The Mediterranean Diet Health and Science

Recent large-scale epidemiological studies have confirmed the pre-eminence of the Mediterranean diet for reducing the risk of primary and secondary heart disease and cancer. There is also increasingly convincing evidence for its protective value against diabetes, dementias and other age-related disorders, and for increasing overall longevity. The Mediterranean Diet: Science and Health is a timely, authoritative and accessible account of the Mediterranean diet for nutritionists and dieticians. It discusses the Mediterranean diet in the light of recent developments in nutritional biochemistry, disease mechanisms and epidemiological studies, and also provides advice on nutrition policies and interventions. The Mediterranean Diet: Science and Health opens with an overview of the Mediterranean diet, and this is followed by a survey of the latest epidemiological evidence for its health benefits. There is detailed nutritional information on olive oil, wine, fish, fruit and vegetables and other components of the Mediterranean diet, and this information is used to explain how the diet protects against a range of age-related diseases. The book emphasises the importance of understanding the Mediterranean diet in its totality by discussing the evidence for beneficial interactions between various components of the diet. There are also discussions of how agricultural practices, as well as food preparation and cooking techniques, influence the nutritional quality of the diet. The book concludes by discussing the social context in which the Mediterranean diet is eaten, and public health issues associated with adopting a Mediterranean diet, especially in the context of more northerly countries. Written by nutritional biochemist Richard Hoffman and the current President of the French Nutrition Society, Mariette Gerber, who between them have many years experience in this area, this exciting and highly topical boook is an essential purchase for all nutritionists and dietitians worldwide. Libraries in all universities where nutrition, dietetics and food science and technology are studied and taught should have copies of this excellent book on their shelves.

Dr. Richard Hoffman, PhD, FRSA, is a Senior Lecturer in Biochemistry at the University of Hertfordshire, UK with over 15 years of experience of Teaching biomedical sciences, nutritional biochemistry and plant biochemistry to undergraduates and postgraduates.

Dr. Mariette Gerber, MD, PhD, DSc, is a past President of the French Nutrition Society, and is currently an Expert at the National Food Council in France.

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

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The Mediterranean Diet Health and Science

Summary

Author Biography

Table of Contents

Supplemental Materials