Something New under the Sun? The Mediterranean Diet and Cardiovascular Health

Sarah W. Tracy, Ph.D.

N Engl J Med 2013; 368:1274-1276April 4, 2013DOI: 10.1056/NEJMp1302616

Increasingly, the Mediterranean diet has become the standard for healthy eating. Adherence to it appears to reduce the risk of cardiovascular disease, cancer, Alzheimer's disease, and Parkinson's disease, as well as the risk of death due to cardiovascular disease or cancer and even premature death overall.1 Largely plant-centered, with high intakes of olive oil, fruit, nuts, and whole-grain cereals, moderate consumption of fish and poultry, low intakes of dairy, red meat, and sweets, and often moderate drinking of red wine, the “classic” Mediterranean diet is younger than the region's history suggests. In fact, this dietary pattern was first observed in Greece, Italy, and Spain in the decade after World War II — an artifact of postwar impoverishment that proved beneficial to health. Unfortunately, it is currently under siege in southern Europe from the globalization of fast foods rich in refined carbohydrates, sweets, and red meat.

In this issue of the Journal, Estruch et al. (pages 1279–1290) report the positive results of PREDIMED (Prevención con Dieta Mediterránea), a randomized trial of the Mediterranean diet (supplemented with either extra-virgin olive oil or nuts) for the primary prevention of cardiovascular events. The data are impressive and seem to support the high ranking of the Mediterranean diet and its constituent foods among various cardioprotective vegetable- and fruit-rich regimens, such as DASH (Dietary Approaches to Stop Hypertension) and Japanese and traditional vegetarian diets. Yet in many ways, that is old news. The history of dietary guidelines for heart health — a project begun in the 1950s when the United States felt threatened by a perceived “epidemic” of heart attacks — reveals that the Mediterranean diet's cardiovascular benefits have been recognized for decades. As early as 1948, the Rockefeller Foundation assessed the health, economic, and social status of Cretan Greeks and noted that their “impoverished” diet was rich in cereal grains, legumes, wild greens and herbs, and fruits, paired with limited meat, milk, and fish. Meals were said to be “swimming” in olive oil and prepared simply in ways that “preserved the nutritive value of the food rather well.”2

The first epidemiologic data supporting the Mediterranean diet came from the Seven Countries Study (SCS), a prospective investigation of diet and other cardiovascular-disease risk factors in 16 cohorts totaling nearly 13,000 men in the United States, Italy, Greece, Yugoslavia, Finland, the Netherlands, and Japan, which began in 1958. The PREDIMED results would come as little surprise to the man behind the SCS, American physiologist and epidemiologist Ancel Keys, who advanced the low-fat diet and the low-saturated-fat Mediterranean diet for the primary and secondary prevention of heart disease. Keys “discovered” the Mediterranean diet's health benefits in the early 1950s, when visiting the region as a medical scientist concerned about the widely reported increase in heart attacks in the United States. After spending several years exploring the dietary patterns and cardiovascular status of men in Italy, Spain, and Crete, Keys launched the SCS. Study data (which are still being collected from elderly “survivors”) offered strong population-level support for the effects of dietary fat and fatty acids on serum cholesterol levels and cardiovascular disease risk.

The still-unfolding story of dietary fat has proven more complicated than Keys envisioned, but his observations about dietary patterns in various cultures — Mediterranean, northern European, and Asian — appear prescient today. The nutritional properties of whole foods and food patterns — rather than macronutrients (such as protein, carbohydrate, and fat) and micronutrients (such as vitamins and minerals) — are an important focus of recent research. Many who study diet's effects on disease note that we do not eat isolated nutrients. Instead, we form food patterns, consuming diets rich in fruits, nuts, vegetables, and oils or, alternatively, in highly processed foods, and these constituent foods interact synergistically.3 Sometimes these synergies confer long-term benefits.

This holistic turn in nutrition science represents something of a paradigm shift. Early in the 20th century, research focused on the roles of micronutrients, often specific vitamins, and the prevention of deficiency diseases such as beriberi, pellagra, and scurvy. By midcentury, chronic diseases such as atherosclerosis, hypertension, and cancer were recognized as the dominant health threats in the developed world. Yet the reductionism that guided the early studies continued to influence explorations of diet and heart disease. In the 1950s and 1960s, biochemists, clinical scientists, and epidemiologists focused on macronutrients as potential contributors to cardiovascular disease and debated what constituted proof of a causal link between dietary fat and heart disease. Individual macronutrients and bioactive compounds in food, such as cholesterol, were the focus of research exploring diet's relation to the health status of populations.

In this context, the American Heart Association (AHA) Ad Hoc Committee on Dietary Fat and Atherosclerosis issued the first dietary guidelines for the prevention of cardiovascular disease in 1957. The guidelines were brief and tentatively worded, reflecting controversy over the hypothesized link between dietary fat and heart disease. Obese people or those with a personal or family history of heart disease were urged to control their weight, reduce dietary fat to 25 to 35% of total energy intake, and substitute polyunsaturated fats for animal fats. The guidelines thus focused on macronutrients, specifically fats. Committed to reducing heart disease, the AHA revised its guidelines throughout the 1960s. By 1968, people of all ages were urged to limit dietary cholesterol as well and to adhere to principles of good nutrition.

When the AHA issued its first “heart healthy” cookbook, in 1973, it was a latecomer. Cookbooks catering to heart health first appeared in the 1950s, offering recipes for limiting caloric intake and reducing dietary fat and cholesterol. The first cookbook to promote the hypothesized relationship between diet and heart health was probably that of physician Helen Gofman, The Low Fat Low Cholesterol Diet (1951). Gofman's husband, the medical physicist and lipidologist John Gofman, also wrote a cookbook, Dietary Prevention and Treatment of Heart Disease (1958), examining the relationship of dietary carbohydrates to dietary fat in atherogenesis. There were many others, but the most popular were two cookbooks by Keys and his biochemist wife, Margaret, Eat Well and Stay Well (1959) and How to Eat Well and Stay Well the Mediterranean Way (1975). These interpreted “diet” in the classic Greek sense, as a “way of life,” and advocated moderate exercise in addition to “heart-healthy eating” that was grounded largely in Italian and Greek cuisine. Cookbooks, with their focus on dietary pattern, allowed Keys to explore the irreducible elements of a healthy diet, something he and others struggled to do in the laboratory. As food-policy expert Marion Nestle has observed, there is striking similarity between Keys's 1959 recommendations and those in recent editions of the Dietary Guidelines for Americans from the U.S. Department of Agriculture (USDA) and the Department of Health and Human Services.4

Since 1980, these guidelines, revised every 5 years, have set dietary standards for an increasingly obese and diabetic American public. In part, they reflect an ongoing dance between evidence-based dietary advice and the food-industry lobby. In part, they reflect a stable dietary foundation for avoiding degenerative diseases: eat more fruits, vegetables, and nuts; limit red meat and dairy; consume more fish and poultry; curtail salt and sugar; use olive and other vegetable oils; and substitute whole grains for refined ones. This advice should sound familiar, yet because the 2010 guidelines often use difficult-to-translate macronutrient language and fill more than 95 pages, they have become less accessible to the public. And the USDA nutritional icon “MyPyramid” (2005) and its replacement, “MyPlate” (2011), intended to distill cumbersome dietary advice, have been criticized for being too simple, misleading, or excessively influenced by the food industry.5

In 2010, the United Nations Educational, Scientific, and Cultural Organization (UNESCO) placed the Mediterranean diet on its Intangible Cultural Heritage list, a sort of endangered-species list of treasured elements of cultures, valuable both in their native lands and globally. The PREDIMED results reinforce the Mediterranean diet's value for health internationally, suggesting a dietary template that may be of particular value as chronic disease becomes a global issue.1 Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr 2010;92:1189-1196

1

Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr 2010;92:1189-1196
CrossRef | Medline

2

Allbaugh LG. Crete — a case study of an underdeveloped area. Princeton, NJ: Princeton University Press, 1953.

3

Jacobs DR Jr, Tapsell LC. Food, not nutrients, is the fundamental unit in nutrition. Nutr Rev 2007;65:439-450
CrossRef | Medline

4

Nestle M. Mediterranean diets -- historical and research overview. Am J Clin Nutr 1995;61:Suppl:1313S-1320S
Web of Science | Medline

5

Datz T. Harvard serves up its own `plate': Healthy Eating Plate shows shortcomings in government's MyPlate. Harvard Gazette. September 24, 2011 (http://news.harvard.edu/gazette/story/2011/09/harvard-serves-up-its-own-plate/).

Limiting “Sugary Drinks” to Reduce Obesity — Who Decides?

Wendy K. Mariner, J.D., M.P.H., and George J. Annas, J.D., M.P.H.

N Engl J Med 2013; 368:1763-1765 May 9, 2013 DOI: 10.1056/NEJM p1303706

Interview with Prof. Wendy Mariner on New York City's invalidated Portion Cap Rule and other efforts to regulate public health. (10:21)

When a judge struck down the New York City Board of Health's partial ban on selling “sugary drinks” in containers of more than 16 fluid ounces, the reaction was swift. The Portion Cap Rule was widely viewed as a signature accomplishment of Mayor Michael Bloomberg's third term as the “public health mayor,” and he vowed to appeal, saying, “I've got to defend my children, and yours, and do what's right to save lives. Obesity kills.”1 But the question before the judge was not about the health risks posed by obesity or even the relationship between obesity and access to large cups of sugary drinks; it was whether the city's Board of Health (part of the New York City Department of Health and Mental Hygiene) had the legal authority to restrict the serving size of such drinks.

Written in the mayor's office, the Portion Cap Rule was adopted by the board on an 8-to-0 vote with one abstention in September 2012 and was almost immediately challenged in court. Judge Milton A. Tingling heard the case and wrote a 36-page opinion striking down the rule.2 There was no dispute that obesity is a serious problem; the only issue considered by the judge was whether the board has the power to adopt the rule. The substance of the rule is that “A food service establishment may not sell, offer, or provide a sugary drink in a cup or container that is able to contain more than 16 fluid ounces.” A “sugary drink” is defined as a nonalcoholic drink that is “sweetened by the manufacturer or establishment with sugar or another caloric sweetener; has greater than 25 calories per 8 fluid ounces of beverage; and does not contain more than 50 percent of milk . . . by volume.”

Legislatures make policy, and administrative agencies carry out the policy made by the legislature. The New York City Board of Health is an administrative agency, which can do only what it is authorized to do by legislation. The threshold question was whether the board exceeded its authority “and impermissibly trespassed on legislative jurisdiction.”2 The judge relied heavily on a 1987 case involving a successful challenge to the state Public Health Council's anti–indoor-smoking rules.3 In that case, the Court of Appeals (the highest court in New York State) examined “the difficult-to-define line between administrative rule-making and legislative policy-making.” Four “coalescing circumstances” persuaded the Court of Appeals that the state administrative agency had crossed the line in that case. The 1987 rules prohibited smoking in a “wide variety of indoor areas that are open to the public” but expressly excluded many venues, including restaurants with fewer than 50 seats, conventions, trade shows, bars, and hotel rooms. The Court of Appeals determined that those rules were based more on economic and social concerns than on public health matters, were written on a “clean slate” rather than simply filling in regulatory gaps left to the agency by the legislature, involved a matter on which the legislature had repeatedly tried and failed to reach agreement, and were developed without the exercise of any special public health expertise.3

Judge Tingling found the indoor-smoking decision to be a controlling precedent in the Portion Cap Rule case. He examined the “coalescing circumstances” to determine whether New York City's board had exceeded its administrative authority. Tingling found first that, like the indoor-smoking rule, the regulation was “laden with exceptions based on economic and political concerns,” which are outside the Board of Health's purview. Next, he concluded that the powers granted to the health department by the New York City Charter (from its origin in 1730 through more than a dozen amendments to date) did not grant the board “the authority to limit or ban a legal item under the guise of `controlling chronic disease.'”2 Third, the judge found that that city's legislature, the New York City Council, had not passed any laws addressing the subject matter. The judge's bottom line is that the health department violated the separation-of-powers doctrine by exceeding its authority as an administrative agency and acting like a legislature. Accepting the city's arguments would, the judge concluded, “create an administrative Leviathan” that would give the Board of Health “authority to define, create, mandate and enforce [rules] limited only by its own imagination.”2

The judge also adopted a separate basis for striking down the Portion Cap Rule, determining that it was arbitrary and capricious because it does not apply to “all food establishments in the City, it excludes other beverages that have significantly higher concentrations of sugar sweeteners . . . on suspect grounds,” and it has many loopholes — for instance, it imposes no limitations on refills, which defeats its purpose.2

The rule and the opinion raise several issues. First, the city's health department has taken other actions without direct authorization by the city council that could now be challenged. For example, in 2005, the Board of Health required laboratories to report to the department the names, dates of birth, addresses, physicians, and blood-sugar levels of people with type 2 diabetes — without patient consent.4

Second, the judge's conclusion that the legislative branch is the proper branch to make public health policy is correct. Both the New York City Council and the New York State legislature have the authority to regulate the sale of soda in large containers and to grant this authority to the city or state health department. Should either legislative body do so, it is much less likely that a court would overturn the Portion Cap Rule as arbitrary and capricious. On the other hand, the rule has been widely ridiculed, which makes its enactment by elected officials highly unlikely. Jon Stewart probably expressed a widespread public sentiment when he joked that he loved the rule because “it combines the draconian government overreach people love with the probable lack of results they expect.”

Third, there are reasonable alternatives to the Portion Cap Rule, such as higher taxes on all sales of sodas. Higher prices often discourage consumption, as has been the case with cigarettes. Such taxes tend to be regressive, however, with disproportionate effects on lower-income people, who in this case could not afford to buy fancy bottled water or juice drinks. That may be one reason why some New York communities oppose such taxes.

Some alternatives, however, are not reasonable — in particular, the current proposals to shame people who are overweight.5 Such shaming amounts to treating a health risk, whose development may be involuntary, as a moral failure. Any public policy entailing overt discrimination based on physical appearance is simply wrong. People who are obese know it; making them feel worse about themselves encourages bullying, another public health problem, and helps no one.

Perhaps the most important lesson is old news: economics often drives health policy. New York City's efforts to reduce obesity grew with its desire to control its health care costs for its residents, a disproportionate share of whom are obese or have diabetes. Meanwhile, large corporations continue to use their influence and money to derail public health measures that could reduce their profits. Although the general public shares the goals of public health, many people remain skeptical of government's choice of means for achieving those goals. Agencies that overstep their bounds or adopt rules that are intrusive or just plain silly invite backlash, which can make effective public health regulation impossible. They make fools of themselves and heroes of the opponents of public health.

1 Grynbaum MM. Court halts ban on large sodas in New York City. New York Times. March 12, 2013:A1.

2 New York Statewide Coalition of Hispanic Chambers of Commerce v. New York City Dept. of Health and Mental Hygiene, No. 653584/12 (N.Y. Sup. Ct., N.Y. Cty., Mar. 11, 2013).

3 Boreali v. Axelrod, 71 N.Y.2d 1, 517 N.E.2d 1350 (1987).

4 Mariner WK. Medicine and public health: crossing legal boundaries. J Health Care Law Policy 2007;10:121-151

5 Callahan D. Obesity: chasing an elusive epidemic. Hastings Cent Rep 2013;43:34-40

Si persevera.... Dios abrirá puertas para usted.

"El favor de Dios nos rodea como un escudo. No importa como sean las circunstancias en su vida. No importa cuantas personas le digan que no puede hacer lo que está intentando, si persevera, declarando el favor de Dios y manteniéndose en una actitud de fe, Dios abrirá puertas para usted y cambiará las circunstancias a su favor."JO

Un mensaje para ti...

Querida Hija Mía:

Sé cuán abrumada te sientes. La carga es tan pesada que a veces sientes que no podrás continuar. El peso de las responsabilidades es tanto que a veces no tienes tiempo ni para descansar. Se ha hecho difícil seguir el camino sin mirar atrás, pero como sabes que la mejor decisión que tomaste ha sido servirme y creer en mí; aunque agotada, no te has rendido.

Yo soy tu Padre Amante, el que te sostiene, quien nunca te ha dejado sola. Aunque no lo logres ver ahora, mis pensamientos y mis caminos son más altos que los tuyos. Mi gracia ha sido derramada sobre ti, yo te he dado las armas para que pelees y ganes esta batalla.

El día de hoy quiero que sientas mi Espíritu Santo inundando tu vida, fortaleciéndote, infundiendo nuevos alientos, depositando una alabanza nueva. Hoy quiero dar un refrigerio especial a tu alma para que puedas recibir la paz que sobrepasa el entendimiento y se sobrepone a las circunstancias.

No hay nada imposible para mí. Conozco cada detalle, lo que te preocupa, lo que callas, lo que te duele, lo que mi pides y lo que esperas. Recibirás respuestas, experimentarás mi gloria, cantarás victoria. ¡No temas, esfuérzate y sé valiente! Cobra ánimo, no desfallezcas. Yo renuevo y deposito de mi aceite sobre tu vida; unción fresca y gozo en medio de la prueba. Tú no estás sola, yo estoy contigo en todo el trayecto.

Cada palabra que he dicho será cumplida. A los tuyos los tengo en el hueco de mi mano. Están a salvo, están seguros. Yo he de suplir todo cuanto falte, tú serás testigo de mi provisión. Tú me has dado, pero yo te daré aún más. Porque el que en lo poco me es fiel, en lo mucho me place poner. Miro tu corazón y quiero que sepas que observo y enjugo cada lágrima. Descansa en mi presencia y espera con tranquilidad la bendición que habrás de recibir.

De tu Padre Que Te Ama,

Dios

"TRES PALABRAS"

En estos momento, heme aquí, Señor, en el silencio y en recogimiento.
Para darte: GRACIAS;

para solicitarte: AYUDA;                                  

para implorarte: PERDON.

G R A C I A S
Señor, por la paz, por la alegría, por la unión que los hombres, mis hermanos me han dado: Por esos ojos que con ternura y comprensión me miraron, por esa mano oportuna que me levantó, por esos labios cuyas palabras y sonrisas me alentaron, por esos oídos que me escucharon, por ese corazón que amistad, cariño y amor me dió, Gracias, Señor. . . me cuesta trabajo decírtelo. . . por el insulto, por el engaño, por la injusticia, por el fallecimiento del ser querido. Tú lo sabes, Señor, cuán difícil fue aceptarlo; quizá estuve al punto de la desesperación, pero ahora me doy cuenta que todo esto me acercó más a Ti. ¡Tú sabes lo que hiciste!
Gracias, Señor, sobre todo por la fe que me has dado en Ti y en los hombres. Por esa fe que se tambaleó pero que Tú nunca dejaste de fortalecer cuando tanta veces encorvado bajo el peso del desánimo me hizo caminar en el sendero de la verdad a pesar de la oscuridad.

A Y U D A
Lo que el futuro me depara, lo desconozco, Señor, vivir en la incertidumbre, en la duda, no me gusta, me molesta, me hace sufrir. Pero sé que Tú siempre me ayudarás. Yo te puedo dar la espalda. Soy libre. Tú nunca me la darás. Eres fiel. Yo sé que contaré con tu ayuda. Tú sabes que no siempre cooperaré. Yo sé que me tenderás la mano. Tú sabes que no siempre la tomaré.
Por eso hoy te pido que me ayudes a ayudarte, que llenes mi vida de esperanza y generosidad. No abandones la obra de tus manos, ayúdame a saber escucharte Señor, a saber cuando es un pensamiento que viene de mí y cuando eres TU SEÑOR quien habla a mi corazón. 

Ayúdame y dale paz a mi corazón SEÑOR, en éstos momentos especiales en mi vida PADRE.

P E R D Ó N
No podía irme sin pronunciar esa palabra que tantas veces te debería de haber dicho por que por negligencia y orgullo he callado.
Perdón; Señor, por mis negligencias, descuidos y olvidos, por mi orgullo y vanidad, por mi necedad y capricho, por mi silencio y mi excesiva locuacidad.
Perdón, Señor, por prejuzgar a mis hermanos, por mi falta de alegría y entusiasmo, por mi falta de fe y confianza en Ti, por mi cobardía y mi temor en mi compromiso.
Perdón porque me han perdonado y no he sabido perdonar.
Perdón por mi hipocresía y doblez, por esa apariencia que con tanto esmero cuido pero que sé en el fondo no es más que engaño a mí mismo.
Perdón por esos labios que no sonrieron, por esa palabra que callé, por esa mano que no tendí, por esa mirada que desvié, por esa verdad que omití, por ese corazón que no amó. . . por ese YO que se prefirió.
Señor, no te he dicho todo. Llena con tu amor mi silencio y cobardía.

GRACIAS por todos los que no te dan gracias.
AYUDA a todos los que te imploran Tu ayuda.
PERDON por todos los que no te piden perdón.

Señor, concédeme serenidad para aceptar las cosas que no puedo cambiar.
Valor para cambiar las cosas que si puedo y sabiduría para distinguir la diferencia.
Me has escuchado... Ahora, Señor, te escucho!"

 NOTA: no se quien de quien es la autoría, pero en éste momento la tomo prestada.

"Todo lo que estás afrontando en este momento está sujeto a cambio. Sacúdete ese espíritu de desánimo y di: Puede que esté derribado, pero no me quedaré derribado. Vuelvo a levantarme y a seguir adelante" JO

El enemigo....

"El enemigo quiere que haya pelea, tensión y presión, que nunca tengamos ningún gozo en nuestros hogares. No caigas en esa trampa.  Cuando tomas tiempo para ayudar a otros en sus luchas, te preparas para victorias aún mayores. Cuando haces por otros lo que ellos mismos no pueden hacer, nunca carecerás del favor de Dios; nunca carecerás de la bendición de Dios. Mira a tu alrededor esta semana. ¿A quien ha puesto Dios en tu vida? Esas personas no están ahí por accidente. Dios pone a personas en nuestro camino a propósito. "Nadie está tan arriba en su ascenso hacia el éxito que cuando se inclina y baja para ayudar a otra persona". Cuando seas un liberador de sueños, Dios se asegurará de que tus sueños se cumplan. El mayor legado no es lo que dejamos para las personas, sino lo que dejamos EN las personas. A veces tienes que detener tus propios sueños temporalmente a fin de poder ayudar a liberar un sueño en otra persona. Lo que tú hagas que suceda para otros, Dios lo hará suceder para ti. Cuando vivas de modo desinteresado y ayudes a otra persona a adelantarse, Dios se asegurará  de que alguien esté ahí para ayudarte a avanzar. " JO

"Dios no te llevó hasta este punto para dejarte donde estás. Él te tiene en la palma de su mano. Él tenía la solución antes de que tú ni siquiera tuvieras ese problema. Él ya tiene un camino de salida. Dios conoce el fin desde el principio" JO

"Si piensas constantemente en tus problemas, en lo que no tienes y en que el futuro parece obscuro, todos esos pensamientos negativos harán que se vaya cualquier pensamiento positivo. Deja de rentar espacio en tu mente a tus problemas. No rentes ese valioso espacio a la autocompasión." JO

"Tenemos la capacidad de enfocarnos en las soluciones, de rodearnos de personas que nos apoyen, de levantarnos por encima de la crítica y del desánimo, y de poner nuestra fe en Dios y confiar en su plan para nuestra vida. Seamos felices así como Dios nos creó y disfrutemos de cada día que nos es dado como un regalo de Él. Si hacemos esto, haremos de cada día un viernes"