The Mediterranean Diet

Preface xi 1 Overview 1 1.1 Development of the MedDiet 1 1.1.1 A brief history of the MedDiet 2 1.1.2 The traditional MedDiet and present day MedDiets 2 1.1.3 International differences 6 1.1.4 National representations of the MedDiet 7 1.1.5 Sources of information for the general public 13 1.2 Lifestyle factors 13 1.2.1 Meal patterns 14 1.2.2 Siestas 16 1.2.3 Physical activity 16 1.2.4 Sunshine 16 1.3 Health benefits 16 1.3.1 Mediterranean dietary patterns 17 1.3.2 Endorsements 19 1.4 The MedDiet, past, present and future 19 1.4.1 Current trends 19 1.4.2 The Greek experience 23 1.4.3 Not all bad news 24 1.4.4 Future prospects 25 References 25 SECTION 1: CONSTITUENTS. 2 Constituents and Physiological Effects of Mediterranean Plant Foods 31 2.1 Introduction 31 2.2 Carbohydrates 32 2.2.1 Glycaemic index 32 2.2.2 Honey 34 2.2.3 Physiological effects of carbohydrates 35 2.2.4 Fibre 36 2.3 Fats 38 2.4 Organic acids 39 2.5 Minerals 40 2.6 Vitamins 40 2.6.1 Water soluble vitamins 40 2.6.2 Fat soluble vitamins 41 2.7 Phytochemicals 44 2.7.1 Classes of phytochemicals 46 2.7.2 Sensory properties of phytochemicals 46 2.7.3 Phenolics 50 2.7.4 Terpenes 56 2.7.5 Sulphur-containing compounds 62 2.7.6 Polyacetylenes 62 2.7.7 Nitrogen-containing compounds 63 2.8 Mediterranean plants as medicines 63 References 64 3 Influences of the Supply Chain on the Composition of Mediterranean Plant Foods 67 3.1 Significance of the supply chain 67 3.2 Growth conditions 68 3.2.1 A brief overview of plant metabolism 68 3.2.2 Soil 70 3.2.3 Sun 71 3.2.4 Water 71 3.2.5 Other environmental factors 71 3.3 Plant cultivar 72 3.4 Food retailers and food processing 74 3.4.1 Anatomical distribution of nutrients 74 3.4.2 Freshness 75 References 76 4 Influences of Food Preparation and Bioavailability on Nutritional Value 77 4.1 Introduction 77 4.2 Food preparation 78 4.2.1 Chopping 78 4.2.2 Cooking 79 4.3 Nutrient bioavailability 82 4.3.1 Pharmacokinetics of phytochemicals 82 4.3.2 Liberation 83 4.3.3 Absorption 83 4.3.4 Distribution 86 4.3.5 Metabolism 87 4.3.6 Excretion 90 4.3.7 Inter-individual variations in phytochemical pharmacokinetics 90 References 92 5 Guide to the Composition of Mediterranean Plant Foods 94 5.1 Types of plant foods consumed as part of a MedDiet 95 5.1.1 Consumption 95 5.1.2 Diversity of consumption 95 5.2 Vegetables 96 5.2.1 Green leafy vegetables 96 5.2.2 Other green vegetables 102 5.2.3 Root vegetables 103 5.2.4 Alliums 104 5.2.5 Solanaceous vegetables 107 5.2.6 Legumes 109 5.3 Wheat products 112 5.4 Fruits 114 5.4.1 Citrus fruits 114 5.4.2 Apples and related fruits 118 5.4.3 Stone fruits 120 5.4.4 Grapes 121 5.4.5 Other berries 122 5.4.6 Pomegranates 122 5.4.7 Figs 123 5.4.8 Dates 123 5.4.9 Olives 123 5.5 Herbs and spices 127 5.6 Nuts and seeds 129 5.6.1 Nuts 129 5.6.2 Seeds 132 References 132 6 Olive Oil and Other Fats 137 6.1 Overview 137 6.2 Olive oil 138 6.2.1 Consumption and production 138 6.2.2 Origin and varieties of olive trees 139 6.2.3 Olive oil production 139 6.2.4 Traceability and European regulations 143 6.2.5 Biochemical composition 144 6.3 Other fat sources 147 6.3.1 Nuts and seeds 147 6.3.2 Herbs and spices 148 6.3.3 Meat and dairy 148 6.3.4 Eggs 150 6.3.5 Fish and shellfish 151 References 151 7 Wine and Other Drinks 154 7.1 Wine 154 7.1.1 Introduction 154 7.1.2 Production 155 7.1.3 Composition 156 7.1.4 Metabolism of wine 158 7.1.5 Consumption patterns and health 159 7.1.6 The resveratrol controversy 162 7.2 Aniseed-flavoured spirits 164 7.2.1 Consumption 164 7.2.2 Composition 165 7.2.3 Physiological effects 165 7.3 Tea 165 7.3.1 Consumption 165 7.3.2 Composition 166 7.3.3 Physiological effects 167 7.4 Coffee 168 7.4.1 Consumption 168 7.4.2 Composition and physiological effects 168 References 169 SECTION 2: HEALTH EFFECTS. 8 Epidemiological Methods 175 8.1 Introduction 175 8.2 Study designs 176 8.2.1 Descriptive epidemiology 176 8.2.2 Ecological studies 178 8.3 Analytical epidemiology 178 8.3.1 Case-control and prospective studies 179 8.4 Intervention studies 180 8.5 Expression and interpretation of data from epidemiological studies 180 8.6 Dietary patterns 181 8.6.1 A priori dietary patterns 181 8.6.2 A posteriori dietary patterns 183 8.7 Criteria for judging epidemiological data 184 References 185 9 General Mechanisms for Disease Prevention 187 9.1 Introduction 188 9.2 Methods for studying the effects of nutrients on disease mechanisms 189 9.2.1 General considerations 189 9.2.2 In vitro models 190 9.2.3 Animal models 191 9.2.4 Human intervention studies 191 9.3 Oxidative stress 192 9.3.1 What are free radicals? 192 9.3.2 Production of reactive species 192 9.3.3 Effects of reactive species 193 9.3.4 Antioxidant defences 195 9.3.5 Measuring antioxidant activity 198 9.3.6 Antioxidant activity in the Mediterranean diet 199 9.3.7 Limitations of the dietary antioxidant theory 204 9.4 Inflammation 205 9.4.1 The inflammatory response 205 9.4.2 The MedDiet and inflammation 206 9.4.3 n-3 Fatty acids 207 9.4.4 Phenolics 210 9.4.5 Pro-inflammatory foods 212 9.5 Modulation of cell signalling pathways by phenolics 212 9.5.1 Cell signalling pathways in disease 212 9.6 Gene interactions 213 9.6.1 Genetic predisposition to diet - nutrigenetics 213 9.6.2 Effects of diet on gene expression 216 9.7 Increased stress resistance 222 9.7.1 The general concept 222 9.7.2 Mechanistic basis of hormesis 225 9.8 Nutrient interactions and the Mediterranean dietary pattern 226 9.8.1 Minimising spikes in plasma concentrations 227 9.8.2 Synergistic interactions 228 References 229 10 Metabolic Disorders 234 10.1 Introduction 234 10.2 Obesity 235 10.2.1 Introduction 235 10.2.2 Epidemiology 237 10.2.3 Mechanisms 239 10.3 Metabolic syndrome 241 10.3.1 Introduction 241 10.3.2 Epidemiology 242 10.3.3 Mechanisms 245 10.4 Type 2 diabetes 249 10.4.1 Introduction 249 10.4.2 Epidemiology 250 10.4.3 Mechanisms 252 References 254 11 Cardiovascular Diseases 258 11.1 Introduction 259 11.2 Nutrition and the biology of CVD 260 11.2.1 Atherogenesis 260 11.2.2 Cardiac arrhythmias 265 11.3 Epidemiological evidence and mechanisms 265 11.3.1 Fat and fatty acids 265 11.3.2 Plant food constituents 269 11.3.3 Whole foods 273 11.3.4 Dietary patterns 283 References 286 12 Cancers 293 12.1 Introduction 293 12.2 Nutritional factors and the biology of cancer 294 12.2.1 Introduction 294 12.2.2 Carcinogenesis 294 12.2.3 The issue of selectivity 309 12.2.4 Mediterranean dietary pattern and cancer prevention 311 12.3 Epidemiological evidence and mechanisms 316 12.3.1 Fats 316 12.3.2 Plant food constituents 318 12.3.3 Tea 322 12.3.4 Coffee 323 12.3.5 Wine and alcohol 323 12.3.6 Plant foods 327 12.3.7 Dietary patterns 330 References 334 13 Neurological and Other Disorders 343 13.1 Introduction 343 13.2 Dementias 344 13.2.1 Introduction 344 13.2.2 Epidemiology 344 13.2.3 Mechanisms 346 13.3 Parkinson's disease 349 13.3.1 Introduction 349 13.3.2 Epidemiology 349 13.3.3 Mechanisms 349 13.4 Depression 350 13.4.1 Introduction 350 13.4.2 Epidemiology 350 13.4.3 Mechanisms 350 13.5 Rheumatoid arthritis 351 13.5.1 Introduction 351 13.5.2 Epidemiology 351 13.5.3 Mechanisms 352 13.6 Age-related macular degeneration 352 13.6.1 Introduction 352 13.6.2 Epidemiology 353 13.6.3 Mechanisms 354 13.7 All cause mortality 354 13.7.1 Fruit and vegetables 355 13.7.2 Alcohol 355 13.7.3 Wine 355 13.7.4 Dietary pattern 356 13.8 General conclusions 357 References 357 14 Public Health Issues 361 14.1 Introduction 361 14.1.1 Public health and its objectives 362 14.1.2 The challenges of public health in Europe 362 14.2 Which MedDiet? 366 14.3 Which constituents are important in the MedDiet? 367 14.3.1 Olive oil 367 14.3.2 Cereals and legumes 368 14.3.3 Fruit and vegetables 368 14.3.4 Herbs and spices 369 14.3.5 Meat and dairy products 370 14.3.6 Wine and tea 370 14.3.7 How can the Mediterranean dietary pattern be implemented? 371 14.4 Transferring the Mediterranean dietary pattern 372 14.4.1 Public health recommendations and education 374 14.4.2 Governments' and communities' food policies 375 14.4.3 Individual choices and attitudes 377 References 378 SECTION 3: APPENDICES. Appendix 1 Abbreviations 383 Appendix 2 Epidemiological Studies 385 Index 389