol:.A.Nonessential.Nutrient.But.a.Critical.Molecule. in.Lipoproteins............................................................................... 39 Micronutrients..................................................................................... 39 Water-. Soluble.Vitamins. ................................................................. 39 Fat-. Soluble.Vitamins......................................................................40 Macrominerals. ............................................................................... 41 Microminerals................................................................................ 42 Water................................................................................................... 42 Dietary.Fiber....................................................................................... 42 Phytochemicals:.Nonnutrient.Molecules.that.Benefit.Health............. 43 Antioxidant.Molecules:.A.Few.Vitamins.and.Many. Phytochemicals. .............................................................................. 43 Summary............................................................................................. 45 Chapter 4 Obesity.and.Type.2.Diabetes.Mellitus................................................ 47 Introduction......................................................................................... 47 Overweight.and.Obesity...................................................................... 48 Diabetes.Mellitus................................................................................ 50 Relationships.among.Obesity,.Insulin.Resistance,.Inflammation,. and.Type.2.Diabetes............................................................................ 52 Effective.Dietary.Patterns.for.Losing.Weight.and.Reducing. Risk.of.Type.2.Diabetes...................................................................... 53 Other.Factors.that.Play.a.Role.in.Obesity.and.Type.2.Diabetes......... 54 Magnesium..................................................................................... 54 Dietary.Fiber.................................................................................. 54 Glycemic.Index. .............................................................................. 55 Summary............................................................................................. 58 ix Contents Chapter 5 Cardiovascular.Diseases.and.the.Metabolic.Syndrome...................... 59 Introduction......................................................................................... 59 Cardiovascular.Diseases..................................................................... 59 Serum.Lipids,.Atherosclerosis,.and.Arterial.Wall.Damage. ...............60 Major.Diet-. Related.Risk.Factors.for.Heart.and.Other. Cardiovascular.Diseases..................................................................... 62 The.Metabolic.Syndrome.................................................................... 62 Preventive.Measures.for.Cardiovascular.Diseases.and.Metabolic. Syndrome............................................................................................64 Intact.versus.Isolated.Dietary.Fiber.................................................... 65 Alcohol.Consumption.and.Cardiovascular.Diseases..........................66 Summary............................................................................................. 67 Chapter 6 Diet-. Related.Cancers.and.Other.Diseases.......................................... 69 Introduction......................................................................................... 69 Diet-. Related.Cancers. .......................................................................... 69 Excessive.Energy,.Fat,.and.Diet-. Related.Cancers.......................... 71 Insufficient.Intakes.of.Micronutrients.and.Antioxidants.and. Diet-. Related.Cancers...................................................................... 72 Phytochemicals.and.Diet-. Related.Cancers. .................................... 76 Free.Radicals.in.the.Development.of.Cancer...................................... 77 Reducing.the.Risk.of.Cancer.............................................................. 78 Other.Diet-. Related.Diseases.or.Conditions........................................ 78 Polycystic.Ovarian.Syndrome........................................................ 78 Arterial.Calcification...................................................................... 79 Chronic.Kidney.Disease. ................................................................ 79 Brain.Lesions.and.Brain.Diseases.................................................. 79 Age-. Related.Macular.Degeneration...............................................80 Immune.Defense. ............................................................................ 81 Decline.in.Bone.Mass.and.Osteoporosis........................................ 81 Summary............................................................................................. 81 Section ii Protective Health effects of the Mediterranean-Style Dietary Pattern Chapter 7 Introduction.to.the.Health.Benefits.of.Mediterranean-. Style. Dietary.Patterns. .................................................................................. 85 Introduction......................................................................................... 85 Balanced.Caloric.Intake...................................................................... 85 Consumption.of.Nutrients.in.Appropriate.Amounts........................... 86 Emphasis.on.Whole.Foods,.Not.Dietary.Supplements....................... 87 Mediterranean.Dietary.Components.that.Promote.Good.Health....... 87 x Contents Chapter 8 High.Consumption.of.Monounsaturated.Fat.and.Low. Consumption.of.Saturated.Fat............................................................. 89 Introduction......................................................................................... 89 Fatty.Acid.Types.in.Fats.and.Oils....................................................... 89 Olive.Oils. ....................................................................................... 91 Bottom.Line........................................................................................ 95 Chapter 9 High.Consumption.of.Fruits,.Vegetables,.and.Legumes. .................... 97 Introduction.........................................................................................97 Legumes....................................................................................... 100 Applying.the.Evidence.on.Fruits,.Vegetables,.and.Legumes.to. Reduce.Risk.of.Chronic.Diseases..................................................... 101 Dark-. Green.Leafy.Vegetables...................................................... 103 Salad.Dressings............................................................................ 104 Potatoes........................................................................................ 104 Sweet.Potatoes.............................................................................. 105 Cooking.Tips................................................................................ 105 Cost............................................................................................... 106 Convenience................................................................................. 107 Pesticides...................................................................................... 107 Bottom.Line...................................................................................... 107 Chapter 10 High.Consumption.of.Whole.Grains................................................ 109 Introduction....................................................................................... 109 Applying.the.Evidence.on.Whole.Grains.to.Reduce.Risk.of. Obesity.and.Type.2.Diabetes. ............................................................ 111 Applying.the.Evidence.on.Whole.Grains.to.Reduce.Risk.of. Cardiovascular.Diseases.and.Metabolic.Syndrome.......................... 112 Understanding.Identification,.Processing,.and.Labeling.of.Grains..... 114 Identification.of.Whole-. Grain.Food.Products.............................. 114 The.Milling.Process..................................................................... 116 Enrichment.of.Flour................................................................ 116 Fortification.of.Flour............................................................... 117 Sodium. ......................................................................................... 117 Gluten.Intolerance.and.Celiac.Disease. ........................................ 118 Bottom.Line...................................................................................... 119 Chapter 11 Moderate.Consumption.of.Nuts.and.Seeds....................................... 121 Introduction....................................................................................... 121 Applying.the.Evidence.on.Nuts.and.Seeds.to.Reduce.Risk.of. Chronic.Diseases............................................................................... 122 Peanuts.............................................................................................. 124 Nut.Butters........................................................................................ 125 xi Contents Qualified.Heart.Health.Claim.for.Nuts............................................. 125 Seeds................................................................................................. 126 Hypotheses.for.the.Beneficial.Effects.of.Nuts.and.Seeds.in. Reducing.CVD.Risk. ......................................................................... 126 Recommended.Number.of.Servings.and.Serving.Sizes.for.Nuts. and.Seeds. .......................................................................................... 127 Bottom.Line...................................................................................... 127 Chapter 12 Moderate.Consumption.of.Fish.and.Seafood.................................... 129 Introduction....................................................................................... 129 Applying.the.Evidence.on.Fish.to.Reduce.Risk.of.Chronic. Diseases............................................................................................. 130 Contaminants.in.Fish........................................................................ 132 Sustainability.and.the.Environmental.Impact.of.Consuming.Fish.... 132 Cooking.Fish..................................................................................... 133 Healthful.Options.for.Fresh.Fish. ...................................................... 133 Fish.Oil.from.Food.and.Supplements............................................... 133 Recommended.Servings.and.Serving.Sizes.of.Fish.and.Seafood..... 135 Bottom.Line...................................................................................... 135 Chapter 13 Low.Consumption.of.Meats.and.Low-. to-. Moderate. Consumption.of.Poultry.and.Eggs.................................................... 137 Introduction....................................................................................... 137 Applying.the.Evidence.on.Meats.to.Reduce.Risk.of.Chronic. Diseases............................................................................................. 138 Issues.Related.to.Meat.Consumption................................................ 140 Applying.the.Evidence.on.Poultry.and.Eggs.to.Reduce.Risk.of. Chronic.Diseases............................................................................... 142 Recommendations.for.Number.of.Servings.and.Serving.Sizes.of. Meat,.Poultry,.and.Eggs.................................................................... 145 Bottom.Line...................................................................................... 145 Chapter 14 Low.Consumption.of.Milk.and.Moderate.Consumption.of. Cheese.and.Yogurt............................................................................ 147 Introduction....................................................................................... 147 Applying.the.Evidence.on.Dairy.Products.to.Reduce.Risk.of. Obesity.and.Type.2.Diabetes. ............................................................ 148 Applying.the.Evidence.on.Dairy.Products.to.Reduce.Risk.of. Cardiovascular.Diseases................................................................... 149 Recommendations.on.Number.of.Servings.and.Serving.Sizes.of. Dairy.Products.................................................................................. 150 Bottom.Line...................................................................................... 151 xii Contents Chapter 15 Moderate.Consumption.of.Alcohol................................................... 153 Introduction....................................................................................... 153 Applying.the.Evidence.on.Alcohol.to.Reduce.Risk.of.Type.2. Diabetes............................................................................................. 154 Applying.the.Evidence.on.Alcohol.to.Reduce.Risk.of. Cardiovascular.Diseases................................................................... 155 Potential.Advantages.of.Red.Wine.Consumption.Compared.to. Other.Types.of.Alcohol..................................................................... 156 Bottom.Line...................................................................................... 157 Chapter 16 High.Consumption.of.Herbs,.Spices,.and.Garlic.............................. 159 Introduction....................................................................................... 159 Additional.Information.on.Selected.Herbs.and.Spices.with. Potential.Benefits.to.Health............................................................... 160 Bottom.Line...................................................................................... 162 Section iii eating the Mediterranean Way Chapter 17 Moving.toward.a.Mediterranean-. Style.Diet.in.Your.Own.Life........ 165 Introduction....................................................................................... 165 Transferring.the.Mediterranean.Dietary.Pattern.to.Non-. Mediterranean.Countries.................................................................. 165 Maintaining a.Mediterranean-. Style.Diet.......................................... 167 Increasing.the.Health.Benefits.of.a.Vegetarian.or.Vegan.Diet. when.Following.a.Mediterranean.Eating.Pattern............................. 169 Choosing.Foods.When.Eating.Out.That.Fit.a.Mediterranean-. Style.Diet........................................................................................... 170 Taking.Steps.to.Begin.Moving.toward.a.Mediterranean-. Style.Diet. .... 172 Summary........................................................................................... 173 Chapter 18 Eat.Like.a.Mediterranean:.Enjoy.Your.Food,.Be.Healthy,.and. Feel.Good.......................................................................................... 175 Introduction....................................................................................... 175 The.Total.Diet.and.the.Slower.Lifestyle. ........................................... 175 Health.Benefits.of.the.Mediterranean.Pattern.of.Eating:.Focus. on.the.Dietary.Components.That.Contribute.to.Health.................... 176 Health.Benefits.of.the.Mediterranean.Pattern.of.Eating:.Focus. on.Prevention.of.Chronic.Diseases................................................... 178 Overweight.and.Obesity............................................................... 179 Type.2.Diabetes.Mellitus. ............................................................. 180 Cardiovascular.Diseases. .............................................................. 180 xiii Contents The.Metabolic.Syndrome............................................................. 181 Diet-. Related.Cancers.................................................................... 181 Other.Chronic.Diseases................................................................ 182 Statistics.on.Chronic.Disease.Reductions.in.Consumers.of.a. Mediterranean-. Style.Diet............................................................. 182 Longevity...................................................................................... 182 Changes.in.Eating.Patterns:.Moving.Slowly.toward.Traditional. Mediterranean.Diets.......................................................................... 183 Healthy.Values.to.Aim.for.by.Mediterranean.Diet.Consumers........ 184 Summary........................................................................................... 184 Research and Other Articles on Mediterranean Diets ..................................... 187 Chapter.1:.What.Is.a.Mediterranean.Diet?.Common.Components. in.Diverse.Dietary.Patterns.Promote.Health.and.Long.Life............. 187 Chapter 2:.Dietary.Patterns.of.the.Mediterranean.Nations:.Then. and.Now............................................................................................ 187 Chapter 3:.Critical.Nutrients.in.Foods.of.Mediterranean.Nations.... 188 Chapter 4:.Obesity.and.Type.2.Diabetes.Mellitus............................ 188 Chapter 5:.Cardiovascular.Diseases.and.the.Metabolic.Syndrome.... 190 Chapter 6:.Diet-. Related.Cancers.and.Other.Diseases. ...................... 193 Age-. Related.Macular.Degeneration............................................. 193 Arterial.Calcification.................................................................... 193 Brain.Lesions.and.Brain.Diseases................................................ 193 Cancers......................................................................................... 194 Immune.Defense. .......................................................................... 195 Polycystic.Ovary.Syndrome......................................................... 195 Skeletal.Decline. ........................................................................... 195 Chapter 7:.Introduction.to.the.Health.Benefits.of. Mediterranean-. Style.Dietary.Patterns.............................................. 196 Chapter 8:.High.Consumption.of.Monounsaturated.Fat.and.Low. Consumption.of.Saturated.Fat........................................................... 196 Chapter 9:.High.Consumption.of.Fruits,.Vegetables,.and.Legumes.... 198 Chapter 10:.High.Consumption.of.Whole.Grains............................. 199 Chapter 11:.Moderate.Consumption.of.Nuts.and.Seeds. ...................200 Chapter 12:.Moderate.Consumption.of.Fish.and.Seafood................ 201 Chapter 13:.Low.Consumption.of.Meats.and.Low-. to-. Moderate. Consumption.of.Poultry.and.Eggs....................................................202 Chapter 14:.Low.Consumption.of.Milk.and.Moderate. Consumption.of.Cheese.and.Yogurt................................................. 203 Chapter 15:.Moderate.Consumption.of.Alcohol............................... 203 Chapter 16:.High.Consumption.of.Herbs,.Spices,.and.Garlic. ..........204 Chapter 17:.Moving.toward.a.Mediterranean-. Style.Diet.in.Your. Own.Life...........................................................................................205 Chapter 18:.Eat.Like.a.Mediterranean:.Enjoy.Your.Food,.Be. Healthy,.and.Feel.Good.....................................................................206 xiv Contents Appendix A: Fiber Content of Foods in Common Portions .............................207 Appendix B: Recipes ............................................................................................. 211 Soups.and.Stews................................................................................ 211 Split.Pea.and.Lentil.Soup............................................................. 211 Tuscan.Chicken.Stew. ................................................................... 212 Sandwiches,.Pizza,.and.Vegetable.Pastas.(Hot)................................ 212 Mediterranean.Goat.Cheese.Sandwiches..................................... 212 Smoked.Salmon.Sandwich.Spread............................................... 213 Ziti.with.Tuscan.Mushroom.Sauce............................................... 213 Greek-. Style.Appetizer.Pizzas. ...................................................... 214 Cold.Salads........................................................................................ 214 Lemon.Couscous.and.Bean.Salad................................................ 214 Chicken.Pasta.Salad.with.Fruit.and.Almonds.............................. 215 Wild.Rice.and.Barley.Salad......................................................... 216 Beans,.Tomato,.and.Feta.Cheese.Salad........................................ 216 Vegetable.Dishes.(Hot)...................................................................... 217 Italian.Beans.and.Tomatoes.with.Rosemary................................ 217 Kale.with.Lemon.and.Cumin....................................................... 217 Fish,.Meat,.and.Poultry.Entrees.(Hot).............................................. 218 Hazelnut-. Crusted.Trout................................................................ 218 Greek.Pasta.with.Tuna. ................................................................. 218 Chicken.Curry.with.Couscous..................................................... 219 Lemon-. Oregano.Lamb.Chops...................................................... 219 Mediterranean.Slow-. Cooked.Turkey........................................... 220 Appendix C: Books on Mediterranean Foods and Cooking ............................. 221 Appendix D: Websites .......................................................................................... 223 Appendix E: Glossary of Terms Used in Text .................................................... 225 Index ....................................................................................................................... 237 xv Foreword Good. nutrition. is. based. on. a. pattern. of. eating. nutritious. foods. in. appropriate. amounts—not. too. much. or. too. little.. This. book. on. Mediterranean. diet. patterns. leads.the.way.toward.the.establishment.of.healthy.eating.habits.and.the.promotion. of.sound.lifestyle.behaviors.that.minimize.the.chronic.diseases.so.common.in.the. Western.world.. For. example,. heart. disease. and. stroke. combined. are. now. the. leading. cause. of. death.and.disability.worldwide,.claiming.more.than.17.million.lives.per.year..Those. who. survive. an. event. frequently. suffer. with. crippling. disabilities. and. symptoms.. Alarming.increases.in.obesity.and.diabetes.are.an.important.factor.contributing.to. this.growing.global.burden.of.cardiovascular.disease..Experts.agree.that.improving. diets.is.an.effective.first.step.toward.preventing.heart.disease.and.stroke.as.well.as. preventing.obesity,.diabetes,.and.certain.forms.of.cancer..In.a.landmark.decision,.the. United.Nations,.working.through.the.World.Health.Organization,.has.set.a.goal.to. reduce.by.25%.the.premature.mortality.caused.by.these.disorders.by.the.year.2025.. To.achieve.this.goal.heightened.interest.worldwide.now.focuses.on.how.a.healthy. diet.can.contribute.to.improved.quality.of.life,.reduction.of.disease,.and.longevity. For.years.epidemiologists.and.others.have.been.interested.in.a.Mediterranean.diet. and. how. its. foods,. and. their. nutrients,. might. relate. to. the. observed. longevity. and. healthy.outcomes.of.certain.populations.in.Mediterranean.countries..Results.from. a.series.of.important.trials.now.support.the.benefits.of.a.Mediterranean.pattern.of. eating.to.prevent.and.reduce.the.prevalence.of.heart.attacks.and.stroke..The.Lyon. (France).Heart.Study.showed.that.individuals.of.a.high-risk.population.who.had.sur- vived.a.cardiovascular.event.did.better.when.they.adhered.to.a.Mediterranean-style. diet..Recently.the.PREDIMED.trial.(Primary.Prevention.of.Cardiovascular.Disease. with.a.Mediterranean.Diet).confirmed.that.a.Mediterranean.diet,.supplemented.with. extra–virgin.olive.oil.or.certain.nuts,.effectively.reduced.the.occurrence.of.a.first. cardiovascular.event..A.systematic.review.of.dietary.factors.and.coronary.heart.dis- ease.has.ranked.a.Mediterranean.way.of.eating.as.most.likely.to.provide.protection. against.coronary.heart.disease.because.of.satisfaction.and.adherence.to.the.diet..In. the.face.of.abundant.evidence.supporting.the.benefits.of.adhering.to.a.Mediterranean. diet.it.remains.essential.to.understand.the.concepts.and.eating.patterns.required.for. its.implementation. This.book.provides.the.tools.and.core.elements.needed.to.understand.and.adopt. a.healthy.way.of.eating.that.can.reduce.the.risk.of.suffering.the.devastating.conse- quences. of. a. heart. attack. or. stroke.. Knowledge. is. fundamental. to. any. successful. change.in.lifestyle.if.it.is.put.into.practice..The.authors.have.written.a.thoughtful,. comprehensive.text.which.will.be.an.asset.to.anyone.with.a.serious.interest.in.devel- oping.a.healthy.lifestyle.and.changing.their.eating.habits..Years.of.experience.and. xvi Foreword research.combined.with.data.from.the.most.recent.trials.have.been.distilled.into.a. readable,.understandable.primer,.which.provides.the.reader.with.valuable.informa- tion..I.highly.recommend.this.thoughtful.review.of.a.Mediterranean.diet.and.urge. all.to.make.a.healthy.diet.and.lifestyle.their.fundamental.personal.choice.and.life- long.commitment. Sidney C. Smith, Jr. MD FACC, FAHA, FACP Professor of Medicine/Cardiology School of Medicine, UNC, Chapel Hill and Former President, American Heart Association Immediate Past President, World Heart Federation xvii Preface No. doubt. exists. that. what. we. eat. has. an. enormous. impact. on. our. health.. Solid. scientific. evidence. accrued. over. many. decades. validates. the. premise. that. a. plant-. based.dietary.pattern,.such.as.the.traditional.Mediterranean.way.of.eating,.not.only. promotes. health. but. also. plays. a. substantial. role. in. risk. reduction. and. prevention. of. several. chronic. debilitating. diseases,. including. type. 2. diabetes,. heart. disease,. and.certain.cancers..In.addition,.this.type.of.dietary.pattern.can.benefit.those.who. already.have.one.of.these.serious.medical.conditions.by.reducing.symptoms,.slowing. disease.progression,.and.increasing.the.length.of.time.in.which.to.feel.good.enough. to.enjoy.life..Research.studies.continue.to.support.the.widespread.health.benefits.of. the.Mediterranean.dietary.pattern. The. Mediterranean. dietary. pattern. encompasses. several. variations. on. a. basic. theme.of.commonly.consumed.foods.rich.in.nutrients.and.beneficial.phytochemicals.. High.amounts.of.fruits,.vegetables,.legumes,.whole.grains,.nuts,.and.seeds.are.types. of.foods.common.to.the.diets.of.most.nations.of.the.Mediterranean.Sea.basin..Olive. oil,.especially.virgin.or.extra-. virgin.olive.oil,.is.also.a.prominent.feature.in.many.of. these.cultures..Different.meats.may.be.used.in.these.nations,.but.meat.consumption. is.generally.low.compared.to.plant.food.intakes,.although.various.kinds.of.fish.and. seafood.are.eaten.in.moderation..Cheese.and.some.fermented.dairy.products,.such. as.yogurt,.are.popular.in.many.regions,.and.wine,.especially.red.wine,.accompanies. meals.in.some.populations.of.the.region. One.of.the.great.advantages.of.the.highly.palatable.Mediterranean.way.of.eating. is.that.it.can.be.transferred.fairly.easily.to.non-. Mediterranean.nations,.where.its.use. can.contribute.to.better.health.indices.and.increased.longevity.of.the.new.popula- tions..The.flexibility.of.a.Mediterranean-. style.diet,.as.opposed.to.a.rigid.diet,.also. contributes.to.the.ease.of.adoption.by.many.different.cultures. This.book.is.written.for.both.general.readers.and.medical.professionals.interested. in. health. promotion. and. disease. prevention. and. treatment.. It. is. not. a. “diet”. book. that. hops.on.the.bandwagon.of. the.latest. fad. diets.or.miracle. foods.. You.will.not. find.“testimonials”.by.selected.people.or.results.only.from.one.small.study.to.back. up.health.claims..What.you.will.find.is.good,.sound.information.about.an.enjoyable,. healthy.way.of.eating.that.has.stood.the.test.of.time,.along.with.practical.suggestions. on.how.to.incorporate.this.type.of.dietary.pattern.into.your.usual.daily.life. The.book.is.divided.into.18.chapters.followed.by.five.appendices.containing.addi- tional.pertinent.and.practical.information..Section.I.deals.with.Mediterranean.diet. patterns.and.the.nutrients.they.provide..The.first.chapter.provides.a.brief.history.of. the.Mediterranean.region.and.the.many.different.influences.over.the.centuries.that. helped.to.shape.food.preferences.and.methods.of.food.preparation..Chapter 2.focuses. on.both.the.shared.and.unique.foods.found.in.the.coastal.regions.of.Mediterranean. nations..Recent.influences.of.processed.foods.and.fast.foods.and.their.effects.on.tra- ditional.Mediterranean.diets.also.are.discussed..Because.the.content.of.Chapter 3.is. scientifically.based,.some.readers.may.wish.to.go.directly.to.Chapter 4.and.pick.up. xviii Preface the.details.of.individual.nutrients.as.they.proceed.to.other.chapters..Chapter 3.pres- ents.information.on.the.macronutrients.(i.e.,.carbohydrates,.fats,.and.proteins).and. their.roles.in.providing.energy.for.the.body’s.needs..In.addition,.carbohydrate.as.a. source.of.sugars.and.starches,.protein.as.a.source.of.amino.acids,.and.fat.as.a.source. of.saturated.and.unsaturated.fatty.acids.are.discussed..A.review.of.vitamins,.miner- als,.phytochemicals,.antioxidant.molecules,.and.fiber.found.in.plant.foods.highlights. their.importance.in.health.maintenance.and.disease.prevention..Chapters.4,.5,.and.6. discuss.obesity,.type.2.diabetes,.cardiovascular.diseases,.metabolic.syndrome,.diet-. related.cancers,.and.other.diseases.and.how.a.