Flashback Friday: Improving on the Mediterranean Diet & Do Flexitarians Live Longer?

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What are the four problematic nutritional aspects of even plant-based Mediterranean diets? Does just reducing one’s intake of meat, dairy, and eggs significantly reduce mortality?

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The traditional Mediterranean diet can be considered as a mainly, but not exclusively, plant-based diet, and certainly not a whole food plant-based diet, as olive oil and wine can be considered essentially fruit juices. Even if one is eating a vegiterranean diet, an entirely plant-based version, there are a number of potentially problematic nutritional aspects that are rarely talked about. For example, lots of white bread, white pasta, not a lot of whole grains. Alcohol can be a problem, the caloric density with all that oil can be high, as well as the salt intake. Let’s go over these one by one.

In this anatomy of the health effects of the Mediterranean diet, the single most important component was the high consumption of plant foods. In contrast, high cereal consumption, meaning high grain consumption, did not appear to help.

This may be because most grains modern Mediterranean dieters eat are refined, like white bread, whereas the traditional Mediterranean diet was characterized by unprocessed cereals—in other words, whole grains. And while whole grains have been associated with a lower risk of diabetes, heart disease, and cancer, refined grains may increase the risk of diabetes, obesity, heart disease, and other chronic diseases. For example, in the PREDIMED study, those who ate the most white bread–but not whole grain bread–gained significant weight.

Alcohol may also be a problem. As a plant-centered diet, no surprise, adherence to a Mediterranean diet is associated with lower cancer risk, but not with lower breast cancer risk. With all the fruits, veggies, nuts, seeds, and beans and low saturated fat, you’d assume there would be a lower breast cancer risk, but alcohol is a known breast cancer risk factor–even in moderate amounts. But if you create a special adapted version of the Mediterranean diet score that excludes alcohol, the diet does indeed appear to reduce breast cancer risk.

The wonderful grape phytonutrients in red wine can improve our arterial function such that if you drink de-alcoholized red wine, red wine with the alcohol removed, you get a significant boost in endothelial function–the ability of our arteries to relax and dilate normally, increasing blood flow. But if you drink the same red wine with the alcohol added back in, it abolishes the beneficial effect; it counteracts the benefit of the grape phytonutrients. So better just to eat grapes.

Similarly, there are components of extra virgin olive oil—the antioxidant phytonutrients–that may help endothelial function, but when consumed as oil, even extra virgin olive oil, it may impair arterial function. So even if white bread dipped in olive oil is the very symbol of the Mediterranean diet, we can modernize it by removing oils and refined grains.

Another important, albeit frequently ignored, issue in the modern Mediterranean diet is sodium intake. Despite evidence linking salt intake to high blood pressure, heart disease, and strokes, dietary salt intake in the U.S. is on the rise. Right now we get about seven to ten grams a day, mostly from processed foods. If we were to decrease that just by three grams, which is about 1,000 mg of sodium, half a teaspoon of table salt, every year we could save tens of thousands of people from having a heart attack, prevent tens of thousands of strokes, and tens of thousands of deaths. There is a common misconception that only certain people should reduce their salt intake, and that for the vast majority of the population, salt reduction is unnecessary. But in reality, the opposite is true.

But there is much we can learn from the traditional Mediterranean diet. A defining characteristic of the Mediterranean diet is an abundance of plant foods, and one thing that seems to have fallen by the wayside. No real main Mediterranean meal is replete without lots of greens, a key part of not only a good Mediterranean diet, but of any good diet.

What accounts for the benefits of a Mediterranean-style diet? An anatomy of health effects was published and the single most important component was the high consumption of plant foods. In contrast, fish and seafood consumption, the only animal foods promoted in the Mediterranean diet, did not seem to help.

In fact, if you look at the four major dietary quality scoring systems, which have all been associated with extending lifespan and lowering heart disease and cancer mortality, they all share only four things in common: more fruit, more vegetables, more whole grains, and more nuts and beans. They are all built on a common core of a diet rich in plant foods, whereas opposite food patterns, rich in animal foods and poor in plant-based foods (in other words, the Western diet), are associated with higher risks. So we need to optimize the food environment to support whole grains, vegetables, fruit, and plant-based proteins.

That’s one of the things all the so-called Blue Zones have in common; the longest living populations not only have social support and engagement, and daily exercise, but nutritionally they all center their diets around plant foods, reserving meat mostly for special occasions. And the population with perhaps the highest life expectancy in the world doesn’t eat any meat at all–the California Adventist vegetarians.

So if the primary benefits of the Mediterranean diet are due to all the whole plant foods, what if you went back to the famous PREDIMED study and created a pro-vegetarian scoring system? We know vegetarians live longer, but because a pure vegetarian diet might not easily be embraced by many individuals, maybe it would be easier to swallow if we just tell people more plant-based foods, less animal-based foods. But would just moving along the spectrum towards more plants actually enable people to live longer? They thought of this food pattern as a “gentle approach” to vegetarianism, figuring that if it improved survival it would be an easily understandable message for health promotion: more plant foods, less animal foods.

So you get points for eating fruit, vegetables, nuts, grains, beans, olive oil, and potatoes, but get docked points for any animal fats, eggs, fish, dairy, or any type of meat or meat products. Of course that means you get a higher score the more potato chips and French fries you eat. That’s why I prefer the term “whole food plant-based” diet since it’s defined by what you eat, not by what you don’t eat. When I taught at Cornell, I had “vegan” students who apparently were trying to live off French fries and beer; vegan does not necessarily mean health-promoting. But did it work? Regardless of healthy vs. unhealthy, if you give points to people for any kind of plant food, processed or not, and detract points for any kind of animal product consumption, do people with higher scores live longer? Yes. The maximum pro-vegetarian score is 60, but even just scoring 40 or more was associated with a 40% drop in mortality. In fact, there were so few deaths in the highest category of adherence to the pro-vegetarian diet, they had to merge the two upper categories for their analysis. This is evidence that simple advice to increase the consumption of plant-derived foods with reductions in the consumption of foods from animal sources confers a survival advantage, a live-a-longer-life advantage.

This modest change is realistic, affordable, and achievable because a sizable proportion of their population was already eating that way. So one can get a significant survival benefit without a radical shift to the exclusive consumption of plant foods–a more gradual and gentle approach more easily translatable into public policy. For example, a 41% drop in mortality rates in the United States would mean saving the lives of hundreds of thousands of Americans every year.

To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.

Please consider volunteering to help out on the site.

Image credit: alex9500 via Adobe Stock Images. This image has been modified.

The traditional Mediterranean diet can be considered as a mainly, but not exclusively, plant-based diet, and certainly not a whole food plant-based diet, as olive oil and wine can be considered essentially fruit juices. Even if one is eating a vegiterranean diet, an entirely plant-based version, there are a number of potentially problematic nutritional aspects that are rarely talked about. For example, lots of white bread, white pasta, not a lot of whole grains. Alcohol can be a problem, the caloric density with all that oil can be high, as well as the salt intake. Let’s go over these one by one.

In this anatomy of the health effects of the Mediterranean diet, the single most important component was the high consumption of plant foods. In contrast, high cereal consumption, meaning high grain consumption, did not appear to help.

This may be because most grains modern Mediterranean dieters eat are refined, like white bread, whereas the traditional Mediterranean diet was characterized by unprocessed cereals—in other words, whole grains. And while whole grains have been associated with a lower risk of diabetes, heart disease, and cancer, refined grains may increase the risk of diabetes, obesity, heart disease, and other chronic diseases. For example, in the PREDIMED study, those who ate the most white bread–but not whole grain bread–gained significant weight.

Alcohol may also be a problem. As a plant-centered diet, no surprise, adherence to a Mediterranean diet is associated with lower cancer risk, but not with lower breast cancer risk. With all the fruits, veggies, nuts, seeds, and beans and low saturated fat, you’d assume there would be a lower breast cancer risk, but alcohol is a known breast cancer risk factor–even in moderate amounts. But if you create a special adapted version of the Mediterranean diet score that excludes alcohol, the diet does indeed appear to reduce breast cancer risk.

The wonderful grape phytonutrients in red wine can improve our arterial function such that if you drink de-alcoholized red wine, red wine with the alcohol removed, you get a significant boost in endothelial function–the ability of our arteries to relax and dilate normally, increasing blood flow. But if you drink the same red wine with the alcohol added back in, it abolishes the beneficial effect; it counteracts the benefit of the grape phytonutrients. So better just to eat grapes.

Similarly, there are components of extra virgin olive oil—the antioxidant phytonutrients–that may help endothelial function, but when consumed as oil, even extra virgin olive oil, it may impair arterial function. So even if white bread dipped in olive oil is the very symbol of the Mediterranean diet, we can modernize it by removing oils and refined grains.

Another important, albeit frequently ignored, issue in the modern Mediterranean diet is sodium intake. Despite evidence linking salt intake to high blood pressure, heart disease, and strokes, dietary salt intake in the U.S. is on the rise. Right now we get about seven to ten grams a day, mostly from processed foods. If we were to decrease that just by three grams, which is about 1,000 mg of sodium, half a teaspoon of table salt, every year we could save tens of thousands of people from having a heart attack, prevent tens of thousands of strokes, and tens of thousands of deaths. There is a common misconception that only certain people should reduce their salt intake, and that for the vast majority of the population, salt reduction is unnecessary. But in reality, the opposite is true.

But there is much we can learn from the traditional Mediterranean diet. A defining characteristic of the Mediterranean diet is an abundance of plant foods, and one thing that seems to have fallen by the wayside. No real main Mediterranean meal is replete without lots of greens, a key part of not only a good Mediterranean diet, but of any good diet.

What accounts for the benefits of a Mediterranean-style diet? An anatomy of health effects was published and the single most important component was the high consumption of plant foods. In contrast, fish and seafood consumption, the only animal foods promoted in the Mediterranean diet, did not seem to help.

In fact, if you look at the four major dietary quality scoring systems, which have all been associated with extending lifespan and lowering heart disease and cancer mortality, they all share only four things in common: more fruit, more vegetables, more whole grains, and more nuts and beans. They are all built on a common core of a diet rich in plant foods, whereas opposite food patterns, rich in animal foods and poor in plant-based foods (in other words, the Western diet), are associated with higher risks. So we need to optimize the food environment to support whole grains, vegetables, fruit, and plant-based proteins.

That’s one of the things all the so-called Blue Zones have in common; the longest living populations not only have social support and engagement, and daily exercise, but nutritionally they all center their diets around plant foods, reserving meat mostly for special occasions. And the population with perhaps the highest life expectancy in the world doesn’t eat any meat at all–the California Adventist vegetarians.

So if the primary benefits of the Mediterranean diet are due to all the whole plant foods, what if you went back to the famous PREDIMED study and created a pro-vegetarian scoring system? We know vegetarians live longer, but because a pure vegetarian diet might not easily be embraced by many individuals, maybe it would be easier to swallow if we just tell people more plant-based foods, less animal-based foods. But would just moving along the spectrum towards more plants actually enable people to live longer? They thought of this food pattern as a “gentle approach” to vegetarianism, figuring that if it improved survival it would be an easily understandable message for health promotion: more plant foods, less animal foods.

So you get points for eating fruit, vegetables, nuts, grains, beans, olive oil, and potatoes, but get docked points for any animal fats, eggs, fish, dairy, or any type of meat or meat products. Of course that means you get a higher score the more potato chips and French fries you eat. That’s why I prefer the term “whole food plant-based” diet since it’s defined by what you eat, not by what you don’t eat. When I taught at Cornell, I had “vegan” students who apparently were trying to live off French fries and beer; vegan does not necessarily mean health-promoting. But did it work? Regardless of healthy vs. unhealthy, if you give points to people for any kind of plant food, processed or not, and detract points for any kind of animal product consumption, do people with higher scores live longer? Yes. The maximum pro-vegetarian score is 60, but even just scoring 40 or more was associated with a 40% drop in mortality. In fact, there were so few deaths in the highest category of adherence to the pro-vegetarian diet, they had to merge the two upper categories for their analysis. This is evidence that simple advice to increase the consumption of plant-derived foods with reductions in the consumption of foods from animal sources confers a survival advantage, a live-a-longer-life advantage.

This modest change is realistic, affordable, and achievable because a sizable proportion of their population was already eating that way. So one can get a significant survival benefit without a radical shift to the exclusive consumption of plant foods–a more gradual and gentle approach more easily translatable into public policy. For example, a 41% drop in mortality rates in the United States would mean saving the lives of hundreds of thousands of Americans every year.

To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.

Please consider volunteering to help out on the site.

Image credit: alex9500 via Adobe Stock Images. This image has been modified.

Doctor's Note

This is two videos combined from my Mediterranean diet series. The rest are:

For more on whole grains, see: 

More on breast cancer and alcohol in Breast Cancer and Alcohol: How Much Is Safe?,  Breast Cancer Risk: Red Wine v. White Wine, and Can Alcohol Cause Cancer?

I’ve touched on olive oil in the other videos in this Mediterranean diet series, but also have an older video Extra Virgin Olive Oil vs. Nuts.

I’ve done a few videos on the health of so-called semi-vegetarians or flexitarians (“flexible” vegetarians). See how they rate in:

The Provegetarian Score reminds me of the animal to vegetable protein ratio in Prostate Cancer Survival: The A/V Ratio. My favorite dietary quality index is the one in Calculate Your Healthy Eating Score. How do you rate? Even the healthiest among us may be able to continue to push the envelope. 

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