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Mediterranean Diet Results Astound Researchers

Eating Style Reduced Heart Attacks by Almost 30%, Strokes by 49%

Health letters, medical blogs, The New York Times, everyone in the healthy-eating research loop is talking about a study reported in The New England Journal of Medicine on April 4, 2013. For the first time, a large, randomized, clinical trial has found that a Mediterranean-style diet can reduce heart attacks, strokes, and deaths from heart disease. Observational studies have only suggested such benefits from eating a diet rich in vegetables, fruits, beans, fish, olive oil, and nuts, including wine in moderation, white meat instead of red or processed meat, and little or no full-fat diary, fatty spreads, soda drinks, and bakery goods. The researchers were so bowled over by the large reduction in risk that they felt compelled to stop the study early, after about five years. In their view, withholding the results would be unethical.

The study was ground breaking on several fronts. Many questioned whether the benefits of an eating style could be clearly shown. As noted, the new study was the first clinical trial to show an absolute reduction in major events. The endpoints were not mere risk factors, such as cholesterol, blood pressure, and weight. They looked at life-changing events—heart attacks, strokes, and death. Whereas the benefits of fish oil in other studies were said to be obscured by state-of-the-art medications such as statins and blood pressure drugs, the findings here appear to be above and beyond the effects of such drugs. Participants here were high risk and, therefore, already benefiting at least to some extent from statins and other drugs.

Lead researcher Ramón Estruch, MD, PhD, professor of medicine at the University of Barcelona, and colleagues traveled the world seeking advice from the Harvard School of Public Health and other prominent research groups seeking advice on the design of the study. They stacked the odds against the Mediterranean diet—high risk subjects and consequential endpoints—and still showed compelling results. (As we'll see, there are naysayers.) 

Study participants (7,447 men and women ages 55 to 80) were free from cardiovascular disease at enrollment, but had either type 2 diabetes or at least three cardiovascular risk factors, such as smoking, high blood pressure, obesity; abnormal cholesterol, or a family history of early heart disease.   

These high risk subjects were randomly assigned to three groups. Two were forms of the Mediterranean diet—one including olive oil and the other nuts. One group was told to consume at least four tablespoons daily of extra-virgin olive oil, and the other group was told to include a quarter cup of mixed nuts daily (half walnuts, and one-quarter each almonds and hazel nuts). The olive oil or nuts were substituted for other forms of fat. The third group, the control group, consumed a low-fat diet. (Fat intake was still above current average levels in the US diet.)

The control group was directed not to consume vegetable oils, nuts, or fatty fish.

All three groups were told to cut down on fatty red and processed meat, bakery products, and fat-based spreads.

The low-fat control group was criticized two ways, with some saying it was a much improved low-fat diet and others calling it a poor substitute for a vegan diet. Either way, it was amazing that the two Mediterranean-style diets proved so advantageous. Results were essentially the same for the olive oil and nut versions of the Mediterranean-style diets.

“It’s impossible to guess what the absolute risk reduction would have been if the control was a standard fare diet (complete with 138 grams per day of sugar), rather than a much improved low fat diet,” Peter Attio, MD, wrote on his “Eating Academy” blog. “I think the Low Fat arm in this study experienced an enormous benefit over their baseline.” In other words, the control group diet was an improvement over what they eat normally, very likely narrowing the gap between the control and the Med-diet groups. Estruch et al agreed: “The control group was given recommendations for a healthy diet, suggesting a potentially greater benefit of the Mediterranean diet as compared with Western diets.”

On the other hand, Drs. Caldwell Esselstyn and Dean Ornish, both proponents of a very-low-fat diet, dismiss both the Mediterranean diets and the “horrible control” as actually disease creating. Clearly, that’s not the consensus view. “Low-fat diets have not been shown in any rigorous way to be helpful,” Dr. Steven E. Nissen, chairman of the department of cardiovascular medicine at the Cleveland Clinic, told New York Times columnist Gina Kolata.

Dr. Estruch and colleagues called their result consistent with earlier research showing “a low-fat dietary approach resulted in no cardiovascular benefit.”

The Estruch team summarized their results as follows: “In this trial, an energy-unrestricted Mediterranean diet supplemented with extra-virgin olive oil or nuts resulted in…a relative risk reduction of approximately 30% among high risk persons who were initially free of cardiovascular disease. These results support the benefits of the Mediterranean diet for cardiovascular risk reductions.” 

The greatest benefit was against stroke, with a 49% lower risk among the Mediterranean-style diet groups. 

The researchers believe their result was likely the result of a dietary pattern, with the “salient components” including “moderate consumption of wine, low consumption of meat and meat products, and high consumption of vegetables, fruits, nuts, legumes, fish and olive oil. Perhaps there is a synergy among the nutrient-rich foods included in the Mediterranean diet that fosters favorable changes in…blood lipids, insulin sensitivity, resistance to oxidation, inflammation, and vasoreactivity.” In short, it’s the whole package that lowers the risk of heart attack, stroke, and death from heart disease.

Perhaps most telling, Dr. Estruch told Gina Kolata that his colleagues have changed their own diets and are now following a Mediterranean-style diet.  

*  *  *

I wrote in Take Charge that I favor the Mediterranean-style diet. The Estruch study reinforces my preference. I’m with the good doctor and his colleagues.

My father, a medical doctor, told patients not to eat any fat they could see—still good advice. I grew up believing that fat was bad, not differentiating between good fat and bad fat. I knew that some fat was essential, but I believed doctors who said a deficiency is practically impossible. I was not alone. Until relatively recently, most doctors and dieticians recommended eating a low fat diet. Some still do.

I have come to appreciate the need for dietary fat more over time.

In 1998, my total cholesterol/HDL ratio improved from "good" to "excellent" after I added a small amount of olive oil (later flaxseed oil) to each of my meals and snacks. My total cholesterol dropped below 200 for the first time in years, perhaps ever. My triglycerides dropped 50 percent, from 153 to 76.

Low fat generally means high carbohydrate, which can be a problem, especially if the carbs are refined, frequently raising triglycerides.

My diet was already low in saturated fat. I was eating very little processed food. My carbohydrate intake was almost all from whole foods. I thought my diet was just about perfect. But something was missing. That something, it seems, was vegetable oil and nuts, which are generally low in saturated fat, and high in poly- and mono-unsaturated fatty acids.

As time went on, I learned about the benefits of omega-3 polyunsaturated fatty acids, found mainly in fatty fish. In 2009, I started taking three fish oil capsules a day, with meals. (I was already having salmon several times a week.) My HDL “good” cholesterol skyrocketed to 78. It went from a very good 60 to stunning (45-70 is the reference range for men.)

Slowly but surely, I stopped trying to cut fat, and started striving for an optimal balance of fats. Emerging research suggested that was on the right track.

The new study from the University of Barcelona is perhaps the most concrete proof so far. It says that a diet with plenty of vegetables, fresh fruit, beans, lentils, fatty fish, vegetable oil, and nuts—and little in the way of red or processed meat, full-fat dairy, and pastries—is good for your health.

My diet also includes whole grains, such as oat groats, hulled barley, kamut, and amaranth.

No one food is the key. It’s the whole package. The Mediterranean diet is not a diet in the usual sense; it’s an eating style—with variations to satisfy almost any palate.

In the new study, the main difference between the two trial groups and the control group was olive oil, nuts, and fatty fish; one group ate olive oil and the other group ate nuts. Both trial groups ate fatty fish. The control group was instructed not to eat olive oil, nuts, or fatty fish..

Good fat also made the difference for me.

In my case, vegetable oil, nuts, and fatty fish rounded out the package. The good fats substantially improved my lipid profile—they were clearly good for me. Importantly, they also added flavor and eating satisfaction. I stayed full and satisfied longer.  

The Mediterranean-style is a wonderful way to eat. What’s not to like?

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