Beneficial Effects Of Mediterranean Diet Research Articles

The effects of Mediterranean diet on cardiovascular risk factors, glycemic control and weight loss in patients with type 2 diabetes: a meta-analysis

To explore the impact of the Mediterranean diet on cardiovascular risk factors, glycemic control and weight loss in patients with type 2 diabetes(T2D) by a meta-analysis of randomized controlled trials (RCTs). We systematically searched PubMed, Cochrance Library, EMBASE and four Chinese databases to identify RCTs that compared the Mediterranean diet with control diets in patients with T2D up to December 2021. The Risk of Bias of the included studies was assessed using the version 2 of the Cochrane risk-of-bias tools for randomized trials (ROB 2). Seven RCTs with 1371 patients met the eligibility criteria and entered into the meta-analysis. Compared to control diets, the beneficial effects of Mediterranean diet were not statistically significant in high-density lipoprotein (MD = 2.33; 95% CI: -0.27 to 4.92), low-density lipoprotein (MD = -2.34; 95% CI -5.67 to 0.99) and total cholesterol (MD = 2.60; 95% CI: -0.95 to 6.15). But Mediterranean diet led to reduce the level of diastolic blood pressure (MD = -1.20; 95% CI: -2.21 to -0.19) and systolic blood pressure (MD = -4.17; 95% CI: -7.12 to -1.22). Meanwhile, Mediterranean diet showed beneficial effects in glycemic control (HbA1[%]: MD = -0.39, 95% CI: -0.58 to -0.20; fasting plasma glucose: MD = -15.12, 95% CI: -24.69 to -5.55) and weight loss (BMI: MD = -0.71, 95% CI: -1.30 to -0.78; WC: MD = -1.69; 95% CI: -3.35 to -0.02) compared to the control diets. The meta-analysis presented evidence supporting the beneficial effects of the Mediterranean diet on blood pressure, glycemic control, and weight loss. However, the impact of the Mediterranean diet on the lipid profile was not found to be significant, warranting further verification. This Meta-analysis was registered on the INPLASY website (Registration number: INPLASY 202160096).

Mobility and muscle strength trajectories in old age: the beneficial effect of Mediterranean diet in combination with physical activity and social support

IntroductionDecline in physical function varies substantially across older individuals due to several extrinsic modifiable factors such as dietary patterns, physical activity and social support. We aimed to determine the association of these factors and their interaction with mobility and muscle strength decline.MethodsWe analyzed data from 1686 functionally healthy individuals aged 60 + from the population-based Swedish National study on Aging and Care in Kungsholmen (SNAC-K). The Mediterranean Diet Score (MDS) was calculated based on a validated food frequency questionnaire. Self-reported physical activity was categorized based on current recommendations, and social support was measured according to participants’ perceived material and psychological support from relatives and friends. Participants’ physical function was assessed over 12 years through changes in walking speed (m/s) and chair stand time (s). Linear mixed models adjusted for socio-demographic and clinical factors were used. In order to explore the combined effect of the different exposures, two indicator variables were created by cross-classifying individuals' levels of Mediterranean diet adherence and social support or physical activity.ResultsParticipants with a high adherence to Mediterranean diet were primarily < 78 years (82.3%), women (56.1%), married (61.1%), with university education (52.8%), high levels of social support (39.3%) and health-enhancing levels of physical activity (51.5%). A one-point increase in MDS (score range 0–9) was associated with less annual deterioration in walking speed (β*time[year] = 0.001; p = 0.024) and chair-stand time (β*time[year] = -0.014; p = 0.008). The potential protective effect of Mediterranean diet was highest among participants reporting high social support (β*time[year] = -0.065, p = 0.026 for chair stands) and high physical activity (β*time[year] = 0.010, p = 0.001 for walking speed), beyond the effect of each exposure individually.ConclusionA higher adherence to Mediterranean diet, especially in combination with recommended levels of physical activity and high social support, may contribute to delay the decline in physical function observed with aging.

Mediterranean Diet as an Antioxidant: The Impact on Metabolic Health and Overall Wellbeing.

It has been established, worldwide, that non-communicable diseases such as obesity, diabetes, metabolic syndrome, and cardiovascular events account for a high percentage of morbidity and mortality in contemporary societies. Several modifiable risk factors, such as sedentary activities, sleep deprivation, smoking, and unhealthy dietary habits have contributed to this increase. Healthy nutrition in terms of adherence to the Mediterranean diet (MD), rich in fruits, legumes, vegetables, olive oil, herbs, spices, and high fiber intake may contribute to the decrease in this pandemic. The beneficial effects of the MD can be mainly attributed to its numerous components rich in anti-inflammatory and antioxidant properties. Moreover, the MD may further contribute to the improvement of reproductive health, modify the risk for neurodegenerative diseases, and protect against depression and psychosocial maladjustment. There is also evidence highlighting the impact of healthy nutrition in female people on the composition of the gut microbiota and future metabolic and overall health of their offspring. It is therefore important to highlight the beneficial effects of the MD on metabolic, reproductive, and mental health, while shaping the overall health of future generations. The beneficial effects of MD can be further enhanced by increased physical activity in the context of a well-balanced healthy lifestyle.

Comment on: Beneficial effect of Mediterranean diet on disease activity and cardiovascular risk in systemic lupus erythematosus patients: a cross-sectional study

Comment on: Beneficial effect of Mediterranean diet on disease activity and cardiovascular risk in systemic lupus erythematosus patients: a cross-sectional study

Gut microbiome and Mediterranean diet in the context of obesity. Current knowledge, perspectives and potential therapeutic targets

Mediterranean Diet has been recognized as one of the healthiest and sustainable dietary patterns worldwide, based on the food habits of people living in the Mediterranean region. It is focused on a plant-based cuisine combining local agricultural products and moderate intake of fish. As eating habits seem to exert a major impact on the composition of gut microbiota, numerous studies show that an adherence to the Mediterranean diet positively influences the microbiome ecosystem network. This has a profound effect on multiple host metabolic pathways and plays a major role in immune and metabolic homeostasis. Among metabolic disorders, obesity represents a major health issue where Mediterranean Dietary regime could possibly slowdown its spread. The aim of this review is to emphasize the interaction between diet and gut microbiota and the potential beneficial effects of Mediterranean diet on metabolic disorders like obesity, which is responsible for the development of many noncommunicable diseases.

Beneficial effect of Mediterranean diet on disease activity and cardiovascular risk in systemic lupus erythematosus patients: a cross-sectional study.

To analyse the influence of the Mediterranean diet (Med Diet) on SLE activity, damage accrual and cardiovascular disease risk markers. A cross-sectional study was conducted on 280 patients with SLE [46.9 (12.85) years]. Med Diet adherence was assessed through a 14-item questionnaire on food consumption frequency and habits (total score from 0 to 14 points; higher score is greater adherence to the Med Diet). CRP, homocysteine, SLEDAI-2K (SLE disease activity), and SLICC/ACR and SDI (damage accrual) were measured. Obesity, diabetes mellitus, hypertension and blood lipids, among others, were considered cardiovascular disease risk factors. Greater adherence to the Med Diet was significantly associated with better anthropometric profiles, fewer cardiovascular disease risk factors, and lower disease activity and damage accrual scores (P ≤ 0.001 for SLEDAI and SDI). An inverse relationship between the Med Diet score and SLEDAI (P ≥ 0.001; β = -0.380), SDI (P ≤ 0.001; β = -0.740) and hsCRP (P = 0.039; β = -0.055) was observed. The odds ratio for having active SLE (SLEDAI ≥5) or the presence of damage (SDI ≥1) was lower among patients whose Med Diet score was higher (P ≤ 0.001). Finally, greater consumption of Med Diet foods (olive oil, fruits, vegetables, fish, etc.) and abstaining from red meat and meat products, sugars and pastries was associated with less SLE clinical activity and damage. Greater adherence to the Med Diet seems to exert a beneficial effect on disease activity and cardiovascular risk in SLE patients. To confirm these findings, further longitudinal studies would be of interest.

Gut microbiome-Mediterranean diet interactions in improving host health

The gut microbiota plays a fundamental role in host health and disease. Host diet is one of the most significant modulators of the gut microbial community and its metabolic activities. Evidence demonstrates that dietary patterns such as the ‘Western diet’ and perturbations in gut microbiome (dysbiosis) have strong associations with a wide range of human diseases, including obesity, metabolic syndrome, type-2 diabetes and cardiovascular diseases. However, consumption of Mediterranean-style diets is considered healthy and associated with the prevention of cardiovascular and metabolic diseases, colorectal cancers and many other diseases. Such beneficial effects of the Mediterranean diet might be attributed to high proportion of fibers, mono- and poly-unsaturated fatty acids, antioxidants and polyphenols. Concurrent literature has demonstrated beneficial modulation of the gut microbiome following a Mediterranean-style diet in humans as well as in experimental animal models such as rodents. We recently demonstrated similar positive changes in the gut microbiome of non-human primates consuming a Mediterranean-style diet for long term (30 months). Therefore, it is rational to speculate that this positive modulation of the gut microbiome diversity, composition and function is one of the main factors intermediating the health effects of Mediterranean diet on the host. The present perspective discusses the evidences that the Mediterranean diet induces gut microbiome modulation in rodents, non-human primates and human subjects, and discusses the potential role of gut microbiota and microbial metabolites as one of the fundamental catalysts intermediating various beneficial health effects of Mediterranean diet on the host.

Gut microbiome-Mediterranean diet interactions in improving host health.

The gut microbiota plays a fundamental role in host health and disease. Host diet is one of the most significant modulators of the gut microbial community and its metabolic activities. Evidence demonstrates that dietary patterns such as the 'Western diet' and perturbations in gut microbiome (dysbiosis) have strong associations with a wide range of human diseases, including obesity, metabolic syndrome, type-2 diabetes and cardiovascular diseases. However, consumption of Mediterranean-style diets is considered healthy and associated with the prevention of cardiovascular and metabolic diseases, colorectal cancers and many other diseases. Such beneficial effects of the Mediterranean diet might be attributed to high proportion of fibers, mono- and poly-unsaturated fatty acids, antioxidants and polyphenols. Concurrent literature has demonstrated beneficial modulation of the gut microbiome following a Mediterranean-style diet in humans as well as in experimental animal models such as rodents. We recently demonstrated similar positive changes in the gut microbiome of non-human primates consuming a Mediterranean-style diet for long term (30 months). Therefore, it is rational to speculate that this positive modulation of the gut microbiome diversity, composition and function is one of the main factors intermediating the health effects of Mediterranean diet on the host. The present perspective discusses the evidences that the Mediterranean diet induces gut microbiome modulation in rodents, non-human primates and human subjects, and discusses the potential role of gut microbiota and microbial metabolites as one of the fundamental catalysts intermediating various beneficial health effects of Mediterranean diet on the host.

The beneficial effects of Mediterranean diet over low-fat diet may be mediated by decreasing hepatic fat content

It is unclear if a reduction in hepatic fat content (HFC) is a major mediator of the cardiometabolic benefit of lifestyle intervention, and whether it has prognostic significance beyond the loss of visceral adipose tissue (VAT). In the present sub-study, we hypothesized that HFC loss in response to dietary interventions induces specific beneficial effects independently of VAT changes. In an 18-month weight-loss trial, 278 participants with abdominal obesity/dyslipidemia were randomized to low-fat (LF) or Mediterranean/low-carbohydrate (MED/LC + 28 g walnuts/day) diets with/without moderate physical activity. HFC and abdominal fat-depots were measured using magnetic resonance imaging at baseline, after 6 (sub-study, n = 158) and 18 months. Of 278 participants (mean HFC 10.2% [range: 0.01%-50.4%]), the retention rate was 86.3%. The %HFC substantially decreased after 6 months (-6.6% absolute units [-41% relatively]) and 18 months (-4.0% absolute units [-29% relatively]; p <0.001 vs. baseline). Reductions of HFC were associated with decreases in VAT beyond weight loss. After controlling for VAT loss, decreased %HFC remained independently associated with reductions in serum gamma glutamyltransferase and alanine aminotransferase, circulating chemerin, and glycated hemoglobin (p <0.05). While the reduction in HFC was similar between physical activity groups, MED/LC induced a greater %HFC decrease (p = 0.036) and greater improvements in cardiometabolic risk parameters (p <0.05) than the LF diet, even after controlling for VAT changes. Yet, the greater improvements in cardiometabolic risk parameters induced by MED/LC were all markedly attenuated when controlling for HFC changes. %HFC is substantially reduced by diet-induced moderate weight loss and is more effectively reduced by the MED/LC diet than the LF diet, independently of VAT changes. The beneficial effects of the MED/LC diet on specific cardiometabolic parameters appear to be mediated more by decreases in %HFC than VAT loss. High hepatic fat content is associated with metabolic syndrome, type 2 diabetes mellitus, and coronary heart disease. In the CENTRAL 18-month intervention trial, a Mediterranean/low-carbohydrate diet induced a greater decrease in hepatic fat content than a low-fat diet, conferring beneficial health effects that were beyond the favorable effects of visceral fat loss. ClinicalTrials.gov Identifier: NCT01530724.

Beneficial Effects of Elderly Tailored Mediterranean Diet on the Proteasomal Proteolysis.

Aging is a multifactorial process characterized by the accumulation of proteins undergoing oxidative modifications, either due to enhanced levels of oxidative stress or due to their decreased clearance; both facts are related to the establishment of chronic inflammatory processes. These processes are directly associated with functional and structural modifications of a key cellular component, namely the proteasome. In this study, levels of oxidized proteins, along with proteasome and immunoproteasome composition and activity on a selected group of 120 elderly volunteers were analyzed before and after the administration of a specific dietary protocol, based on an elderly tailored Mediterranean diet (the “NU-AGE diet”). A significant negative correlation between levels of oxidized/carbonylated proteins and proteasome function was confirmed, both before and after intervention. Furthermore, it was demonstrated that subgroups of non-frail subjects and women receive a greater benefit after the intervention, concerning specifically the proteasome content and activity. These data highlight the putative beneficial effects of Mediterranean diet on the major cellular proteolytic mechanism, the proteasome, in elderly people.

Quantifying the benefits of Mediterranean diet in terms of survival.

Beneficial effects of Mediterranean diet (MD) have been consistently documented. However, to fully understand the public health implications of MD adherence, an informative step is to quantify these effects in terms of survival time differences. The aim of this study was to evaluate the impact of MD on survival, presenting results in terms of differences in median age at death. We used data from 71,333 participants from a large population-based cohort of Swedish men and women, followed-up between January 1, 1998, and December 31, 2012. A total score of MD, ranging from 0 to 8, was calculated by including information on vegetables and fruits consumption, legumes and nuts, non-refined/high fiber grains, fermented dairy products, fish, red meat, use of olive oil/rapeseed oil, and moderate alcohol intake. Multivariable-adjusted differences in median age at death were estimated with Laplace regression and presented as a function of the MD score. During 15years of follow-up we documented 14,697 deaths. We observed a linear dose-response association between the MD score and median age at death, with higher score associated with longer survival. The difference in median age at death between participants with the extreme scores (0 vs 8) of MD was up to 2years (23months, 95% CI: 16-29). In this study we documented that adherence to MD may accrue benefits up to 2years of longer survival.

The Effect of the Mediterranean Diet on Serum Total Antioxidant Capacity in Obese Patients: A Randomized Controlled Trial

Objective: The aim of this work was to evaluate the combined effect of physical activity and 1 and 12 months’ adherence to Mediterranean diet (MD) on serum total antioxidant capacity (TAC) in obese patients, as well as factors contributing to TAC.Methods: One hundred twenty-four patients were randomly assigned to either MD combined with physical activity or standard hypolypemic diet (SHD) with physical activity. Both groups received counseling and education during the initial week and were invited for the follow-up visits, where data on body weight and blood samples were collected. TAC was determined by Trolox equivalent antioxidant capacity and urate was determined using a uricase spectrophotometric method at the initial visit and after 1 and 12 months.Results: Eighty-four patients finished the 12-month program and were analyzed. The baseline and 1- and 12-month mean (±SD) TAC values in the MD group (n = 40) were 2.38 ± 0.48, 2.51 ± 0.47, and 2.47 ± 0.45 mmol Trolox equivalent (TE)/L, respectively. In the SHD group (n = 44), TAC values were 2.37 ± 0.49, 2.48 ± 0.49, and 2.31 ± 0.51 mmol TE/L, respectively. There was a statistically significant main effect for time (p < 0.001), as well as statistically significant time–diet interaction effect (p = 0.009). There was no statistically significant correlation between TAC and uric acid after 1 month (p = 0.733) or 12 months (p = 0.844) of the intervention. Based on the regression model, which included gender, diet, physical activity level, and percentage body weight change, the type of diet was the only significantly contributing factor to TAC change after the 12-month period, F = 3.867, df = 3, p = 0.012, R = 0.358, R2 = 0.128.Conclusion: This randomized controlled trial with diet and physical activity intervention and TAC as a primary outcome demonstrated initial antioxidant improvement in both MD and SHD groups and a long-term beneficial effect of MD. The results imply that diet composition—olive oil, nuts, and fish in particular—combined with physical activity modify antioxidant capacity.

Peripheral Arterial Disease and Cardiovascular Risk

Peripheral arterial disease (PAD) refers to the obstruction of large arteries of the body. The prevalence of PAD in the general population is estimated to be around 12% to 14% and increases up to 20% of those over 70 years old. It is of interest that 70% to 80% of affected individuals are asymptomatic and only a minority requires revascularization or amputation. Major risk factors for PAD are smoking, physical inactivity, dyslipidemias, hypertension, diabetes, and, consequently, the metabolic syndrome (MetS); PAD affects approximately 30% of people with diabetes mellitus. Since the early 1990s, studies revealed the association between PAD and mortality from cardiovascular disease (CVD). For example, Criqui et al evaluated the association of large-vessel PAD with mortality rates from CVD and reported that the relative risk of dying among patients with large-vessel PAD when compared to those with no largevessel disease was 3.1-fold higher (95% confidence interval [CI] 1.9-4.9) for all-cause mortality and 5.9-fold higher (95% CI 3.0-11.4) for CVD mortality. Diet has long been investigated in relation to CVD risk and its major risk factors, like dyslipidemia, hypertension, diabetes, and the MetS. A recent systematic search of the literature based on 15 relevant observational studies that evaluated the direct effect of diet on CVD risk reported that the attributable risk of an unhealthy dietary pattern varies from 9% to 37%; moreover, the authors observed that the inclusion of diet component in CVD risk scores may increase the accuracy of the models and better identify people at high risk. The Mediterranean diet is one of the most known and studied dietary patterns in relation to human health. It was described in the late 1960s by Ancel Keys in the Seven Countries Study. This traditional dietary pattern is characterized by daily consumption of olive oil, fruits and vegetables, nonrefined grains and dairy products as well as weekly consumption of fish and poultry, potatoes, olives, nuts and legumes, and monthly consumption of red meat. Another major characteristic of this dietary pattern is the moderate consumption of alcohol, mainly wine (1-2 glasses/d), usually with meals. However, it should be acknowledged that although the dietary patterns that prevail in the wider Mediterranean region share many common characteristics, the macronutrient distribution varies from area to area. Nevertheless, studies from the Mediterranean region as well as from other parts of the world strongly support the cardioprotective role of this dietary pattern, mainly through its beneficial role on cardiometabolic markers. At this point it is important to mention that the Mediterranean diet may exert its positive influence on human health and CVD particularly due to its antioxidant and anti-inflammatory effects. Despite the large body of evidence regarding Mediterranean diet and CVD mortality and morbidity, the role of this traditional dietary pattern on risk of PAD has been rarely studied. Very recently, Ruiz-Canela et al, in a randomized trial conducted from October 2003 and December 2010 in Spain, assessed the association between Mediterranean diet and the occurrence of symptomatic PAD in 7477 participants with type 2 diabetes mellitus or at least 3 cardiovascular risk factors, aged 55 to 80 years and without clinical PAD or baseline CVD. Participants were randomized to the following groups: a Mediterranean diet supplemented with extra virgin olive oil, a Mediterranean diet supplemented with nuts, or counseling on a low-fat diet (control group). All participants received a comprehensive dietary educational program on a quarterly basis. Both Mediterranean diet intervention groups were associated with lower risk of PAD compared to the control group. A mechanistic hypothesis of the beneficial effect of Mediterranean diet on PAD may be due its pleiotropic beneficial effects on endothelial function, arterial blood pressure, lipids, and glucose

EDITORIAL: Is the Beneficial Effect of Mediterranean Diet on Cardiovascular Risk Partly Mediated through Better Blood Pressure Control?

1 Endocrinology Clinic, Hippocration Hospital, Thessaloniki, Greece; 2 Department of Internal Medicine, Military Hospital of Thessaloniki, Thessaloniki, Greece; 3 Second Prop. Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece; 4 Department of Endocrinology and Metabolism, Agios Pavlos Hospital, Thessaloniki, Greece

Postprandial Activation of P53-Dependent DNA Repair Is Modified by Mediterranean Diet Supplemented With Coenzyme Q10 in Elderly Subjects

Alterations in the expression levels of genes and proteins involved in oxidative stress and DNA damage response underlie the phenotypic changes associated with aging. We have investigated whether the quality of dietary fat alters postprandial gene expression and protein levels involved in p53-dependent DNA repair and whether the supplementation with Coenzyme Q10 improves this situation in an elderly population. Twenty participants were randomized to receive three isocaloric diets each for 4 weeks: Mediterranean diet supplemented with Coenzyme Q10, Mediterranean diet, saturated fatty acid-rich diet. After a 12-hour fast, volunteers consumed a breakfast with a fat composition similar to that consumed in each of the diets. Gadd45a, Gadd45b, OGG1, APE-1/Ref-1, DNApolβ, and XPC gene expression and nuclear Gadd45a, APE-1/Ref-1, and DNApolβ protein levels were determined in peripheral blood mononuclear cells. Mediterranean diet and Mediterranean diet supplemented with Coenzyme Q10diets downregulated Gadd45a protein levels compared with the saturated fatty acid-rich diet. Moreover, Mediterranean diet supplemented with Coenzyme Q10diet evoked lower postprandial Gadd45a, Gadd45b, XPC, DNApolβ and OGG1 gene expression and lower APE-1/Ref-1 and DNApolβ protein levels than the saturated fatty acid-rich diet. Our results support a beneficial effect of Mediterranean diet and Mediterranean diet supplemented with Coenzyme Q10 on DNA damage as compared to the detrimental action of a saturated fatty acid-rich diet, which triggers the p53-dependent DNA repair machinery.

Mediterranean diet and health

Over the last decades, a considerable body of evidence supported the hypothesis that diet and dietary factors play a relevant role in the occurrence of diseases. To date, all the major scientific associations as well as the World Health Organization and the nonscientific organizations place an ever-increasing emphasis on the role of diet in preventing noncommunicable diseases. Many studies have evaluated the associations between food groups, foods, or nutrients and chronic diseases, and a consensus about the role of nutritional factors in the etiology of common diseases, such as cardiovascular and neoplastic diseases, has gradually emerged. Indeed, data from analytical and experimental studies indicated a relation between increased consumption of some food categories such as fruits and vegetables, fiber and whole grains, fish, and moderate consumption of alcohol and reduced risk of major chronic degenerative diseases, whereas increased total caloric intake, body weight, meat, and fats are associated with greater risk. However, the appropriate dietary strategy to prevent chronic degenerative diseases remains a challenging and a highly relevant issue. Recently, Mediterranean diet has been extensively reported to be associated with a favorable health outcome and a better quality of life. In the present review, we encompass the updated evidence of the beneficial effects of Mediterranean diet in the occurrence of major chronic degenerative diseases.

Mediterranean Diet and Minimizing Neurodegeneration

Neurodegenerative diseases, a complex of diseases that ranges from cognitive decline, dementia, to Alzheimer’s disease represent, to date, a public health priority all over the world. Recently, an increasing interest for a possible relationship between diet and cognitive health has been reported. Several models of diet have been proposed but, until now, the highest attention of researchers, clinicians, and institutions has been focused on the Mediterranean diet. Mediterranean diet is a model of diet characterized by a high consumption of complex carbohydrates, fruit and vegetables, legumes, with olive oil as the principal source of fats. Mediterranean diet has been extensively reported to be associated with a favorable health outcome and a better quality of life, but inconsistencies on the possible association with neurodegenerative diseases have been reported. The purpose of this review was to examine the most updated evidence of the beneficial effects of Mediterranean diet on the occurrence of neurodegenerative diseases.

The mediating effect of parents’ educational status on the association between adherence to the Mediterranean diet and childhood obesity: the PANACEA study

To investigate the potential mediating effect of parental education on the association between adherence to the Mediterranean diet and obesity, in 10-12years old children. A cross-sectional survey was performed among 1,125 (529 male) children in Greece. Children and their parents completed standardized questionnaires, which evaluated parents' educational level and dietary habits. Body mass index was calculated and children were classified as normal, overweight or obese (IOTF classification). Adherence to the Mediterranean diet was assessed using the KIDMED score. 27.7% of the children were overweight and 6.3% were obese; 12.3% of children reported high adherence to the Mediterranean diet. Multi-adjusted analysis, stratified by parental education, revealed that adherence to the Mediterranean diet was inversely associated with children's obesity status only in families in which at least one parent was of higher educational level (stratum-specific adjusted odds ratio: 0.41; 95% CI 0.17-0.98), but not those in which both parents were of low educational level. Parental education status seems to play a mediating role in the beneficial effect of Mediterranean diet on children's obesity status.

Introduction to Nutraceuticals Special Issue

Despite that the therapeutic armamentarium to prevent cardiovascular disease grew in the last two decades, myocardial infarction and stroke still represent the first cause of mortality and morbility in the western country. New antiatherothrombotic therapies added to ACE-inhibitors, statins and antiplatelet drugs are far from entry in the market also because identification of novel mechanisms involved in the process of athero-trombosis are still in progress. Antioxidants therapy represented a potentially attractive approach because of the putative role of oxidative stress in the initiation and progression of atherosclerosis. However, trials with antioxidants failed to show beneficial effects also for serious methodological issues related to patients inclusion, drug compliance, follow-up duration and confounding factors such as concomitant use of antioxidant molecules like statins [1]. In absence of new therapeutic approach in the near future, dietary intervention may represent an interesting alternative to retard the progression of atherosclerosis and its clinical sequelae. There are at least three dietary interventions that have been associated with reduced incidence of cardiovascular disease. Since the classic study by Kyes et al [2], several observational studies showed people living in the South of Europe following a Mediterranean diet had lower incidence of cardiovascular disease compared to people living in the North of Europe. Mediterranean diet is characterized by high intake of fruits, vegetables, legumes, monounsaturated fatty acids (essentially olive oil), and a moderate intake of fish and wine. The beneficial effect of Mediterranean diet in preventing cardiovascular disease has been documented in interventional studies performed in patients with or without previous cardiovascular diseases. In a large prospective study performed in 22,043 adults in Greece [3]: people who closely followed the Mediterranean diet had lower probability (−25%) to die compared to those who poorly adhered to the diet during a median follow-up of 44 months. The beneficial effect of Mediterranean diet has also been demonstrated in secondary prevention trial in which patients with previous cardiovascular diseases following a typical Mediterranean diet had reduced risk of myocardial infarction and stroke [4, 5]. Several nutrients of the Mediterranean diet have been suggested to play a role in reducing cardiovascular events. Fruits, vegetables and wine are supposed to play an important role among them. For instance, the Nurses’ Health Study and the Health Professionals’ Follow-up Study demonstrated that consumption of fruits and vegetables are associated with reduced risk of coronary heart disease [6]. The Indian Heart Study randomized 505 survivors of myocardial infarction to a usual care or a diet rich in fruits, vegetables, nuts and grains. After one year of follow-up, there were fewer cardiac events and lower overall mortality in patients on interventional diet [7]. Assumption of wine has also been associated with reduced risk of cardiovascular diseases as suggested by a meta-analysis showing an inverse association between 200 mL/day wine intake and cardiovascular diseases [8]. Together these data prompted to speculate that the antioxidants contained in fruits and vegetables and the polyphenols contained in the wine were responsible for such beneficial effects. A series of studies have been done in experimental models of atherosclerosis and in humans to assess the efficacy of these supplements containing antioxidants and polyphenols. Nutrition based on high fish intake has also proved to protect against coronary heart disease. Since the pioneering studies in Greenland showing that consumption of fish protect Eskimos against cardiovascular disease [9], many observational studies have provided support to this preliminary research. In a recent meta-analysis of these observational studies, the rate of weekly fish consumption inversely correlated with mortality from cardiovascular disease: fish consumption up to two to four times weekly was associated with 38% risk reduction [10]. Also, in the Physicians’ Health Study the risk of sudden death was inversely correlated with the blood concentration of n-3 fatty acids [11]. As in the case of the Mediterranean diet interventional trials with fish oils or n-3 fatty acids supplements have been planned to assess their efficacy in preventing cardiovascular diseases. There are several questions that should be addressed concerning the use of supplements in clinical practice. A crucial issue regards the real effectiveness of such supplements in preventing cardiovascular disease and the potential harmful effects especially in case of long-term assumption. Another issue is related to the population who could potentially benefit from such treatment. In other words, it is to define if supplements are useful for primary of secondary prevention and if early assumption may halt atherosclerotic progression. This is another crucial issue as the use of supplements has been investigated in the early infancy in children at risk of cardiovascular disease [12]. For all these reasons I believe that a special issue regarding supplements will be of interest for readers who are looking for new approaches for prevention of cardiovascular diseases.