The What, Why, and How of a Mediterranean-Style Eating Pattern

The What, Why, and How of a Mediterranean-Style Eating Pattern Section 1: Welcome This session will be presented in a voice-narrated format that allows you to follow along with a PowerPoint slide presentation. A high-speed Internet connection is required. This module is divided into multiple sections; see the menu bar on the left for the course outline, which will enable you to complete and/or review content at your own pace. Printable handouts, if applicable, will be presented prior to the section in which they are referenced. Please complete a brief, multiple-choice survey before you start this session and again at the end of this session. Once you have completed the survey, you will be free to advance to the course content by clicking on the Next Section button at the bottom of the page. If at any time you wish to take a break from the session, simply log out and return to the course when you are ready to continue. When you sign back in to the session, you will be taken directly to the section where you left off. To review a section you have already completed, click on the desired section on the left menu bar. Slide 1 Section 2: Introduction (Slides 1-3) So what exactly is a Mediterranean-style eating pattern? It s more than switching to olive oil! Eating Mediterranean involves an eating lifestyle and includes social and cultural elements. The enjoyment of food preparation and eating with others are celebrated. Physical activity is an important element, as is social engagement. A Mediterranean-style eating pattern is for healthy adults and is not intended to treat disease. Individuals with a diagnosis of diabetes or are recovering from cardiovascular events need to be under the care of a physician and possibly a Registered Dietitian, as well. Slide 2 At the completion of this session, you should be able to: Compare a Mediterranean-style eating pattern to the typical American diet; List health benefits associated with a Mediterranean-style eating pattern; Explain the recommended fat, protein, and dairy choices consistent with a Mediterranean-style eating pattern; and Describe social and other aspects of the Mediterranean culture that may confer health benefits associated with a Mediterranean-style eating pattern. 1

Slide 3 In this session, we ll describe: Slide 4 What a Mediterranean-style eating pattern is; Why it may be beneficial for your health; and How you can adopt all or some elements of a Mediterranean-style eating pattern. Section 3: What? (Slides 4-10) The study of nutrition has moved away from individual nutrient deficiencies and their consequences to a whole-diet approach and the prevention of diet-related chronic disease. Nutrition science now confirms that a healthful diet is rich in plant sources of fat and protein, nuts, whole grains, and fruits and vegetables. A healthful diet avoids partially hydrogenated fats and limits red meat and refined carbohydrate. Prior advice to reduce all fat or all carbohydrates has not stood the test of science. We now know we need to consider the type of fat and the type of carbohydrate, as well as different protein sources. Slide 5 A Mediterranean eating pattern does not represent any one region or cuisine. The Mediterranean region includes Greece, Italy, France, and Spain, as well as other counties along the Mediterranean Sea. Greece, Italy, France, and Spain have distinct cuisines but share common key elements. The traditional Mediterranean eating pattern reflects Greece during the 1950s and 1960s. The health benefits associated with a Mediterranean-style eating pattern can be attributed to other factors beyond food. For example, cultural values include physical activity and social engagement. Some researchers have proposed that the amount of sunlight exposure and vitamin D production may also contribute to the health benefits associated with a Mediterranean-style eating pattern. Slide 6 It is interesting to note that the results of these research studies consistently supported the health benefits associated with a Mediterranean-style eating plan. As a result of this evidencebased research, a Mediterranean eating pattern is one of three diets recommended by the Dietary Guidelines for Americans. The other two recommended eating patterns are MyPlate and the DASH diet, or Dietary Approaches to Stop Hypertension. Slide 7 This is a simple pyramid design showing recommended daily, weekly, and monthly foods. However I think the figure on the next slide better captures a Mediterranean-style eating pattern and lifestyle. 2

Slide 8 This slide depicts the recommendations of a scientific consortium on a Mediterranean eating pattern. The consortium members sought to identify common food elements associated with the Mediterranean region while making the eating pattern accessible to other cultures. This representation of a Mediterranean eating pattern should not be considered prescriptive. Rather, it suggests general guidelines based on the best available research that supports the health benefits associated with a Mediterranean-style eating pattern. Guidelines are included for each meal, each day, and each week. Also, cultural aspects associated with the eating pattern are depicted. Notice that serving sizes aren t included. Serving sizes are based on frugality and local habits; i.e., small portions are the hallmark of this eating pattern. Slide 9 Objective measures of Mediterranean eating pattern adherence have been developed. This slide depicts the Mediterranean diet score used in some research studies. Eleven items are assessed for their frequency of consumption. They include: Slide 10 Non-refined cereals, i.e., whole grains, Potatoes, Fruits, Vegetables, Legumes, Fish, Red meat and products, Poultry, Full-fat dairy products, Olive oil in cooking, and Alcoholic beverages. This slide shows the Mediterranean diet score answer key. For each item, a score between zero and five is determined based on recommendations. The higher the score, the closer the actual eating pattern reflects the Mediterranean eating pattern. Mediterranean diet scores can range from zero to 55. You can use the Mediterranean diet score to evaluate you own eating pattern to determine how closely it resembles a Mediterranean-style eating pattern. 3

Slide 11 Section 4: Why? (Slides 11-18) So far, we described a Mediterranean-style eating pattern and its associated lifestyle characteristics. Next, we ll discuss the why, which reviews some of the health benefits associated with a Mediterranean-style eating pattern. Slide 12 The Dietary Guidelines for Americans acknowledged the Mediterranean eating pattern as a healthful option. Compared to the usual U.S. intake, a Mediterranean-style eating pattern has more vegetables, fruit, juice, and nuts; fewer grain foods; more fish and seafood; less solid fats; and fewer added sugars. Slide 13 Research on the benefits of a Mediterranean-style eating pattern to health is relatively new and limited. Current and emerging research suggests a Mediterranean-style eating pattern is associated with longevity and less cardiovascular disease. The eating pattern may reduce the risk for type 2 diabetes and metabolic syndrome. A benefit may exist for some brain disorders, such as cognitive and neurological impairment and depression. Given this emerging field of study, it shouldn t be surprising that some research findings are inconclusive and/or inconsistent. However, many studies support the health benefits associated with this eating pattern. Human research using blood indicators suggests a Mediterranean-style eating pattern is lower in saturated fat, has a lower glycemic index, and reduces the formation of inflammation markers. Research regarding a beneficial association of a Mediterranean-style eating pattern with obesity has not been conclusive. Therefore, at this time, a Mediterranean-style eating pattern should not be considered a weight-loss diet. However, eating smaller food portions and increasing physical activity will result in weight loss regardless of the eating plan. Slide 14 This may be the most important slide of the entire presentation. Identifying the exact constituent and mechanism associated with a specific health benefit is complex. Possible explanations may relate to: Components found in foods, such as monounsaturated fats and omega-three fatty acids; Health properties of individual foods, such as olive oil, seafood, and nuts; The composite eating pattern, such as adherence to the Mediterranean eating pattern; and/or General lifestyle factors. 4

Research suggests that people who adhere to a Mediterranean-style eating pattern tend to be affluent, educated, nonsmokers, and generally speaking have overall healthier lifestyles. While we may not be able to tease-out individual causes and effects, adoption of a Mediterranean-style eating pattern and its associated lifestyle is widely recognized as healthful. Slide 15 The rate of aging is determined by a combination of genetic and environmental factors; chronic disease hastens the rate of aging. Many factors, such as diet and lifestyle practices, can slow the progression of age-related disease. A review of 12 studies concluded that greater adherence to the Mediterranean eating pattern was associated with a significant reduction in mortality from cardiovascular disease and total mortality in general. The Mediterranean eating pattern is associated with increased longevity despite its relatively high fat intake. This may be due to the fact that the majority of the fat is from olive oil instead of animal sources. Also keep in mind that a Mediterranean-style eating pattern is part of a lifestyle that involves physical activity and social engagement, both of which are associated with improved quality of life. Slide 16 Authors of a current review came to the conclusion that the reduction in cardiovascular disease associated with a Mediterranean-style eating pattern was mainly due to the overall dietary pattern and the interactions between different components rather than any single food or nutrient. It was noted that subjects in this study had improved blood lipid profiles, reductions in blood pressure, less insulin resistance, and fewer serum markers for inflammation. Slide 17 A Mediterranean-style eating pattern isn t prescriptive for those who have diabetes. However, evidence suggests that new cases of type 2 diabetes could be reduced 30-65% with lifestyle interventions. Some studies show adherence to a Mediterranean-style eating pattern can reduce the incidence of developing type 2 diabetes. Healthy adherents to the eating pattern tend to have lower levels of Hemoglobin A1c. Other lifestyle factors associated with a Mediterranean-style eating pattern, such as ample physical activity, may also play a role in reducing the risk of type 2 diabetes. Metabolic syndrome is a health condition characterized by abdominal obesity, dyslipidemia, elevated blood pressure, and impaired glucose tolerance. Diet has been identified as a major factor in the prevention and treatment of metabolic syndrome. The authors of a recent review 5

concluded that adherence to a Mediterranean-style eating pattern played a protective role regarding the presence and progression of metabolic syndrome. Slide 18 A few relatively recent studies have examined the association between a Mediterranean-style eating pattern and brain disorders. The results have been mixed. If the diet does slow cognitive decline, it s uncertain if it s due to food components or to the overall eating pattern. For example, an eating pattern with a higher monounsaturated-tosaturated fat ratio and the consumption of whole grains are both proposed factors in slowing the decline of cognition. A review of published research suggested a high adherence to a Mediterranean-style eating pattern was beneficial to the central nervous system and inversely associated with stroke, cognitive impairment, and depression. This positive association could be due to the eating pattern and/or other factors, such as physical activity. Some adherents to the eating pattern report fewer problems with cognition, memory, anxiety, stress, self-esteem, and improved general health. These observations, while fascinating, need confirmation with research. No doubt, future research will help shed light on these proposed health benefits of a Mediterranean-style eating pattern. Slide 19 Section: 5 How? (Slides 19-36) Now that we ve reviewed some of the health benefits of a Mediterranean-style eating pattern and lifestyle, let s address how we might adopt a Mediterranean-style eating pattern. Slide 20 How difficult do you think adopting a Mediterranean-style eating pattern would be for you and your family? Use a one to ten scale, with one being very easy and ten being very difficult. Is there a downside to adopting a Mediterranean-style eating pattern? The eating pattern may be more expensive than your current grocery spending budget. Some food staples of a Mediterranean-style eating pattern can be expensive. Olive oil is expensive, compared to other oils. Some olive oils cost four or more times as much as canola or other oils. Seafood may be expensive when compared to poultry. Nuts and seeds can be expensive, compared to other snacks such as crackers. To successfully adopt the Mediterranean-style eating pattern, you need to enjoy food shopping, preparation, and cooking. Alcohol isn t for everyone. Folks can adhere to a Mediterranean eating pattern while refraining from alcohol. Wine isn t a necessary component of a Mediterranean-style eating pattern. 6

Adopting any new eating pattern may initially cause intestinal gas, which will subside with time. A Mediterranean-style eating pattern is not designed for weight loss. Portion size does matter, however. Snacking on bowls of nuts or soaking bread in olive oil can result in too many calories. Some food items may have more calories per serving than what you are used to eating. While it makes these food items more satiating, you may need to adjust to smaller portions to avoid gaining weight. Adoption of a Mediterranean-style eating pattern can be done gradually, in a step-wise fashion. Slide 21 MyPlate is the USDA s recommended eating pattern for the U.S. population. Can you follow the MyPlate guidelines and still eat a Mediterranean meal pattern? The answer is, Yes. A variety of foods from all five food groups are included in a Mediterranean-style eating pattern. A Mediterranean-style eating pattern is not vegetarian. However, it does have an abundance of plant foods at its core; foods from animals are peripheral. Bread is eaten without margarine or butter. Vegetables, salads, fruit, nuts, seeds, and olives are frequently consumed. Olive oil is the principle fat. An analysis of a Mediterranean-style eating pattern describes it as being low in saturated fat, or 8% or less of daily calories. The total fat content is about 35% of energy. Slide 22 This slide has some general tips for a Mediterranean-style eating pattern. Let s review them. Slide 23 When planning your meals, plan for one half of your dinner plate to be covered with fruits and/or vegetables. When selecting grain foods, choose whole grains more often. Substitute plant protein for some of the animal protein you are currently eating. Eat fish and/or seafood at least twice each week. Remember your calcium-rich foods. Include yogurt and cheese in your daily eating pattern. Switch to olive oil for cooking and extra virgin olive oil for salad dressings. Limit your consumption of sweets and foods containing solid fats, as well as processed foods. Drink water or tea instead of sweet drinks. If you drink alcohol, choose wine with meals, and remember to observe recommended limits. There is an abundance of research supporting the health properties of fruits and vegetables. Unfortunately, many people do not eat the amount and variety of fruits and vegetables needed 7

to benefit from these health properties. Include more fruits and vegetables in your daily eating pattern. Choose fruits and vegetables that are fresh, in season, and local when possible. Slide 24 When you are selecting grain foods, make most of your choices whole grain. Include one or two small servings of whole grain with each meal. Whole grains can include a slice of whole wheat toast, a corn tortilla, or brown rice. Include a variety of whole-grain foods in your Mediterranean-style eating pattern. Slide 25 Increase plant-based protein foods by consuming legumes, nuts, and seeds. Legumes can be added to soups and side dishes. Chickpeas can be added to salads. Nuts and seeds can be healthful snacks when eaten in small amounts. They can also be a healthier alternative to chips and crackers. Slide 26 A Mediterranean-style eating pattern includes a higher ratio of plant to animal protein. You may want to increase your servings of fish, seafood, and legumes while eating smaller and infrequent servings of red and processed meats. Use lean meat as a condiment, rather than the centerpiece, of the meal. Slide 27 The Dietary Guidelines for Americans recommend two servings of fish/seafood per week because of the research associated with its health benefits. Some research studies suggest that fish and/or the omega three fatty acids from fish can reduce the risk for diminished cognition and depression. Better fish choices are cold water fish/seafood. Also, better fish preparation methods are broiling, grilling, and baking. Fish to avoid include shark, swordfish, king mackerel, and tilefish because they may contain high levels of mercury. Responsibly farm-raised fish can be as healthy as wild and are sustainable. Slide 28 Moderate amounts of dairy foods are included a Mediterranean-style eating pattern. This is a departure from MyPlate, which recommends three servings of calcium-rich dairy foods per day. If a Mediterranean-style eating plan is followed as described, the amount of calcium from MyPlate s third dairy serving could be made up with vegetables, nuts, and seeds. Traditionally, dairy foods associated with a Mediterranean-style eating plan are fermented products, such as yogurts and cheese. The eating pattern includes cheese and yogurt from goat, sheep, buffalo, cow, and camel. Cream cheese, sour cream, and butter are fat and not a dairy source of calcium. Therefore, they aren t considered as dairy foods when meal planning. 8

Slide 29 The health benefits of olive oil are related to its large portion of monounsaturated fat, relatively low saturated fat, and Vitamin E. The differences between extra virgin olive oil and olive oil are related to the level of processing. Compared to plain olive oil, extra virgin olive oil is: More expensive, Less processed, Less acidic, and Better tasting and used for salad dressings and bread dipping when flavor is especially important. Cook with less expensive olive oil. Use olive oil in broiling, sautéing, and frying. In contrast, extra virgin olive oil is best for dipping bread and in salad dressings. Slide 30 Making a vinegar and oil dressing at home is easy. To make one cup of dressing, use one-fourth cup of acid, such as red wine vinegar, and three-fourths cup oil, such as extra virgin olive oil. Add seasonings, such as mustard or herbs. Recipes for homemade salad dressings can easily be found on the Internet. Slide 31 Sweets should be limited to a small serving and no more than twice a week. Solid fats such as butter, margarine, sour cream, and well-marbled meat should be limited or avoided. Spreads, such as butter and margarine, are seldom included in a Mediterranean-style eating pattern. These products are high in solid fats. Substituting olive oil is a more healthful choice. Saturated fat, trans fat, and cholesterol increase the risk for cardiovascular disease. This may be one reason why people who follow a Mediterranean-style eating pattern tend to have a lower incidence for cardiovascular disease. Processed foods may be high in sodium, sugars, and solid fats. Read nutrition labels and compare products carefully when selecting processed foods. Processed meats should be limited to no more than two small servings per month. Processed meats include hot dogs, sausage, bacon, and lunch meat. Slide 32 Water is a better choice than fruit aids or carbonated beverages, such as soda that contains added sugars. Emerging research on tea indicates that drinking tea may lower the risk for some cancers, metabolic syndrome, cardiovascular disease, and neurodegenerative disease. Tea is a source of the nutrient fluoride, which helps to build to strong bones and teeth. 9

However, tea is also a source of caffeine, which should be limited to about 300 milligrams per day by most healthy adults. Slide 33 It is possible to adhere to a Mediterranean eating pattern and not consume alcohol. When alcohol is consumed, it is usually wine with meals in moderation. Moderation is defined as one glass of wine per day for women and no more than two glasses of wine per day for men. Consuming alcohol has its downside. For example, alcohol consumption can increase the risk for breast cancer in women who have breast cancer risk factors. Slide 34 Retain favorite elements of your local and cultural cuisine that are consistent with a Mediterranean-style eating pattern. For example, emphasize fruits, vegetables, nuts, seeds, whole grains, and fish/seafood. When feasible, modify recipes. For example, if you live in Texas, instead of beef fajitas use vegetables, seafood, or chicken. Serve with whole grain corn tortillas accompanied by whole beans and whole-grain rice with tomatoes, onions, and peppers. If you choose to drink alcohol, try Sangria with chopped fruit. Keep food servings consistent with a Mediterranean-style eating pattern philosophy. That is to say, practice frugality; keep portions small. This may be easier when using smaller-sized plates. Slide 35 It may be helpful to keep these food items on hand to assist with meal planning and preparation. Additional items to purchase during grocery shopping will depend on the menu plan. Menu planning will take many factors into consideration, some of which include recipe ingredients, foods on sale, and the availability of seasonal produce. Slide 36 We ve now reviewed how we can adopt a Mediterranean-style eating pattern through our food choices. Remember, too, that this is also a lifestyle. The eating pattern and lifestyle characteristics go hand-in-hand if you want to obtain the health benefits we talked about earlier. Slide 37 Section 6: Review and Conclusion (Slides 37-38) As mentioned earlier, eating Mediterranean involves an eating lifestyle and includes social and cultural elements. Several health benefits are associated with a Mediterranean-style eating pattern, including a longer life, less cardiovascular disease, and a reduced risk for diabetes, metabolic syndrome, and cognitive and neurological impairment. Compared to the typical U.S. eating pattern, a Mediterranean-style eating pattern has more olive oil, fruits, vegetables, whole grains, nuts, seeds, legumes, fish, and seafood. 10

Characteristics of a Mediterranean-style eating pattern include olive oil, plant protein sources, fish and seafood, as well as yogurt and cheese. Important components of a Mediterranean lifestyle are enjoyment of food preparation and eating with others. The lifestyle includes daily physical activity and social engagement. The health benefits associated with a Mediterranean-style eating pattern may be in part due to these social and cultural aspects. Slide 38 In conclusion, I d like to paraphrase a quote that appeared in the publication Epidemiology. there is increasing clarity that Mediterranean dietary patterns may indeed confer protection It is unclear whether it is the overall dietary pattern that is important, or whether select aspects of the diet, or other lifestyle factors that may travel with Mediterranean diets, or perhaps the whole package is most important. These studies do suggest, however, that the pleasures of Mediterranean cuisine can have [beneficial] health effects Slide 39 Section 7: Author (Slide 39) This session was developed by Dr. Sharon Robinson, an Associate Professor and Extension Nutrition Specialist at Texas A&M University. Thank you for your interest and engagement in this topic. Educational programs of the Texas A&M AgriLife Extension Service are open to all people without regard to race, color, sex, religion, national origin, age, disability, genetic information, or veteran status. The Texas A&M University System, U.S. Department of Agriculture, and the County Commissioners Courts of Texas Cooperating 11