Mediterranean Diet Linked to Drop in CVD Risk

Adherence to the Mediterranean diet (MED) is associated with a 25% reduction in the risk for cardiovascular disease (CVD), compared with those who do not follow this diet, new research suggests.

Investigators used data from the Women’s Health Study, which followed close to 26,000 women between their late forties and early sixties over a 12-year period, assessing 40 biomarkers known to be associated with CVD risk.

Higher baseline MED intake was associated with a 28% relative risk reduction in CVD events, attributed mostly to a reduction in biomarkers of inflammation, glucose metabolism and insulin resistance, and adiposity, the researchers say.

“The cardiovascular benefit seen with a Mediterranean dietary pattern in this large US population of women was similar in magnitude to benefit from statins or other commonly used preventive medications,” senior author Samia Mora, MD, MHS, Center for Lipid Metabolomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, told | Medscape Cardiology.

“Even modest changes in CVD risk factors with a heart-healthy diet contribute to the benefit of the Mediterranean diet on CVD risk and may have important downstream consequences for primary prevention,” she said.

The study was published online December 7 in JAMA Network Open .

Precise Mechanisms Unknown

“The Mediterranean diet has been associated with lower risk of CVD events, but the precise mechanisms through which Mediterranean diet intake may reduce long-term risk of CVD are not well understood,” Mora said.

“We aimed to investigate the biological mechanisms that may mediate this cardiovascular benefit,” she noted.

Previous observational studies have reported that a 20-percentile higher MED intake was associated with a 9% lower CVD event risk reduction, but the follow-up period was short (only 4 years), leaving uncertainty about whether MED intake protects against CVD events in American populations over the long term.

To elucidate the question, the researchers analyzed blood samples of 25,994 participants in the Women’s Health Study (mean [SD] age, 54.7 [7.1] years).

At baseline, participants completed a 131-item questionnaire on their dietary patterns and provided demographic information about history of hypertension, use of postmenopausal hormone therapy, smoking, physical activity, alcohol consumption, and family history of myocardial infarction (MI).

Body mass index (BMI) and blood pressure were also reported at baseline.

A MED score was calculated on the basis of nine components of MED intake, including vegetables, fruits, nuts, whole grains, legumes, fish, and the ratio of monounsaturated fatty acids to saturated fatty acids.

The primary end point was incident CVD, defined as a first event of MI, stroke, coronary arterial revascularization, or cardiovascular death. Coronary and stroke events were also examined separately.

Because baseline measures of MED intake “attenuate with time,” the primary analyses were conducted with a maximum follow-up of 12 years from baseline, whereas secondary analyses were performed in the sample with a median (IQR) follow-up of 21.4 (19.2 – 22.1) years.

The researchers measured total cholesterol, high-density cholesterol (HDL), low-density cholesterol (LDL), high-sensitivity C-reactive protein (hsCRP), triglycerides, apolipoprotein (apo)B100, and apoA1, soluble intracellular adhesion molecule 1 (ICAM-1), fibrinogen, creatinine, and homocysteine.

Nuclear magnetic resonance (MR) spectroscopy was used to measure lipoprotein subfraction particles for LDL, HDL, and very low-density lipoproteins (VLDL), branched-chain amino acids, glycoprotein acetylation (a measure of inflammation).

Lipoprotein insulin resistance index and insulin resistance diabetes risk factor index are insulin resistance scores, including subfractions of triglyceride-rich lipoproteins also derived from nuclear MR spectroscopy.

Quarter Reduction

Of the 25,994 female participants, 39.0%, 36.2%, and 24.8% had low (≤3), middle (4 or 5), and high (6 – 9) MED scores, respectively, and of the total sample, 3.96% experienced a first CVD event.

Participants with higher MED intake had a higher intake of vegetables, fruits, nuts, whole grains, legumes, and fish, and a greater ratio of monounsaturated to saturated fat. They also had a lower intake of processed and red meat.

Participants with low MED intake experienced the most incident CVD events (4.2%), followed by those with middle and high MED intake scores (both 3.8%).

The middle and upper groups experienced the greatest CVD risk reductions, with respective hazard ratios (HRs0 of 0.77 (95% CI, 0.67 – 0.90) and 0.72 (95% CI, 0.61 – 0.86, P for trend <.001), compared with the lowest group.

A total of 1030 individuals experienced a first CVD event during a maximum follow-up of 12 years (mean [SD], 11.6 [1.5] years), including 681 coronary events and 339 strokes.

The middle and upper groups both showed CVD risk reduction (HR, 0.77; 95% CI, 0.67 – 0.90 and 0.72, 0.61 – 0.86, respectively, P for trend < .001), compared with the reference group of participants with low MED intake.

The researchers also observed CVD relative risk reductions of 23% and 28% for middle and higher groups, respectively, compared with the lower MED intake group, after adjusting for age, randomized treatment, and energy intake.

“American women consuming a Mediterranean-type diet had a quarter reduction in CVD events over long-term (12 year) follow-up,” Mora summarized.

Inflammatory Mediators Most Important

Beyond actual CVD events, MED intake was generally associated with more favorable profiles of CVD risk factors and biomarkers.

However, there were several exceptions. For example, total cholesterol was actually significantly more elevated in the higher than in the lower MED intake group (median, 209.0 [184.0 – 236.0] and 207.0 [183.0 – 234.0], respectively; P = .03).

In contrast, systolic blood pressure, LDL-C, apoB100, LDL particle concentration, creatinine, and HbA1c were similar across the groups (P > .05).

However, when separate Cox models were additionally adjusted with each of the individual biomarkers one at a time, there was some attenuation of HRs (comparing higher vs lower MED intake) before and after adjustment for most variables, except for LDL-C, total cholesterol, Lp(a), citrate, and creatinine.

Biomarkers of inflammation turned out to be the largest mediators of the CVD risk, accounting for 29.2%of the MED-CVD association, followed closely by glucose metabolism and insulin resistance (27.9%), and body mass index (27.3%).

Blood pressure, traditional lipids, HDL measures or VLDL measures (26.6%, 26.0%, 24,0%, and 20.8%, respectively) were next, with lesser contributions from low-density lipoproteins (13.0%), branched-chain amino acids (13.6%), apolipoproteins (6.5%), or other small-molecule metabolites (5.8%).

The fully adjusted CVD HRs for the middle- and upper-intake groups, compared with the low-intake group, were 0.88 (0.76 – 1.02) and 0.89 (0.74 – 1.06), respectively (P for trend = .15).

The total mediation effect was 27.3%, with a “generally similar pattern of risk reduction” was observed for CHD and stroke risk.

When the researchers repeated these analyses using the total follow-up of 21.4 median years, they observed “materially similar results.”

“For the MED-CVD risk reduction, biomarkers of inflammation, glucose-metabolism/insulin resistance, and adiposity contributed most to explaining the association, with additional contributions from pathways related to blood pressure and lipids — in particular, HDL or triglyceride-rich lipoprotein metabolism and, to a lesser extent, LDL cholesterol, branched chain amino acids, and small molecule metabolites,” Mora said.

“Palatable and Achievable”

Commenting on the study for | Medscape Cardiology, Erin D. Michos, MD, MHS, associate professor of medicine and epidemiology and associate director of preventive cardiology, Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, who was not involved with the study, said that, although it is observational, “it helps to fill in a few gaps.”

She noted that the study focused on “a broad pattern of eating more adherent to Mediterranean style and did not focus on any single component of the score,” suggesting that overall dietary patterns, “rather than any single component, matter.”

She said her patients frequently ask about “reducing inflammation,” and that “a Mediterranean-style diet pattern may be one means to do so.”

Diet is frequently tied to “sociocultural norms,” and behaviors can be “difficult to change,” so the Mediterranean diet might be a good choice to recommend because “it is very palatable and achievable, not too restrictive or extreme,” she suggested.

“Dietary recommendations likely need to be tailored to the individuals, based on personal preferences and cardiometabolic considerations,” and “there is no one diet that fits all,” Michos advised.

Also commenting on the study for | Medscape Cardiology, Thomas Keyserling, MD, MPH, professor of medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, who was not involved with the study, called it “consistent with prior studies; that is, a Mediterranean dietary pattern is associated with a substantial reduction in risk for CVD events.”

The study “adds to the literature on the mechanisms of risk reduction, including the Mediterranean diet’s impact on inflammation and glucose metabolism,” he said, adding that more research into this association is needed.

Mora suggested that there “may be additional pathways, such as improvements in vascular function or antiarrhythmic effects, which could be improved with the Mediterranean diet, that we did not measure in our study.


What are the best foods to reverse symptoms of rheumatoid arthritis?

Image: What are the best foods to reverse symptoms of rheumatoid arthritis?

Rheumatoid arthritis is a debilitating disease that causes the joints, usually in the hands, to become inflamed and painful. It usually affects older individuals, although people as young as 30 can suffer from the disease. Like most autoimmune diseases, there is no cure for rheumatoid arthritis, but effectively managing it begins with eating the right food.

There is strong evidence supporting the link between food and the symptoms and effects of rheumatoid arthritis, which can include swollen joints, pain, and disability. In a study published in the journal Frontiers of Nutrition, researchers found that the state of a person’s microflora, the bacteria in the gut, as well as a leaky gut, all contribute to the occurrence of rheumatoid arthritis.

Changes in a person’s diet, they found, can also have pronounced benefits. For instance, fasting produces ketones that help suppress the pro-inflammatory molecules that cause pain in rheumatoid arthritis. Shifting to a plant-based diet has also been found to reduce immune reactivity to antigens found in certain foods.

The Mediterranean diet against rheumatoid arthritis

Because of the close link between rheumatoid arthritis and inflammation, it goes without saying that the best diet for sufferers is one that incorporates a lot of anti-inflammatory foods. When it comes to ingredients that fight inflammation, nothing does it better than the Mediterranean diet.

The Mediterranean diet places a lot of emphasis on fresh fruits and vegetables, high-quality proteins, and whole, unrefined carbohydrates. According to experts, this diet is so healthy that it gives over 1,500 mg of polyphenols every day. Polyphenols are natural compounds with anti-cancer, anti-diabetic, and anti-allergenic properties.

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The Mediterranean diet is linked to a lower incidence of cardiovascular disease. One explanation for this is the liberated use of anti-inflammatory ingredients in almost any dish. Research has proven that many of the staples in this diet can help reduce the expression of pro-inflammatory compounds that may worsen rheumatoid arthritis. (Related: Study finds Mediterranean diet more effective cure for acid reflux than meds.)

Here are some of the pain-relieving and anti-inflammatory nutrients found in many of the foods under the Mediterranean diet:

  • Anthocyanins – These plant pigments are found in blueberries, blackberries, and eggplants. They are powerful antioxidants that reduce oxidative stress and help prevent inflammation.
  • Reservatrol – This antioxidant is abundant in grapes and red wine. Just like anthocyanins, it is a powerful antioxidant that helps protect the joints from inflammation and damage.
  • Mangiferin – Another antioxidant, this time found in mangoes, mangiferin is so powerful that it has been described as having the ability to prevent the destruction of joints.
  • Kaempferol – A compound found in grapefruit, kaempferol reduces the molecules that destroy the bones and the cartilage. The degradation of these parts is one of the main causes of pain of rheumatoid arthritis.
  • Bromelain – This compound from pineapples is known for being a potent anti-inflammatory agent. Studies vouch for its efficacy as a pain reliever that does not cause any adverse effects.
  • Oleic acid – Found in olive oil, this is one of the hallmark ingredients in the Mediterranean diet. This compound is known to provide therapeutic and protective effects from rheumatoid arthritis. When consumed by people without the condition, oleic acid can lower the risk of developing the disease.
  • Curcumin – This compound is found in turmeric and is known for its antioxidant and anti-inflammatory effects. Some studies say that turmeric is best combined with ginger, yet another anti-inflammatory food, to maximize its ability to relieve rheumatoid arthritis pain.
  • Probiotics – These “friendly” bacteria help promote digestion and improve the overall health of the gut. They can help prevent the negative effects of leaky gut and offset bad bacteria that may be causing damage to the body. Probiotics are found in fermented foods. Lactobacillus casei, for instance, is found in yogurt.

Learn which foods you need to eat to relieve body pain at

Sources include:

Mediterranean Diet Linked to Improved Sleep Quality

Adherence to the Mediterranean diet (MeDi) may improve quality of sleep in older adults, new research suggests.

Investigators analyzed sleep duration and quality, as well as adherence to the MeDi, in more than 1600 adults. Results showed that in individuals aged 65 to 75 years, sleep quality was better for those who adhered to the MeDi than for those who did not, even after adjusting for possible confounding factors, including cognitive status.

The association disappeared, however, in individuals older than 75 years. No connection was found between diet and sleep duration.

“The findings of the present study show that sleep quality, rather than sleep duration, is positively associated with adherence to the Mediterranean diet in a large sample of adults aged 65 years and above,” senior author Mary Yannakoulia, PhD, associate professor of nutrition and eating behavior, Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, Athens, Greece, told Medscape Medical News.

“Adopting or adhering to a Mediterranean-type dietary pattern has been repeatedly shown to have multiple beneficial effects for older people, including [avoiding] cognitive decline. So, according to our findings, following such a diet would also be good for the sleep habits of older adults,” Yannakoulia said.

The study was published online September 5 in Geriatrics and Gerontology International.

Synergistic, Antagonistic Effects

“Sleep curtailment and low sleep quality are common referred problems in older adults, with several parameters, including dietary factors, that may affect sleep duration and quality,” Yannakoulia said.

“Previous research has focused on caloric intake, individual nutrients, or foods that may be related to sleep patterns, but still, the assessment of individual food intake does not account for their potential synergistic or antagonistic effects on sleep parameters,” she added.

“Our previous research experience looking at the components and health effects of the MeDi — a holistic, whole-diet approach — motivated us to evaluate potential associations between this plant-based pattern and sleep.”

Although previous research suggested that adherence to the MeDi had beneficial effects on sleep patterns in older adults, it did not take cognitive status into account.

To investigate these questions, the researchers assessed participants in the Hellenic Longitudinal Investigation of Aging and Diet study. This population-based, multidisciplinary, collaborative study was designed to estimate the prevalence and incidence of mild cognitive impairment (MCI), Alzheimer’s disease, and other types of dementia in the Greek population. It also evaluated several factors that contribute to the health status of older people.

Participants were community-dwelling older adults (n = 1639; mean age, 72.7 years) who provided information about their diet and sleep patterns.

Habitual diet during the previous month was assessed using the validated, 69-question, semiquantitative food frequency questionnaire (FFQ), which was completed by each participant or, if necessary, a caregiver.

The FFQ included questions about consumption of various foods. Participants indicated the absolute frequency of consuming a predetermined amount of food using a 6-point scale. Reponses were then converted to indicate daily intakes of specific food items and were extrapolated to indicate energy intake.

The investigators used the MedDietScore, an 11-item composite score based on the FFQ-based food consumption, to evaluate adherence to the MeDi for each participant.

Participants also completed the Sleep Scale, from the Medical Outcomes Study, consisting of 12 self-reported items. Sleep quality was used as a continuous variable (ranging from 1 to 54), with higher scores indicating greater sleep dysfunction.

Covariates included age, sex, years of education, total energy intake (kcal/day), body mass index (BMI), and depression. The researchers also assessed physical activity using the Athens Physical Activity Questionnaire.

The statistical analyses used the MedDietScore either as a continuous variable or as tertiles. The first tertile (ie, lowest adherence to the MeDi) was the reference group, which was compared with the other tertiles. The last tertile represented the greatest adherence to the MeDi.

Potential Role of Melatonin?

Compared with participants with middle and high MeDi adherence, participants with lower MeDi adherence were found to be older (72.4 ± 5.6 and 72.1 ± 5.4 vs 73.4 ± 5.9 years, respectively) and to have a higher frequency of depression (20.4% and 15.3% vs 25.7%), higher BMI (28.6 ± 4.5 and 28.6 ± 4.3 vs 29.5 ± 5.0), and lower total energy intake (1985 ± 535 kcal/day and 2118 ± 509 kcal/day vs 1829 ± 519 kcal/day).

For participants with low MeDi adherence, sleep quality was worse, as indicated by higher Sleep Scale scores, than for those with middle and high MeDi adherence (18.8 ± 7.7 vs 17.6 ± 7.8 and 16.3 ± 7.2, respectively).

The positive association between MeDi adherence in the unadjusted model persisted after adjustment for age, sex, depression, years of education, BMI, level of physical activity, and total energy intake.

In both the unadjusted and adjusted models, sleep duration was not associated with MeDi adherence. The findings did not change when the researchers excluded participants with MCI.

Further analyses of the associations between MedDietScore and individual components of sleep quality revealed that adherence to the MeDi was negatively associated with trouble falling asleep and sleep disturbance and was positively associated with sleep adequacy, even after controlling for the aforementioned covariates.

The results did not change when the sample population was divided into male and female subgroups.

However, when the sample was divided into participants aged 75 years or younger and those older than 75, both unadjusted and adjusted models showed that sleep quality was positively associated with MeDi adherence only in the younger group. Sleep duration remained unrelated to MeDi adherence in both age groups.

Yannakoulia cautioned that because the study had a cross-sectional design, it could not establish causal relationships. Rather, it is “stating hypotheses for future investigations,” she said.

She suggested that one possible hypothesis for the findings is that “poor sleep quality is linked to high levels in markers of inflammation and oxidation, and anti-inflammatory as well as antioxidative properties have been extensively attributed to the Mediterranean dietary pattern.”

Moreover, “some foods characterizing the Mediterranean dietary pattern, such as olives, some kinds of fish, and seasonal fruits, are good sources of melatonin, a neurohormone that modulates circadian rhythms and is involved, among others, in the sleep-wake cycle by promoting sleep and subsequently enhancing sleep quality,” she said.

“Compelling Evidence”

Commenting for Medscape Medical News, Tasnime Akbaraly, PhD, French Institute of Health and Medical Research and the University of Montpellier, France, said that the study adds to increasingly “compelling evidence that there is a relationship between the quality of diet and several depressive disorders and mental health.”

There may be a “bidirectional association between cardiometabolic disorders and sleep disorders,” suggested Akbaraly, who was not involved with the study.

She added that, although more evidence is needed to assess whether diet directly affects sleep disorders, “the strong evidence already linking diet to cardiovascular diseases and depressive disorders — two conditions closely related to sleep problems — should lead clinicians to implement dietary habit assessments and dietary counseling during medication consultation, especially given the social and economic costs associated with unhealthy diets.”

Also commenting on the findings for Medscape Medical News, Marie-Pierre St-Onge, PhD, associate professor of nutritional medicine and center director of the American Heart Association’s Go Red Research Network, said that other studies have shown a relationship between specific nutrients and sleep quality and duration, but “this study shows that overall pattern of intake is also important.”

She cautioned that because this is a cross-sectional study, “we don’t know if poor diet leads to poor sleep quality or the other way round,” but the study does have important take-home messages for clinicians, “including dietary recommendations to sleep hygiene recommendations for healthy sleep may be useful to the patients,” St-Onge said.

“We should not forget that the Mediterranean diet is part of the Mediterranean lifestyle that includes, apart from the diet per se, adequate rest, regular physical activity, and conviviality,” Yannakoulia added.

Mediterranean Diet May Cut Stroke Risk for Women

The Mediterranean diet may do more than help you reach and maintain a healthy weight: New research suggests that women who follow it also lower their stroke risk.

But men did not reap the same benefit from the diet, which concentrates on fish, fruits, nuts, vegetables and beans, and avoids meat and dairy products.

“Simple changes in dietary habits may bring a substantial benefit regarding reducing stroke, which remains one of the leading causes of death and disability worldwide,” said lead researcher Dr. Phyo Myint. He is clinical chair of medicine at the University of Aberdeen School of Medicine in Scotland.

Although the Mediterranean diet is considered healthy, this study could not prove that the diet itself caused stroke risk to drop.

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In addition, why men’s risk for stroke isn’t also lowered isn’t yet clear, Myint said.

But, “it is widely acknowledged that men and women are very different with regard to normal physiology,” he added.

Women have unique stroke risk factors that include using oral contraceptives or hormone replacement therapy. And during pregnancy, having preeclampsia and gestational diabetes are considered risk factors for stroke, Myint pointed out.

“It may be that certain components in the Mediterranean diet may influence risk of stroke in women more than in men,” he said.

For the study, the investigators collected data on more than 23,000 men and women, aged 40 to 77, who took part in a large cancer study. The participants were followed for 17 years.

The researchers found that, overall, those who followed a Mediterranean diet cut their risk for stroke 17 percent. When looking at men and women separately, however, women saw a reduction in risk of 22 percent, while men saw a 6 percent drop in risk. The risk reduction among men, however, might be so small that it is a “chance” finding, the scientists added.

Moreover, among those with a high risk for stroke, the risk was lowered 13 percent for those who followed a Mediterranean diet, the findings showed. This association, however, was mainly due to a 20 percent reduction in risk among women, the researchers found.

The findings were published online Sept. 20 in the journal Stroke.

According to Samantha Heller, a senior clinical nutritionist at NYU Langone Medical Center in New York City, “The Mediterranean eating style, which has great variations among several different cultures, is characterized by foods high in anti-inflammatory compounds, including fiber, vitamins, minerals and healthy plant compounds.”

Previous research has suggested that the Mediterranean diet reduces the risk of heart disease, type 2 diabetes, certain cancers, obesity and declines in thinking skills, she said.

Foods such as olive oil, zucchini, lemons, hummus, tabouleh, pasta, eggplant, lentils, tomatoes, artichokes, salads and spices are staples in many parts of the Mediterranean, Heller explained.

“In contrast, the typical Western diet is high in foods that increase inflammation, such as burgers, hot dogs, steak, butter, sodium, sugary beverages, fried foods, fast and junk foods, all of which have been associated with increased risks of chronic diseases,” she said.

Heller suggests skipping the ham and cheese on white bread with mayo for lunch, and instead trying hummus on whole wheat pita with cucumbers and tomatoes. For dinner, try going meatless a few nights a week with a pasta primavera, roasted vegetables, Greek salad, quinoa and lentil-stuffed lettuce wraps, she added.

Vegetarian or Mediterranean? Both Diets Improve Weight, Lipids

Three months of a low-calorie vegetarian and a low-calorie Mediterranean diet were equally beneficial in reducing weight and improving cardiovascular risk profiles, in the first randomized crossover trial comparing the two directly.

The vegetarian diet was more effective in reducing LDL cholesterol, whereas the Mediterranean diet led to a greater reduction in triglycerides, which was not surprising, the researchers say.

These findings from the Cardiovascular Prevention With Vegetarian Diet (CARDIVEG) by Francesco Sofi, MD, PhD (University of Florence, Italy), and colleagues were published online February 26 in Circulation.

Participants received individual, in-person counseling from nutritionists on how to adhere to each of the two evidence-based healthy eating patterns. The vegetarian diet excluded meat and fish but included dairy and eggs.

This was the first “intervention study that follows the principles of evidence-based medicine, in a general population at low risk of cardiovascular disease, that compared these two beneficial diets,” Sofi told | Medscape Cardiology.

“We can conclude that both diets are beneficial for heart health,” she said. The result was not surprising, she said, because both diets have a strong foundation of healthy foods, such as fruits and vegetables, whole grains, and legumes.

“We [now] have data on two strategies that might be helpful in reducing cardiovascular risk and promoting cardiovascular health,” Cheryl AM Anderson, PhD, MPH, MS, University of California, San Diego, author of an accompanying editorial, told | Medscape Cardiology.

“This is a study that provides some evidence base on which you can begin to feel reasonably reassured in counseling patients that there’s not necessarily one path to Rome, but multiple strategies can be helpful.”

“It’s easy to focus on meat vs no meat, but what’s really important is the rest of the diet,” Anderson stressed.

A healthy diet should be “nutrient dense; rich in vegetables and fruits, whole grains, legumes and nuts; low in refined grains and commercially processed foods with added sugars, saturated fats, and sodium; sustainable; culturally relevant; and enjoyable.”

There is helpful information and tools online at, she noted, which are based on the most recent US guidelines.

Two Healthy Diets

The Mediterranean diet is widely reported to be one of the healthiest eating patterns to prevent cardiovascular disease, Sofi and colleagues note. In an earlier meta-analysis, the researchers reported that a vegetarian eating pattern was associated with improvements in cardiovascular risk factors.

To compare the two diets, the CARDIVEG trial randomly assigned 118 participants (78% women) living in Florence in 2014 to 2015 who were age 18 to 75 years and overweight (BMI ≥ 25 kg/m2).

The participants also had one or more of the following risk factors for cardiovascular disease, as defined by the European Society of Cardiology (ESC) guidelines: total cholesterol greater than 190 mg/dL, LDL cholesterol greater than 115 mg/dL, triglycerides greater than 150 mg/dL, and glucose greater than 110 but less than 126 mg/dL.

On average, they were 51 years of age, weighed 84 kg, and had a BMI of 31 kg/m2. Close to half (48%) were obese (BMI > 30 kg/m2).

All participants received in-person, individual counseling as well as a detailed, 1-week menu plan for each diet and recipes for the vegetarian diet.

After a run-in period, they ate a vegetarian or Mediterranean diet for 3 months and then switched diets for another 3 months. A total of 85% of the participants (50 for each intervention) completed the study.

Both diets had similar low calories and consisted of 50% to 55% carbohydrates, 25% to 30% fat, and 15% to 20% protein.

The participants ate a similar number of servings of cereals, fruits and vegetables, potatoes, sweets, and olive oil on both diets, but on the vegetarian diet they ate more legumes, nuts, eggs, and dairy products, as well as flaxseed and avocado (to compensate for the lack of essential fatty acids from fish).

Both diets were similarly effective for weight loss. After 3 months, the participants lost a mean of 1.88 kg and 1.77 kg while on the vegetarian and Mediterranean diets, respectively.

They also lost a similar amount of fat mass (about 1.3 kg) and lowered their BMI by a similar amount (about 0.65 kg/m2).

During the vegetarian diet, 46 participants (44%) modified their cardiovascular risk category by reaching ESC-recommended target levels: Sixteen reached the target for total cholesterol, 17 for LDL cholesterol, 6 for triglycerides, and 14 for BMI.

During the Mediterranean diet, 35 participants (34%) modified their cardiovascular risk category: Seven reached the target for total cholesterol, 6 for LDL cholesterol, 8 for triglycerides, and 10 for BMI.

The vegetarian diet is low in cholesterol, total fat, and saturated fatty acid, leading to lower rates of cholesterol in the bloodstream, whereas the Mediterranean diet “can reduce triglyceride levels through its beneficial components, including olive oil, dietary fiber, and many phytonutrients,” Sofi and colleagues explain.

Vitamin B12 levels were significantly lower with the vegetarian diet.

However, there were no significant differences in levels of oxidative stress markers or inflammatory cytokines after 3 months of each diet.

The study shows that “if a person would like to follow a lacto-ovo-vegetarian diet he/she can obtain a beneficial effect as well as with the Mediterranean diet, or probably in a greater extent as for cholesterol and lipid variables,” Sofi said. “The most important thing is that he/she needs to be followed and instructed by an expert nutritionist in order to avoid possible deficiencies.”

Although these diets should be investigated in larger studies in other populations, this research suggests that “a low-calorie healthy vegetarian or Mediterranean diet pattern may offer a possible solution to the ongoing challenges to prevent and manage obesity and cardiovascular diseases,” Anderson said.

The researchers are continuing to follow the study participants, Sofi said, and “a considerable portion of them declared that they learned how to eat without meat, at least in part and for a short period. In my opinion, this is already a good result.”

Success rate of IVF increases with Mediterranean diet

Mediterranean diet may help protect older adults from becoming frail

Mediterranean diet could slash risk of deadly breast cancer by 40pc


A table with Mediterranean food laid out
A diet high in fruit, vegetables and olive oil could stave off heart attacks and strokes 
Eating a Mediterranean diet can help reduce risk of one of worst types of breast cancer by 40 per cent, a major study suggests.

The research which tracked more than 60,000 women over two decades found that those who ate a diet rich in fruit, vegetables, fish, nuts, whole grains and olive oil had a far lower chance of developing an aggressive form of the disease.

Every year, 53,000 women in the UK are diagnosed with breast cancer.

The major new study funded by the World Cancer Research Fund, which tracked women aged between 55 and 69 for 20 years, found that those who adhered most closely to a Mediterranean diet had a far lower chance of disease.

Overall, they had a 40 per cent reduced risk of oestrogen-receptor negative breast cancer.

Around one in three cases of breast cancer falls into this category, which is more deadly than other types of disease.

The Mediterranean Diet pattern is one that includes a high intake of plant-based proteins, such as nuts, lentils and beans, whole-grains, fish and monounsaturated fats – also known as “good fats”, such as olive oil.

This diet also has a low intake of refined grains such as white bread or white rice, red meat and sweets.

Med diet
The Mediterranean diet has been linked to a longer lifespan 

Although the traditional Mediterranean Diet involves moderate consumption of alcohol, in this study alcohol was excluded from the criteria, as this is a known risk factor for breast cancer, and linked to 12,000 cases annually.

Breast cancer is the most common cancer in women in the UK with over 53,000 new cases each year.

Around 40 per cent of all cancers are linked to lifestyle, with breast cancer risks heightened by excess weight, poor diet, alcohol and smoking.

Dr Panagiota Mitrou, Director of Research Funding at World Cancer Research Fund, said:

“This important study showed that following a dietary pattern like the Mediterranean Diet, could help reduce breast cancer risk – particularly the subtype with a poorer prognosis. With breast cancer being so common in the UK, prevention is key if we want to see a decrease in the number of women developing the disease.

“We would welcome further research that helps us better understand the risk factors for the different breast cancer subtypes.”

Professor Piet van den Brandt, lead researcher on this study at Maastricht University said:

“Our research can help to shine a light on how dietary patterns can affect our cancer risk.

“We found a strong link between the Mediterranean Diet and reduced estrogen-receptor negative breastcancer risk among postmenopausal women, even in a non-Mediterranean population. This type of breast cancer usually has a worse prognosis than other types of breast cancer”.

Emma Pennery, Clinical Director at Breast Cancer Care, said the findings were “intriguing”.

“This study adds to evidence that a healthy diet, full of ‘good’ low-saturated fats, plays a part in lowering risk of the disease,” she said.

“However, it’s important to remember while lifestyle choices like eating a well-balanced diet and taking regular exercise can help reduce the risk of cancer, they don’t guarantee prevention. So it’s crucial women know the signs and symptoms of breast cancer, and contact their GP with any concerns.”

 A plate of fish
Swapping red meat for fish and upping fruit and vegetable intake lowers the chance of heart problems 

Separate US research found that women already being treated for breast cancer could boost survival chances by eating a diet rich in soy.

Women with estrogen-receptor negative breast cancer who added the Japanese ingredient to their diet were able to reduce their risk of dying by up to a fifth, the study found.

Scientists founds that foods rich in isoflavones – the active ingredient in soy – appeared to boost survival.

The ingredient is found in meat replacement foods such as tofu, as well as in soy sauce, Miso soup, soy milk and edamame beans.

Study leader Dr Esther John, of the Cancer Prevention Institute of California, said: “Whether lifestyle factors can improve survival after diagnosis is an important question for women diagnosed with this more aggressive type of breast cancer.

“Our findings suggest that survival may be better in patients with a higher consumption of isoflavones.”

Why the Mediterranean Diet Is so Successful

The Mediterranean diet is one that has managed to maintain popularity through changing fads, and for good reason. A number of studies have confirmed its health benefits — most of which are likely due to it being low in sugars, moderate in protein and high in fresh fruits and vegetables, along with healthy fats.

Story at-a-glance

  • A number of studies have confirmed the health benefits of a Mediterranean-style diet — most of which are likely due to it being low in sugars, moderate in protein and high in fresh fruits and vegetables, along with healthy fats
  • Eating a Mediterranean-style diet has been linked to a number of health benefits, including prevention and reversal of metabolic syndrome, improved cardiovascular health and reduced risk for stroke
  • Other benefits include reduced risk of adult acne, rheumatoid arthritis, Parkinson’s, Alzheimer’s disease and cancer, and improved overall health and longevity

Contrary to popular belief, there’s actually no single “Mediterranean diet.” At least 16 countries border the Mediterranean Sea, and dietary habits vary from country to country due to differences in culture, ethnic background, religion and agricultural production.

That said, a primary hallmark of a Mediterranean-style diet is a focus on whole, minimally processed foods. The emphasis on fresh vegetables alone makes it far healthier than the standard American diet, which is very high in processed foods.

Health Benefits Associated With a Mediterranean-Style Diet

Eating a Mediterranean-style diet has been linked to a number of health benefits, including:

Prevention and/or reversal of metabolic syndrome, a cluster of risk factors for heart disease and diabetes.

One review of 35 clinical trials found it helped reduce belly fat and high blood pressure, elevate HDL cholesterol and improve blood sugar levels, compared to those who ate a low-fat diet.1

Improved cardiovascular health and a significantly reduced risk of stroke — effects linked to higher amounts of animal-based omega-3 fats (primarily from fish).2,3

According to recent research, marine animal-based omega-3 may lower your risk of heart disease even if you’re already at increased risk due to high levels of low-density lipoprotein (LDL) cholesterol and/or triglycerides.4,5

Higher levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) from seafood or supplements was associated with a 16 percent lower risk of heart disease in those with high triglycerides, and a 14 percent reduced risk in those with high LDLs.

Reduced risk of acne in adult women. According to recent research, adult women who ate fresh fruits, vegetables and fish less than four days a week had double the risk of adult acne.6,7

Reduced risk of rheumatoid arthritis,8 Parkinson’s, Alzheimer’s disease and cancer.9

Improved overall health and longevity. In one study, women who closely followed a Mediterranean-style diet in their 50s and 60s were 46 percent more likely to live past the age of 70 without chronic illness or cognitive problems.10

Mediterranean Diet Linked to Healthier Brain

Overall, the Mediterranean diet is one of the best conventional diets for brain and heart health. For example, research has shown diets rich in healthy fats from nuts, avocados and olive oil may boost memory and cognition in older adults.11,12

Previous research has also suggested a Mediterranean diet may lower your odds of Alzheimer’s disease, but it wasn’t clear whether the diet was responsible, or if people who eat this way also make many other healthier lifestyle choices that decrease their risk.

In an effort to shed more light on the potential links between diet and cognition, the researchers randomly assigned nearly 450 seniors with risk factors for cardiovascular disease — such as overweight, high blood pressure and/or high cholesterol — to follow one of three diets:13,14

  • A Mediterranean diet supplemented with 1 liter of extra virgin olive oil per week
  • A Mediterranean diet supplemented with 30 grams of nuts a day
  • A low-fat diet

Brain function tests were conducted before and after the study. Those following a Mediterranean diet with supplemental nuts showed significant improvement in memory, while those who got supplemental olive oil experienced significantly improved cognition.

The low-fat group, on the other hand, experienced a significant decrease in both memory and cognitive function.

Older Adults Suffer Less Brain Shrinkage on Mediterranean Diet

More recently, scientists found that a Mediterranean-style diet also helps reduce age-related brain shrinkage in older adults. As reported by the LA Times:15

“In a group of 562 Scots in their 70s, those whose consumption patterns more closely followed the Mediterranean diet experienced, on average, half the brain shrinkage that was normal for the group as a whole over a three-year period …

The researchers used the food-frequency surveys to divide the group into two — those who at least approximated a Mediterranean-style diet and those who came nowhere close.

Even though many in the Med-diet group were far from perfect in their adherence, the average brain-volume loss differed significantly between the two groups.”

Your Brain Needs Healthy Fats for Optimal Function

Results such as these certainly make sense when you consider how important healthy fats are for your brain function. After all, your brain is composed of at least 60 percent fat — the most important of which is DHA, found in seafood such as clean fish and krill oil. That said, it’s important to choose your seafood wisely.

What you’re looking for are fish high in healthy fats, such as omega-3, while also being low in mercury and other environmental pollutants. Good choices include smaller fatty fish like sardines, anchovies and herring.

As a general rule, the lower on the food chain the fish is, the less likely it is to contain harmful levels of contaminants. Many of these smaller fish also contain higher amounts of omega-3, so it’s a win-win. Wild-caught Alaskan salmon is another healthy choice. If you avoid fish, it’s important to take a high-quality omega-3 supplement such as krill oil.

Besides fish, other examples of beneficial fats that your body (and your brain in particular) needs for optimal function include avocado, organic grass-fed raw butter, clarified butter called ghee, olives, organic virgin olive oil and coconut oil, nuts like pecans and macadamia and free-range eggs.

It’s also important to avoid sugars and processed grains. Research from the Mayo Clinic shows diets rich in carbohydrates are associated with an 89 percent increased risk for dementia, while high-fat diets are associated with a 42 percent reduced risk.16

Omega-3 Is Important for Other Psychiatric Conditions as Well

Animal-based omega-3 in combination with vitamin D has also been shown to improve cognitive function and behavior associated with certain psychiatric conditions, including ADHD, bipolar disorder and schizophrenia — in part by regulating your brain’s serotonin levels.17,18,19

The omega-3 fat EPA reduces inflammatory signaling molecules in your brain that inhibit serotonin release from presynaptic neurons, thereby boosting your serotonin levels. DHA — which is an important structural component of your brain cells — also has a beneficial influence on serotonin receptors by increasing their access to serotonin.

Other diets shown to be particularly beneficial for brain health include the DASH and the MIND diets,20 the latter of which emphasizes fruits and vegetables, especially leafy greens and berries, whole grains, nuts, olive oil, beans, poultry and fish, while limiting red meat, cheese, butter, sweets and fried foods.

What these three diets have in common is an emphasis on whole foods, particularly fresh fruits and vegetables, and at least SOME healthy fats. Considering the importance of eating real food, it’s not so surprising that the DASH diet, Mediterranean diet and MIND diet rank No.1, 2 and 3 respectively as the best overall diets for good health, according to a panel of health experts.21

Benefits of the DASH Diet

The DASH diet in particular has been shown to be quite effective for lowering your risk of hypertension. However, I believe the real reason for this effect is not due to the reduction in salt but rather the reduction in processed foods, which is high in fructose.22,23 As your insulin and leptin levels rise in response to net carbs, it causes your blood pressure to increase.

Excess fructose promotes hypertension to a far greater degree than excess salt. One 2010 study24 discovered that those who consumed 74 grams or more per day of fructose (the equivalent of about 2.5 sugary drinks) had a 77 percent greater risk of having blood pressure levels of 160/100 mmHg (stage 2 hypertension). Consuming 74 grams or more of fructose per day also increased the risk of a 135/85 blood pressure reading by 26 percent, and a reading of 140/90 by 30 percent.

Elevated uric acid levels are also significantly associated with hypertension (by inhibiting nitric oxide in your blood vessels), and fructose elevates uric acid. In fact, uric acid is a byproduct of fructose metabolism. So, by eliminating excess sugar and fructose from your diet, you effectively address root issues that contribute to high blood pressure.

I recommend keeping your total fructose consumption below 25 grams per day. If you’re insulin resistant (about 80 percent of Americans are), have high blood pressure, diabetes, heart disease or other chronic disease, you’d be wise to limit your fructose to 15 grams or less per day, until your condition has normalized.

As for the issue of salt (which the DASH diet restricts), it’s important to realize that salt is actually essential for maintaining and regulating blood pressure. The key is to use the right kind of salt. Ideally, replace all processed table salt with a natural unprocessed version, such as Himalayan salt, which contains a variety of trace minerals your body actually needs.

Part of the DASH diet’s effectiveness for hypertension may also have to do with the fact that it focuses on vegetables, which helps improve your sodium-to-potassium ratio. Your body needs potassium to maintain proper pH levels in your body fluids, and it plays an integral role in regulating your blood pressure. It’s actually possible that potassium deficiency may be a greater contributor to hypertension than excess sodium (but not likely a greater factor than fructose).

Mediterranean Diet May Cut Your Heart Disease Risk by Nearly One-Third

The importance of healthy fats cannot be overstated in my view. Fats are important for so many biological processes, especially those related to your brain and heart function. In the case of the latter, a Spanish trial,25 which included nearly 7,450 volunteers between the ages of 55 and 80, was stopped early for ethical reasons as the low-fat control group was deemed to be at a dangerous disadvantage.

The participants had all been diagnosed with high risk of cardiovascular disease, but were asymptomatic at the outset of the study. Participants were followed for a median of 4.8 years. The volunteers were randomly divided into three groups (two intervention groups and one control):

  • Mediterranean diet rich in fresh vegetables, fruits, seafood, whole grains and mono-unsaturated fats, very low in meat and dairy and supplemented with 30 grams (1.05 ounces) of nuts per day (15 grams walnuts, 7.5 grams almonds and 7.5 grams hazelnuts)
  • Mediterranean diet (as above) supplemented with 50 milliliters (1.7 ounces) of virgin olive oil per day instead of nuts
  • Low-fat diet (control)

There were no calorie restrictions for any of the groups, nor was physical activity promoted or required. Compliance with olive oil and nut consumption was tested via blood and urine analysis. The primary end point was a composite of myocardial infarction, stroke and death from cardiovascular causes. Secondary end points were stroke, myocardial infarction, death from cardiovascular causes and death from any cause.

Remarkably, in less than five years, the two intervention groups achieved a 30 percent relative risk reduction for cardiovascular disease, and stroke reduction was an impressive 49 percent. No wonder they felt the trial had to be stopped for ethical reasons!

Sadly, low-fat diets remain among the most accepted diets in the medical community, both for weight management and cardiac health. There’s no telling how many millions of people have prematurely died from this fatally flawed and scientifically-refuted advice.

Are You Eating Enough Fish?

According to the latest report26 by the National Oceanic and Atmospheric Administration (NOAA), Americans increased their seafood consumption by nearly 1 pound per person in 2015, to an average of 15.5 pounds per year, or just over 4.75 ounces per week.

That’s the largest increase in seafood consumption in two decades, yet we still fall short of dietary recommendations, which call for 8 ounces of seafood per week. Ideally, aim for two to three servings of fish like salmon or sardines, anchovies, mackerel and herring each week, to obtain healthy levels of omega-3. Avoid canned tuna, mackerel, swordfish, grouper, marlin, orange roughy, snapper and halibut, as they have some of the highestlevels of contamination.

For more information about mercury in fish, see the Mercury Policy Project’s website, “Mercury and Fish: The Facts.”27 They have a helpful guide you can print out for reference.28 A 2015 article in Investigate West also addressed this issue, and includes a guide to how many meals per week you can safely eat based on any given seafood’s contamination level.29

Why Higher Fish Consumption Is Likely Part of Mediterranean Diet’s High Success Rate

Besides omega-3 fats and other valuable nutrients, fish is also a good source of high-quality protein. However, most fish contain only HALF of the protein found in beef and chicken, and this is actually a very good thing. While we do need protein for muscle, bone and hormone health, eating more than your body actually needs can stimulate your mammalian target of rapamycin (mTOR) — a pathway that plays an important role in many cancers, among other things.

In fact, Valter Longo, Ph.D.,30 — a professor of biological science at the University of California and a well-known longevity researcher — believes the reduced protein content in fish may be one reason why the Mediterranean diet is linked to life extension and reduced risk for chronic disease. In essence, those who eat more fish than red meat automatically get far less protein, thereby preventing the excessive stimulation of mTOR.

For Health and Longevity, Be Sure to Optimize Your Omega-3

If you do not eat this amount of fish on a weekly basis, consider taking a daily omega-3 supplement such as krill oil. As for dosage, the amount of omega-3s you need depends on your body size, age, health status, the type of omega-3 and more. Your best bet is to get an omega-3 index test. This test measures the omega-3 in your red blood cells, which is really the only way to determine if you’re getting enough from your diet or supplements. Your index should be above 8 percent.

While there’s no set recommended standard dose of omega-3 fats, some health organizations recommend a daily dose of 250 to 500 milligram (mg) of EPA and DHA for healthy adults. Higher amounts (upwards of 1,000 to 2,000 mg of EPA and DHA daily) are typically recommended for the prevention of memory loss, depression and heart disease.

If you’re pregnant or breastfeeding, your body will likely require additional omega-3 fats. The American Dietetic Association and Dietitians of Canada recommend pregnant and lactating women (along with all adults) consume at least 500 mg of omega-3s, including EPA and DHA, daily.

Other Vital Reasons Why Mediterranean-Style Diet Is a Good Choice

Aside from the important dietary components mentioned above, there are at least three other lifestyle factors that contribute to the benefits achieved by those actually living in the Mediterranean countries. The obvious one is that these are subtropical countries and most people are able to achieve a healthy level of sun exposure, as the opportunities to go outside with minimal clothing on are far more frequent than for most of us living in the U.S.

The other two are related in that they are social variable. There is less reliance on cars and automated tasks that allow them to walk and be more active and mobile than many of us in the U.S. Additionally, there is an important social component to most meals that is typically not encountered in the U.S.

Is There Something Better Than the Mediterranean Diet?

If you are healthy and have an ideal body fat percentage, then the dietary choices discussed above are a sound choice, especially if you integrate the other variables discussed in the section above.

But the sad reality is that well over 80 percent of those in the U.S. do not fit this profile, as they are either overweight, have cancer, heart disease, diabetes, autoimmune or neurodegenerative diseases. If this applies to you or someone you love, then I firmly believe you need to teach your body to burn fat as its primary fuel before you engage in this type of diet.

My new book, “Fat for Fuel,” discusses how to radically limit your carb and protein intake while integrating periods of feast and famine cycling, which will help your body regain its ability to burn fat as its primary fuel. Once you normalize your weight and other conditions, and your body has regained the capacity to burn fat as your primary fuel, then it makes loads of sense to shift to a Mediterranean diet.

Mediterranean diet could prevent brain shrinking in old age, study suggests

Acans of the brain of a normal patient (left) versus an Alzheimer's disease patient

Acans of the brain of a normal patient (left) versus an Alzheimer’s disease patient

Following a Mediterranean diet could prevent the brain shrinking in old age and help prevent cognitive decline, a new study suggests.

Scientists have known for some time that eating healthily can help stave off dementia but did not know how it protected the brain.

Now a new study shows that it may help slow down the inevitable brain shrinkage that happens in later life, keeping more brain cells active for longer.

   This adds to the growing body of evidence highlighting the importance of proper diet on our brain healthDr Sujoy Mukherjee, West London Mental Health NHS Trust

“As we age, the brain shrinks and we lose brain cells which can affect learning and memory,” said study author Dr Michelle Luciano, of the University of Edinburgh.

“This study adds to the body of evidence that suggests the Mediterranean diet has a positive impact on brain health… and may be able to provide long-term protection to the brain.”

A Mediterranean diet could stop the brain shrinking in later life 
A Mediterranean diet could stop the brain shrinking in later life 

The Mediterranean diet includes large amounts of fruits, vegetables, olive oil, beans and cereal grains such as wheat and rice, moderate amounts of fish, dairy and wine, and limited red meat

To find out if it was having an impact on the brain scientists gathered dietary information for 401 70-year-olds and then scanned their brains at the age of 73 and 76, measuring brain volume and the thickness of the cerebral cortex.

They found those who closely followed a Mediterranean diet retained more volume over the period.  The difference in diet explained 0.5 percent of the variation in brain volume, an effect that was half the size of that due to normal aging.

Dr Clare Walton, Research Manager at Alzheimer’s Society, said: “There is an increasing amount of evidence to indicate that eating a healthy diet that’s rich in oily fish, fresh veg and nuts is good for your brain and can help to maintain your memory as you get older.

“Our brains shrink by 1-2 per cent per year in old age and this study suggests that a Mediterranean-style diet could also potentially help to slow down this shrinking process.

“While the evidence suggests a Mediterranean diet can help keep your brain healthy as you age, we can’t yet say that it prevents dementia.

“What’s good for you heart is also good for your head and a healthy lifestyle that features regular exercise, a balanced diet and not smoking can help to lower your chances of dementia.”

&amp;amp;lt;img src=”/content/dam/pensions-retirement/2016/11/30/Abbeyfield-House-small_trans_NvBQzQNjv4Bq5yQLQqeH37t50SCyM4-zeERf_Wk3V23H2268P_XkPxc.jpg” alt=”Living a healthy lifestyle is known to keep people sharper in later life&amp;nbsp;” width=”320″ height=”200″ class=”responsive-image–fallback”/&amp;amp;gt; Living a healthy lifestyle is known to keep people sharper in later life 
Living a healthy lifestyle is known to keep people sharper in later life 

Dr David Reynolds, Chief Scientific Officer at Alzheimer’s Research UK,

added:“The brain, just like other parts of the body, can be affected by the way we live our lives.

“While a balanced diet is one way we can help to maintain a healthy brain, the best current evidence points to a number of other lifestyle factors that can also play a role. These include not smoking, staying mentally and physically active, only drinking in moderation and keeping blood pressure and cholesterol in check.”

Dr Sujoy Mukherjee, Consultant Psychiatrist, West London Mental Health NHS Trust, said: “It is a well-designed study in a relatively large number of healthy elderly to show that Mediterranean diet may protect from subsequent brain atrophy.

“This adds to the growing body of evidence highlighting the importance of proper diet on our brain health. ”

The study was published in the journal Neurology.