Is Mediterranean diet still a common dietary pattern in the Mediterranean area?

A large amount of literature has been published over the last decade emphasising on the impact of the traditional Mediterranean dietary pattern on human health (Martini 2019). Several benefits have been reported, with convincing evidence (agreement between meta-analyses of cohort studies and interventional randomised clinical trials) towards cardiovascular (Grosso et al. 2017; Estruch et al. 2018) and metabolic health (Kastorini et al. 2011; Godos et al. 2017; Dinu et al. 2020), and its potentiality for cancer (Schwingshackl et al. 2017), cognitive disease and mental health impairment prevention (Loughrey et al. 2017). The Mediterranean diet refers to a plant-based dietary pattern characterised by well-defined features, including (i) frequent consumption of plant foods, such as fruits, vegetables, nuts and whole grains, (ii) regular (few times per week) consumption of fish (in the maritime areas) and legumes as main sources of protein, and moderate consumption of dairy foods (iii) use of extra-virgin olive oil (EVOO) as main dressing, (iv) moderate consumption of (red) wine during meals, and (v) low consumption of meat products and sweets (D’Alessandro & De Pergola 2018). These features have been somehow modified and adapted to be applied not only in the Mediterranean countries but also to testing for adherence outside the Mediterranean area, for instance estimating the mono-unsaturated fatty acids (thought to be among the mediators of the benefits of olive oil) in populations with low consumption of olive oil (Martínez-González et al. 2017; Mocciaro et al. 2018). These overall results indicate that the Mediterranean diet is a suitable dietary pattern to be advised to prevent major non-communicable diseases worldwide.

Several mechanisms have been proposed to provide a rationale behind the benefits of the Mediterranean diet on human health. Plant foods provide fibre and a variety of vitamins and other phytochemicals, such as polyphenols, while nuts, olive oil and fish are rich in mono- and polyunsaturated fatty acids (Real et al. 2020). Compared to vegetarian diets, moderate to low consumption of meat products is still present in the Mediterranean diet and, while an excess in meat intake has been associated with adverse health outcomes, a moderate consumption of red meat (ideally not processed) may contribute to reach the adequate intake of iron, vitamin B12, and essential amino acids (Wyness 2016). An intriguing hypothesis has been tested in the article published by Martini et al (2020) in this issue, as the authors suggest that the oxidative phenomena occurring during digestion after intake of meat could be counteracted by the phenolic compounds contained in foods commonly consumed within the context of a Mediterranean dietary pattern. In this work, the authors found that a “Mediterranean” polyphenolic profile, including flavonols and anthocyanins in onions, phenolic acids in tomato and basil, and tyrosol-derivatives in black olives and EVOO, was able to limit lipid peroxidation during co-digestion of turkey breast meat.

Albeit the evidence on its benefits is shared by the scientific community, the evolution of modern societies has led to a “nutrition transition” process with slow distancing from traditional Mediterranean dietary patterns in favour of more “Westernized” ones, characterised by higher content in so called fast-foods and ready-to-use foods, and a radically reduced consumption of plant-based whole foods (Rico-Campà et al. 2019). There is evidence suggesting that people living in the Mediterranean countries have reduced their adherence to the Mediterranean diet (Vilarnau et al. 2019) and results from cohort studies suggest that this is also the result of the economic crisis occurred in the last decade, and from the rise in costs of healthier foods (Bonaccio et al. 2016). A recent summary of evidence showed that the adherence to the Mediterranean diet has become particularly low in children and adolescents (Grosso & Galvano 2016). In this issue, Grassi et al (2020) and Zuccotti et al (2020) confirmed such trends in Italian children and toddlers, with overall low adherence to Mediterranean diet and excessive intake of simple carbohydrates, proteins, sodium, paralleled by low intake of iron and fibre. Specifically, high adherence to the Mediterranean diet (out of three categories of adherence) has been reached by only about 13% of children, with no actual differences in terms of parents’ education and occupation, while a significant difference was reached for the different proportion of “medium” adherence, which was higher in children with parents graduated and employed. These findings confirm the results of previous studies conducted in Italy, in which socio-economic-cultural levels were able to affect the adherence to the Mediterranean diet in Mediterranean countries. It is still not clear whether this can be related to increased availability of high quality foods, a natural tendency towards health-conscious lifestyle choices, or a stronger connection with the Mediterranean cultural heritage. While these reports are important to further document the changes in adherence to the Mediterranean diet, we need to intervene to prevent the younger generations from giving up entirely this traditional and healthy dietary pattern over the next decades.

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No potential conflict of interest was reported by the author(s).