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7 Introduction to the

Health Benefits of
Dietary Patterns

This chapter serves as an introduction to the next several chapters that focus separately
on the various foods and food groups that figure prominently in a Mediterranean-­
style dietary pattern.
This unique dietary pattern encompasses a wide variety of palatable foods, pro-
vides flexibility in food choices and in macronutrient distribution to meet individual
needs, and has been shown to be sustainable over time. Most important, adher-
ence to this dietary pattern is associated with a reduced incidence of obesity, type 2
diabetes, cardiovascular diseases, the metabolic syndrome, diet-­related cancers, and
other chronic diseases. The early report of these health benefits, especially of the
heart, by Christakis in 1965 initiated additional investigations throughout the fol-
lowing decades that continued to expand our knowledge of why Mediterranean diets
had such a strong positive effect on health. Considerable evidence indicates that the
closer one follows this way of eating, the lower the risk is for these chronic diseases.
A Mediterranean dietary pattern is used increasingly for weight management
as it supplies all the nutrients necessary to help ensure healthy weight loss when
consumed in moderate amounts. Even if an individual makes healthy food choices,
consuming more calories than needed will lead to an increase in weight.
Consistent with a Mediterranean-­style dietary pattern, this chapter and Chapters 8
through 16 provide dietary recommendations that have been supported by findings
from published peer-­reviewed scientific research.


A traditional Mediterranean way of living typically balances total caloric intake
(i.e., energy from the macronutrients) with total energy expenditure (i.e., through an
active lifestyle) to help manage weight in adults. Although the distribution of energy
obtained from the three macronutrients may not be precisely established, the standard
percentages often recommended are approximately 50% from carbohydrates, 30%
to 35% from fat, and 15% to 20% from protein. Total caloric intake (i.e., quantity)
likely affects weight to a greater degree than macronutrient composition.

86 The Mediterranean Way of Eating

Highlight: Total caloric intake (i.e., quantity) likely affects weight to a greater
degree than macronutrient composition.

Excessive energy consumption clearly leads to increased storage of fat molecules,

and a high intake of refined and highly processed carbohydrates may be the greatest
contributor to triglyceride (TG) or fat production in both adipose (fat) and muscle
tissues. In addition to the likelihood of weight gain, excess carbohydrate intake
causes the pancreas to secrete more and more insulin. Over time, an elevation of
serum insulin leads to insulin resistance by adipose and muscle tissues and hinders
the beneficial action of insulin (i.e., moving glucose out of the bloodstream into the
body’s cells). Therefore, these constraints on caloric intake from both dietary fats
and carbohydrates help prevent development of the insulin-­dependent diseases, such
as obesity and type 2 diabetes, and help delay the onset of cardiovascular diseases,
the metabolic syndrome, diet-­related cancers, and other conditions.


As stated, a balanced intake of energy-­generating macronutrients from the basic
food groups serves as the basis for a healthy diet. Because so many different micro-
nutrients are provided along with the macronutrients in a variety of plant and animal
foods, recommendations for specific foods or groups of similar foods also are now
recognized as important for promoting health and reducing risk for chronic diseases.
Two examples of specific micronutrients illustrate the importance of consuming
appropriate amounts from foods within their food groups—not too much or too little.
The first example is folate, a water-­soluble B vitamin. Folate is the naturally occur-
ring form in food; folic acid is the synthetic form used in fortified foods and dietary
supplements. The best sources of naturally occurring folate come from legumes and
many green vegetables, while cereals tend to have the highest levels within fortified
foods. The body uses folate to help produce DNA and RNA, both critical for forming
healthy new cells. The recommended intake for most adult men and non-­pregnant
women is 400 micrograms per day (μg/­day).
Previously, folate deficiency has been a major concern because of increased rates
of neural tube birth defects. In addition, low folate consumption in both men and
women over time may lead to megaloblastic anemia and may increase risk of some
cancers, especially of the colon and alcohol-­related cancers. These concerns asso-
ciated with folate deficiency were somewhat alleviated when federal law in 1998
required manufacturers of cereal and grain products to fortify these food products
with folic acid. Recent evidence, however, suggests that excessive folic acid con-
sumption from supplements and fortified foods may have adverse health effects,
including a possible increased risk of some cancers, including lung and prostate as
well as colon cancer, especially in older adults with precancerous colon polyps. High
intakes of folic acid may mask a B12 deficiency, causing a delay in diagnosis, which
can lead to neurological damage. Some evidence also suggests high intakes may
increase the risk of heart attack in people who have heart problems.
Introduction to the Health Benefits of Mediterranean-­Style Dietary Patterns 87

The second example is calcium, a mineral needed in large quantities on a daily

basis. The amount of calcium needed each day, although not precisely established, is
considered to be about 1,000 milligrams per day (mg/­day) for adults—after skeletal
growth has ceased. The major food group that provides large amounts of calcium
is dairy, but vegans and other individuals who do not consume milk or milk-­based
products may find it difficult to obtain sufficient daily intakes of calcium. Fortunately,
a number of other calcium-­containing food sources are available, including dark-­
green, leafy vegetables, calcium-­fortified orange juice, and calcium-­set tofu. Adults
who do not consume an adequate amount of calcium may be increasing their risks
of developing osteoporosis late in life. On the other hand, consuming more calcium
than the recommended amounts may pose other health risks, such as calcification of
arteries and renal stones.


Traditional Mediterranean-­style dietary patterns rarely contained nutritional supple-
ments, if any. Pills and other dietary supplements contain only one, or at best, several
vitamins, minerals, or phytomolecules compared to the hundreds of beneficial ones that
are found in foods, especially fruits, vegetables, legumes, and whole grains. The major
health benefits derived from consuming food rather than supplements likely result from
the synergistic effects of all the nutrients and other vital substances in foods acting
together. Furthermore, when sorting out substances from whole food, it is not usually
known what amount is safe to take, what amount is necessary to provide a therapeutic
effect, or even in what ways a specific vitamin, mineral, or phytomolecule is affected
by the presence of other substances in the whole food. Supplements do not have to
be tested or approved by the Food and Drug Administration (FDA) and may contain
contaminants or have lower or higher amounts of a nutrient than indicated on the label.
Taking high amounts of certain vitamins, minerals, or other substances may actu-
ally cause serious adverse health effects. Besides, supplements are expensive, so put
your money to better use by purchasing nutritious foods such as fruits, vegetables,
legumes, and whole grains. Use nutritional supplements only when needed and in
appropriate amounts.


The basic Mediterranean dietary components include

• balanced caloric intake;

• high consumption of fruits, vegetables, legumes, and whole grains;
• higher consumption of monounsaturated fat than saturated fat;
• moderate consumption of nuts, seeds, fish, seafood, and alcohol (red wine)
in populations where alcohol is acceptable;
• low consumption of meats and milk and low-­to-­moderate consumption of
poultry, eggs, cheese, and yogurt; and
• high consumption of herbs, spices, and garlic.
88 The Mediterranean Way of Eating

The Mediterranean Diet Pyramid (see Chapter 1, Figure 1.2) offers a visual rep-
resentation of the dietary components and their proportionate amounts in this type
of dietary plan. Each component common to the Mediterranean-­style dietary pattern
listed is highlighted in Chapters 8 through 16 in conjunction with the major chronic
diseases covered in Chapters 4 through 6.