Episode 14

The Modern Mediterranean Diet

Published on: 4th August, 2022

Scientists and dieticians consistently  rank The Modern Mediterranean Diet (MED diet) as the diet most recommended.  But often people don't know what the MED diet is. This post will  define the Med diet.

Critics of the Med Diet

Critics  argue that there is no uniform MED diet. They make these assertions based on one of these three arguments:

  1. That there is no uniform diet of the Mediterranean Region. There are over 20 countries on the 26,000 miles of coastline of the Mediterranean Sea. Each country with their own unique diets. Many of which have adopted a more modern American style diet.
  2. The diet is simply made up and therefore should be ignored.
  3. Finally some point out that there are many Med Diets as the literature.

Heart disease and Diet

Ancel Keys is the scientist most responsible for not only the Med diet but the relationship of heart disease to diet. In the 1950's, heart disease was thought to be a disease of aging, and smoking but not diet or lifestyle.

In the 1950's, much like today, heart disease was the number one cause of death among of middle aged executives. While there was a clear association between smoking and heart disease, there were far more deaths than could be explained from smoking.  Then an Italian scientist told Dr. Keys about the low incidence of cardiovascular deaths of men in Naples.

Heart Disease and Diet in Europe

Keys confirmed this claim when he took a sabbatical in Oxford in 1952.  Keys found there was a difference of heart disease between the poor and the executives of Italy. He developed the hypothesis that diet might explain difference  between the two groups.  To confirm this Keys, and his wife, then traveled throughout Europe catalog different diets and rates of heart disease.

In 1955 Keys presented his data to the World Health Organization, concluding  that diet played a significant role in heart disease.  Many members of the WHO mocked his  "diet-heart theory."  Keys then organized the seven countries study (click here).

Seven Countries Study

The seven countries study was an observational study looking at biomarkers, lifestyles and their relationship to heart disease.  Those countries were Greece, Italy, former Yugoslavia, Finland, The Netherlands, Japan, and the United States. The cohorts were chosen because of diverse diets, lifestyle, and risk factors. Dietary and lifestyle influence on cardiovascular disease was unknown at the time.

The seven country study was to answer the question about dietary influence and heart disease.

The French Paradox

Low-carb bloggers accuse the seven country study of leaving out France. They cite the French Paradox, that the French eat a diet high in saturated fat but have a low incidence of heart disease.

However, France was not left out of the study.  French investigators were present at the original pilot study in Nicotera Italy, but ultimately decided not to participate in the study.  France was recovering from World War 2 and simply didn't have the resources to commit to such a study.

In fact, The French Paradox was "coined" in the 1980s, over twenty years after the  start of the seven country study. The investigators didn't have access to that data, or the term. Low-carb bloggers  didn't read the seven country study or the French paradox.

French Paradox Explained

Two factors explain the French Paradox.

The high fat diet was not widely adopted by the French prior to the mid 1970's. It  takes time for a  habit to have an effect on cardiovascular disease. For example, one doesn't develop heart disease after the first cigarette. The primary French diet in the 1950's through 70's was a Mediterranean Diet.  Thus, the effect of the high fat diet would not be evident for twenty plus years after it was adopted.

The second explanation is that French physicians consistently underreported heart disease. Of note, Wine consumption has been the most studied aspect of the French Paradox. Red wine sales increased dramatically after the airing of the "French Paradox" on Sixty Minutes.  Wine is an important component of the Med diet.

Seven Country Study and The Med Diet

From 1958 to 1970  over 12,000 men were tracked for diet, weight, smoking, physical activity, vital signs, cholesterol, and lung capacity. During that time there were about 2300 deaths, 27% from heart disease. Different countries had different rates of deaths from heart disease: USA 50%, Northern Europe 40%, Southern Europe 17%, Japan 5%.  The dietary pattern that was identified in this study became the basis of what Keys would call The Mediterranean Diet. Key's book became a bestseller, describing not only the first version of the Mediterranean Diet, but providing healthy recipes for a country trying to fight the number one killer. Keys even wrote a best selling cookbook with his wife touting the benefit of the diet.

Adopting the Mediterranean Diet

Keys died shortly before his 101'st birthday. There are a number of great articles written about Keys, but the obituary here is one of the finest.

The Nine Point Scale

The first scoring system for the Med diet was proposed in 1995 (here). Other studies began to arise to determine the Med diet for cancer, autoimmune diseases, longevity, dementia, and other disease states.

One of the more famous was a meta analysis of twelve studies looking at longevity. Greater adherence in this scale also showed lower incidence of Parkinson's disease, Alzheimer's disease as well as cardiovascular mortality.

This scale gave points for increased consumption of vegetables, fruits, legumes, cereals, fish, and moderate red wine consumption. While those who had "above the median" of red and processed meats and dairy were given zero points. Ultimately this was refined further with the use of monounsaturated fatty acids (olive oil) as the primary fat (60% or greater).

EPIC Study

Trichopoulou, and her colleagues began the European Prospective Investigation into Cancer and Nutrition (EPIC) study in 1994 after the pilot study in 1991. The study enrolled more than 521,000 participants from 23 centers in 10 western European countries, detailing diet, lifestyle, medical history, and vital signs.

They used a validated food frequency questionnaire of over 150 foods commonly consumed in Greece. "For this analysis, we focused on nine nutritional variables: vegetables, legumes, fruits and nuts, dairy products, cereals, meat and meat products, fish and seafood, monounsaturated to saturated lipid ratio, and ethanol." (11).

Conclusions of the EPIC study

A two point increase in the Mediterranean diet score  led to a decrease in mortality of 14%.

Diet Pyramids

Diet pyramids were common in the 1990's . One of the more famous was from Oldways where they developed a pyramid in 1994 to describe the Mediterranean Diet. (12). This pyramid was based primarily on the diet from the Island of Crete and southern Italy from the 1960's.

Diet pyramids are of little use in scientific studies, as they don't quantify the amounts of foods consumed. Some argue that diet pyramids are a useful way to display the data.

Lyon Heart Study

The Lyon heart study was a randomized secondary trial testing the Mediterranean Diet against the French Prudent diet. After 46 months there were 1.24 per one hundred patients who had either a cardiac death or nonfatal infarction. This compared to 4.07 per one hundred who had the standard cardiac diet. They also noted that most patients, after a few years, were still following the Mediterranean Diet, showing that adoption and compliance was not difficult.

Obesity and the Mediterranean Diet

The Mediterranean Diet is useful not only for disease, but for weight management. The latest drugs for obesity are GLP-1 agonists (Wegovy, Ozempic) there is a clear benefit from polyunsaturated fatty acids (PUFA) and raising GLP-1. While obese patients have lower GLP-1 response to glucose than non-obese, the PUFAs in the Mediterranean diet provide an increase in GLP-1.

Further the polyphenolic compounds of the Mediterranean Diet provide another benefit. People with the highest intake of polyphenols (especially the flavonoids) were associated with an 11 percent decrease risk of developing type 2 Diabetes.

Finally the antioxidant rich Mediterranean Diet has been seen as a potent tool against the inflammatory cascade seen in obese patients.

Closer adherence to the Mediterranean Diet has been shown to have decreased rates of obesity, as well as better lipid profiles.

Weight Loss Surgery Patients

We took over 180 patients who had various forms of weight loss surgery and calculated their Mediterranean Diet Score. We then compared those scores to their postoperative weight loss after five years. Those patients who had a score of 5 or more all were in the greater than 50% of weight loss regardless of the type of weight loss surgery. Those patients who had a score of 0-3 were in the lowest quarter of weight loss or even weight regain. The score of 4 seemed to be all over the scale.

Type 2 Diabetes Mellitus and the Mediterranean Diet

The Mediterranean Diet has been found to both decrease the risk of type 2 Diabetes, but a potent reversal of type 2 diabetes. This occurs through lifestyle intervention, and has been found best for long term weight loss.

Current Adoption of the Mediterranean Diet

Click the link below to see the modern Med Diet score card.


Most papers have discussed the 9 point system and this is consistent throughout the literature in the last fifteen years. The scoring is reasonably simple,  or can be completed through a validated food frequency questionnaire.

The Mediterranean Diet continues to be the most studied diet on the planet, with the most reproducible results for chronic diseases from obesity, diabetes, heart disease, dementia and autoimmune diseases.

Closer adherence to the Mediterranean Diet is associated with longevity.



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About the Podcast

Fork U with Dr. Terry Simpson
Learn more about what you put in your mouth.
Fork U(niversity)
Not everything you put in your mouth is good for you.

There’s a lot of medical information thrown around out there. How are you to know what information you can trust, and what’s just plain old quackery? You can’t rely on your own “google fu”. You can’t count on quality medical advice from Facebook. You need a doctor in your corner.

On each episode of Your Doctor’s Orders, Dr. Terry Simpson will cut through the clutter and noise that always seems to follow the latest medical news. He has the unique perspective of a surgeon who has spent years doing molecular virology research and as a skeptic with academic credentials. He’ll help you develop the critical thinking skills so you can recognize evidence-based medicine, busting myths along the way.

The most common medical myths are often disguised as seemingly harmless “food as medicine”. By offering their own brand of medicine via foods, These hucksters are trying to practice medicine without a license. And though they’ll claim “nutrition is not taught in medical schools”, it turns out that’s a myth too. In fact, there’s an entire medical subspecialty called Culinary Medicine, and Dr. Simpson is certified as a Culinary Medicine Specialist.

Where today's nutritional advice is the realm of hucksters, Dr. Simpson is taking it back to the realm of science.

About your host

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Terry Simpson

Dr. Terry Simpson received his undergraduate, graduate, and medical degrees from the University of Chicago where he spent several years in the Kovler Viral Oncology laboratories doing genetic engineering. Until he found he liked people more than petri dishes. Dr. Simpson, a weight loss surgeon is an advocate of culinary medicine, he believes teaching people to improve their health through their food and in their kitchen. On the other side of the world, he has been a leading advocate of changing health care to make it more "relationship based," and his efforts awarded his team the Malcolm Baldrige award for healthcare in 2018 and 2011 for the NUKA system of care in Alaska and in 2013 Dr Simpson won the National Indian Health Board Area Impact Award. A frequent contributor to media outlets discussing health related topics and advances in medicine, he is also a proud dad, husband, author, cook, and surgeon “in that order.”