May is Mediterranean Diet Month

Established in 2009 by Oldways, a non-profit organization teaching people about various traditional diets, Med Diet Month actually celebrates the Mediterranean Lifestyle which involves more than just eating certain foods.

Definition

Diet Component

This plant-forward diet is fibre-rich, low in sodium and saturated fats, high in potassium and unsaturated fats.

This generally breaks down as follows:

  • Every day: whole grains, fruits, vegetables, legumes, herbs, spices, nuts, seeds and healthy fats such as olive oil every day
  • At least twice weekly: fish and seafood
  • Moderate: dairy, eggs, and poultry
  • Infrequent: red meat and sweets

Lifestyle Component

In addition to the diet aspect of this component, the Mediterranean Lifestyle also encourages community and connection, regular movement, and life balance.

  • Community and connection: where possible, eat with others and connect regularly with those who matter to you
  • Movement: lots of walking, moving naturally through your day
  • Life balance: laugh often, simply, do things for fun

Research

At this time, the Mediterranean Diet remains the most researched dietary pattern. In fact, there have been over 3000 studies published in the last 3 years alone on topics as varied as cancer, osteoporosis, heart disease, cognition, diabetes, arthritis, acne, and ADHD.

Despite this interest, it’s important to know that nutrition research is a very tricky thing to do right. Not only is it unethical to force people to eat only certain things (obviously), but it is also impossible to achieve certain other desirable study components such as “blinding” since you can’t prevent people from knowing what they are actually eating. It is for these reasons, and more, that nutritional research often gets described as unreliable.

Although that’s partially true, researchers have been reframing how nutritional investigations should be done, and are finding ways to adjust for these issues which has led to some exciting new results.

The latest study looking at the Mediterranean diet and heart health specifically is hot-off-the-presses recent, released less than a week ago (of my writing this blog). Titled “Long-term secondary prevention of cardiovascular disease with a Mediterranean diet and low-fat diet: a randomised controlled trial”1, this study (also known as the CORDIOPREV trial) looks at whether a Mediterranean diet rich in olive oil reduces risk of heart disease events more than a low-fat diet.

Approximately 1000 Spanish patients who had already been diagnosed with heart disease were separated into an olive oil group and a low-fat group and followed for 7 years, making it the longest study of its kind. After that time it was observed that the people in the olive oil group collectively had fewer major cardiovascular events than the low-fat group. Yay Med Diet with olive oil!

What’s particularly interesting is that the low-fat group was already eating a pretty decent Mediterranean-like diet with a good amount of fibre and less saturated fat. So the study actually showed that high-risk groups can benefit from even relatively modest changes to their diet.

How great is that?

Where do I start?

A commonly used tool to help people work on following more of a Mediterranean Diet-style of eating is the Medi Diet Score adapted from the PREDIMED trial2.

Each “Yes” answer gets 1 point.

Results from the PREDIMED trial suggests that if you can find a way to increase your total score by 2 points, you can reduce your risk of many chronic conditions.

  1. Do you use olive oil as main culinary fat?
  2. Do you consume more than 4 Tbsp of olive oil per day (including oil used for frying, salads, out of house meals, etc.)?
  3. Do you consume 2 or more servings of vegetables per day? (1 serving = 200g – consider side dishes as 1/2 serving)
  4. Do you consume 3 or more servings of fruit per day?
  5. Do you consume less than 1 serving of red meat, hamburger, or meat products (ham, sausage, etc.) per day? (1 serving = 100-150 g)
  6. Do you consume less than 1 serving of butter, margarine, or cream per day? (1 serving = 12 g)
  7. Do you drink less than 1 sweet/carbonated beverages per day?
  8. Do you drink 7 or more glasses of wine per week?*
  9. Do you consume 3 or more servings of legumes per week? (1 serving = 150 g)
  10. Do you consume more than 3 servings of fish or shellfish per week? (1 serving: 100-150 g fish, or 4-5 units or 200 g shellfish)
  11. Do you consume fewer than 3 servings of commercial sweets or pastries (not homemade), such as cakes, cookies, biscuits, or custard per week?
  12. Do you consume 3 or more servings of nuts (including peanuts) per week? (1 serving = 30 g
  13. Do you preferentially consume chicken, turkey or rabbit meat instead of veal, pork, hamburger or sausage?
  14. Do you consume vegetables, pasta, rice, or other dishes seasoned with sofrito (sauce made with tomato and onion, leek, or garlic, simmered with olive oil) at least twice per week?**

*growing research suggests that this factor has more to do with socializing during meals than with the wine itself so it is not recommended to start drinking if you are not already doing so

**sofrito is a Mediterranean-specific sauce in this context, please consider the addition of tomato and onion/garlic and/or leek in other contexts

Long story short

How we eat matters, but it isn’t everything. Even Mediterranean Diet proponents agree that the lifestyle factors contribute to its magic. That said, data continues to build supporting the above dietary recommendations, especially when combined as an overall dietary pattern.

Happy eating!

1. Delgado-Lista, J. et al. Long-term secondary prevention of cardiovascular disease with a Mediterranean diet and a low-fat diet (CORDIOPREV): a randomised controlled trial. Lancet 399, 1876–1885 (2022).

2. Estruch, R. et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts. New Engl J Med 378, e34 (2018).

Four Heart Disease Risk Factors You May Not Know About

Given that heart disease affects millions of Canadians, it’s somewhat mystifying to me that we (health professionals) only seem to highlight the broad strokes of risk.

I think it’s fair to say that many people know that things like cholesterol, blood pressure, smoking, diet, and exercise all have something to do with heart health. You may not understand what the relationship is, but you probably know it exists. It’s true; these factors are definitely important and improving them can make a huge difference.

But what about the other elements that can contribute to developing heart disease later on in life? We just don’t hear as much about them. Now, in all fairness, some of these things have only been recently identified. But that is not the case for all of them. Given that these circumstances aren’t rare, we should be doing a better job of getting the word out.

A quick note about risk factors

Remember that we’re talking about potential consequences, not definite ones. Having a risk factor for something means you are more likely to develop or experience that thing at some point. You may be a little more likely or a lot more likely. You may never experience it at all even if your chances were higher than someone else’s. I think of identifying and managing risk factors as better setting you up for success.

  1. Complications in Pregnancy

Pregnancy has been called a natural stress test. What the human body accomplishes and withstands during this time is simply amazing. But various complications aren’t that rare; it’s believed the issues below may occur in up to as many as 20% of pregnancies. If you’ve experienced these situations in any of your pregnancies, you’re at greater risk of developing heart disease later in life.1

  • Preeclampsia or gestational hypertension
  • Gestational diabetes
  • Preterm delivery
  • Delivering a small for gestational age (SGA) baby
  1. Early menarche (first period) and/or menopause

Hormones of all kinds are involved in heart health. Estrogen in particular plays an important role and both the timing, and lifetime exposure, seem to impact risk. Both starting *and* stopping your period early increase your chance of developing heart disease in the future.1

What does early mean?

  • Premature menarche (< 10 years of age)
  • Premature menopause (menopause < 40 years of age, due to premature ovarian failure or surgical/medical menopause)
  • Early onset menopause (40-45 years of age)
  1. Inflammatory Disorders

Chronic inflammation increases cardiovascular disease risk. This seems to be particularly true in certain autoimmune conditions, termed immune-mediated inflammatory diseases (IMIDs) such as rheumatoid arthritis, ankylosing spondylitis, lupus, and inflammatory bowel disease.2

This risk relationship is actually fairly complicated and warrants in-depth discussion with your healthcare provider. Managing your condition by reducing inflammation is crucial, but certain anti-inflammatory drugs (such as NSAIDs and steroids) are problematic for heart health in other ways.

A particular note with rheumatoid arthritis is the presence of something called the “lipid paradox”. This paradox, observed during times of active disease (or flare up), consists of unexpectedly low cholesterol levels.3 Unfortunately this does not lead to lower risk and should not be mistaken for “good cholesterol levels”.

  1. Radiation Treatments

It is an unfortunate truth that some medical treatments create problems as they necessarily solve others. This can be particularly true in cancer care. Radiation therapy is used to treat a number of cancers including ones located in, and around, the chest such as Hodgkin’s lymphoma and breast cancer. In these cases, the proximity of the area being treated to the heart is problematic.4,5 Although the intensity of exposure has diminished over time as techniques have improved and safety measures better understood, that was not the case many years ago.

Although some radiotherapy side effects are obvious in the short term, it is the delayed effects I want to emphasize. Radiation-induced heart disease can manifest over time as damaged coronary arteries, valves, or the heart muscle itself. To complicate things, it isn’t uncommon for past cancer treatments to go unmentioned when discussing current health concerns, especially if the treatment was literally decades ago.

Where to Go from Here (aka wow, Alex, that was discouraging – what do I do now?)

As I often say, knowledge is power. If these situations are your situations, I hope you’re able to use that information to help put any pieces together you’ve been wondering about. I hope you feel more confident reaching out to your healthcare providers to discuss your circumstances. I hope that you feel motivated to be proactive in regards to the aspects of your cardiovascular health which can be supported. And there are so many!

You can “know your numbers”; staying on top of your cholesterol and blood pressure. You might feel extra incentive to work on those nutrition and exercise goals. You could decide this is the time to finally quit smoking.

The good news is that there are things you can do to head off your risk and improve your overall heart health. We may not be able to control all the things, but we sure can make a ton of difference overall.

Yours in Health,

Dr. Alexandra Verge, ND

1. Agarwala, A., Michos, E. D., Samad, Z., Ballantyne, C. M. & Virani, S. S. The Use of Sex-Specific Factors in the Assessment of Women’s Cardiovascular Risk. Circulation 141, 592–599 (2020).
2. Agca, R., Smulders, Y. & Nurmohamed, M. Cardiovascular disease risk in immune-mediated inflammatory diseases: recommendations for clinical practice. Heart 108, 73–79 (2022).
3. Myasoedova, E. et al. Lipid paradox in rheumatoid arthritis: the impact of serum lipid measures and systemic inflammation on the risk of cardiovascular disease. Ann Rheum Dis 70, 482 (2011).
4. Kirkham, A. A., Beaudry, R. I., Paterson, D. I., Mackey, J. R. & Haykowsky, M. J. Curing breast Cancer and killing the heart: A novel model to explain elevated cardiovascular disease and mortality risk among women with early stage breast Cancer. Prog Cardiovasc Dis 62, 116–126 (2019).
5. Nimwegen, F. A. van et al. Cardiovascular Disease After Hodgkin Lymphoma Treatment: 40-Year Disease Risk. Jama Intern Med 175, 1007–1017 (2015).