The Mediterranean diet was first considered by Ancel Keys and his colleagues as a low saturated lipid diet that was conveying protection against coronary heart disease by lowering plasma cholesterol levels1. Over the years, however, the emphasis has shifted away from the low saturated lipid content of this diet towards its high content of olive oil and its overall composition. Moreover, the study of the Mediterranean diet expanded beyond its effects on coronary heart disease to include possible effects on cancer occurrence, and total mortality.

The role of diet in the causation of many chronic diseases has been studied for over four decades and many foods and nutrients with beneficial or adverse effects have been identified. Relatively few investigations, however, have focused on the role that whole diets or particular dietary patterns may play in health and disease.

The Mediterranean Diet Defined
From 1995 and on, we and others have operationalized the Mediterranean dietary pattern by developing a score that captures all the principal aspects of this diet. The score is very simple and has 9 components that can be combined into a uni-dimensional scale. The components are the following: high olive oil consumption; high consumption of legumes; high consumption of unrefined cereals; high consumption of fruits; high consumption of vegetables; moderate consumption of dairy products (mostly as cheese and yogurt); moderate to high consumption of fish; low consumption of meat and meat products; and moderate wine consumption.

What we know now
Adherence to the traditional Mediterranean diet was assessed by a 10-point Mediterranean-diet scale that incorporated the above mentioned salient characteristics of this diet. The results of studies which have been recently published or are currently under consideration indicate the following:

•  A higher degree of adherence to the Mediterranean diet is associated with a reduction in total mortality. A significant inverse association is evident for both death due to coronary heart disease and death due to cancer. Associations between individual food groups contributing to the Mediterranean-diet score and total or cause-specific mortality are generally much weaker.

•  The previously indicated Mediterranean diet score, modified so as to apply across Europe, was associated with increased survival among older people in most European populations..

•  Adherence to the Mediterranean diet in variable ways, chosen at will by coronary patients in the general population, is associated with a significant reduction in long-term mortality (fatality).

•  Adherence to the Mediterranean diet is inversely associated with arterial blood pressure.

•  The Mediterranean diet does not substantially affect body mass index and the high prevalence of overweight people in Mediterranean countries is probably accounted for by the high prevalence of inactivity in conjunction with relative excess energy intake.

A healthy alternative to a low animal fat diet
The Mediterranean diet could offer a healthy alternative approach to a low animal fat diet. Its expanded range of options could promote adherence, particularly over the long term. The Mediterranean diet is not sharply different from other recommended diets, though two elements distinguish it from these other prudent diets. First, it stresses the pattern of eating rather than individual components of the diet and, second, provides no restriction on lipid intake, so long as said lipids are not saturated and are preferably in the form of olive oil.

The high content of Mediterranean diet in lipids and the suspicion surrounding lipids as possible promoters of obesity deserve special consideration. The rise in obesity has reached epidemic proportions. It is not limited to any one country, or group of developed countries, but has escalated into a worldwide problem. The basis for seeking solutions should be the realization that current dietary guidance policies and messages have not been successful for whatever reason.

Therefore, new directions in dietary guidance policies are needed.