Slide 1

Mr Chairman, thank you. It’s a privilege for me and a pleasure to be here. It’s a privilege to address a distinguished audience and it is a pleasure because I was given the opportunity to talk about the Mediterranean diet, a topic which expresses both my scientific beliefs and my love for the Mediterranean way of life.
Well many groups in the Mediterranean area and elsewhere have studied the relation to health of the Mediterranean diet but I’m taking the liberty tonight to focus more or mainly on the work of our group for two reasons, first because I am more familiar with the work of our group and second because we were among the first in our generation to focus on this issue.

Slide 2

So, what is the Mediterranean diet? Ansel Keys and his colleagues in the early 60s in the famous Seven Country Study considered the Mediterranean diet as a low saturated diet which conveyed protection from coronary artery disease. This was the main message as it was developed by Ansel Keys and his colleagues but in the course of the years emphasis has shifted to olive oil and to the overall composition of the Mediterranean diet. Furthermore, more recently there is a lot of work going on the association of the Mediterranean diet with longevity and chronic diseases.

Slide 3

Well, this is a pictorial presentation of the Mediterranean diet and expresses the nutrition guidelines of the Greek Ministry of Health and is based on a traditional Mediterranean diet, well, the Greek traditional Mediterranean diet. A Mediterranean diet is basically a plant based diet but does not exclude anything. It’s a question of how much and how often and not to say no to any food. So centrally in the Mediterranean diet there is olive oil and of course, vegetables and fruit and non-refined cereals.

Slide 4

Well, let’s see what was happening in the 60s in Greece and why are we talking about the 60s? Why when we’re talking about or when we want to describe the traditional Mediterranean diet we go as back as to the 60s? Because in the 60s the problems which we had in Europe after the Second World War had been overcome and then yet we didn’t have the big changes in technology, on social grounds, globalisation hadn’t arrived yet in all parts of Europe and so we were quite traditional. So at this period of time you can see in this table that a Greek man at the age of 45 was the most long-lived man in the world and was much more ahead the Japanese who today are the most long-lived people in the world. Then again, the mortality ad morbidity from chronic diseases like coronary heart disease or cancers or various types of cancers were much lower even than Japan and in the United States.

Slide 5

What were we doing at that time? I want to point only one to one thing. At that time in Greece 37% of our caloric intake was coming from so-called fat, from lipids mainly from olive oil. So, the Mediterranean diet in some parts of the Mediterranean is not so low in fat. Why do we say quite often to reduce fat’? Because it’s a question of the type of fat and not unanimously to talk about reducing fat. Of course, we were drinking 2.5 glasses of wine per day.

Slide 6

Thus we could say that the characteristics of the Mediterranean diet are high olive oil consumption, legumes, cereals, fruit and vegetables, moderate consumption of dairy products mostly cheese and yoghurt because Mediterraneans are sensitive, we are deficient in lactate and moderate to high consumption of fish. In Spain, for example, a Mediterranean country they consume a lot of fish. In other parts of the Mediterranean there is not so much fish and so with low fish but fish is not available in high quantities. Low consumption of meat and meat products and a moderate wine consumption if it is accepted by religion and social grounds, as in some parts of North Africa and the Near East when alcohol is not accepted on social grounds.

Slide 7

So well, in the last 40 years emphasis has been given and very good papers have been published relating several foods and nutrients with beneficial or detrimental effects to health. But relatively few studies that have been published have consider the diet as a whole or as a dietary pattern.

Slide 8

But yet dietary patterns have the ability to integrate complex effects or many dietary exposures, things that in a diet we’re eating 4, 5 fruits and these fruits have more than 1000 ingredients, nutrients. We don’t know how they interact between them the nutrients, we say we eat apples and we eat oranges or we eat berries. How the 1000 and more nutrients all these fruits they contain interact? In a pattern this can be overcome, as well as when we work with dietary patterns we bypass problems generated by multiple testing and also the high correlations that may exist among the various confounders.

Slide 9

So thus we developed a score, which was based on the 9 characteristics which were previously mentioned to you, the 9 characteristics of the Mediterranean diet. According to this score we could evaluate the adherence to the Mediterranean diet and we found out that by a 2 unit increase in the Mediterranean diet score we had a reduction in total mortality by 25%. Moreover, adherence to the Mediterranean diet was associated with 23% less in coronary heart disease and we were surprised for that because this was one of the very first papers which mentioned that. There was a 24% reduction of cancer mortality.

Slide 10

What was interesting in this analysis which was based in 28.000 Greeks? Those Greeks are part of the Greek arm of the EPIC and they have been followed up for the past 14 years. That rather than single food nutrients the pattern was expressing a protective effect. When we tested statistically if this food or these nutrients were beneficial to health, we could not find a statistical significant association. So, it’s the pattern which protects us much more than the individual foods and this is something which I think we have to keep in mind.

Slide 11

Again, we repeated the same exercise, we tested if the adherence to the Mediterranean diet was beneficial to people who have had a coronary heart attack and again we found out a 27% reduction in overall mortality for patients that have already had at least on heart attack.

Slide 12

So, we could say that greater adherence to the Mediterranean diet is associated with a significant reduction in mortality among individuals diagnosed as having coronary heart disease.

Slide 13

Again, there are several papers on olive oil and they associated the olive oil consumption with a significant reduction of both systolic and diastolic blood pressure. In Spain and in Italy they have similar results.

Slide 14

Here in Barcelona, I think it’s the group of Doctor Covas which is working in order to decipher the mechanisms through which the Mediterranean diet has its beneficial effects. They found out that it’s not only the monosaturated lipids that are beneficial but it’s the phenolic content of olive oil which provides benefits for plasma lipid levels and oxidative damage.

Slide 15

Last year to our surprise a paper was published which was associating the Mediterranean diet with Alzheimer’s disease. Then several other papers followed pointing to the same direction. We don’t the mechanisms, there are some speculations, well, there are some indications that there might be an association but this I think is the most important as Alzheimer’s is increasing all around the world as we’re getting older and older.

Slide 16

Again, last month to our surprise two papers were published in Thorax claiming that the Mediterranean diet halves the risk of heart disease. The first paper was published based on the data of the health professionals in the Boston group and they found out that it’s beneficial in preventing chronic obstructive pulmonary disease and the other was in a cohort in Crete, a children cohort and they found that the Mediterranean diet is beneficial in preventing asthma and allergies among the children.
So things are going on and every month, every year we have more and more information also about the mechanisms of the way the Mediterranean diet is beneficial for our health.

Slide 17

What I want to point out is quite often the Mediterranean diet is considered as conducive to obesity because especially in Greece it’s really high in fat content because we cook everything, especially vegetables, in olive oil.

Slide 18

We and others, in Spain a group from Navara and another group form Italy we found out that there is no important association between the Mediterranean diet score and BMI and W/H ratio.

Slide 19

In the Mediterranean region we’re getting fatter and fatter because we have increased our energy intake and we don’t exercise. Obesity is energy, nothing else.

Slide 20

So, in the next 3 or 5 minutes which are left I want to raise the issue of traditional food because we are talking about the Mediterranean diet but in a diet we’re getting food and a part of the Mediterranean diet which has been overlooked is that a Mediterranean diet is traditional Mediterranean food.

Slide 21

In Greece in the last 15 years we have analysed chemicals in more than 100 traditional foods. It’s not only that we registered them because we are afraid that after 5, 10 or 20 years they will disappear forever. Nevertheless, I will show you 2 or 3 slides with some information.

Slide 22

Here is the traditional pie with greens, wild greens we have more than 150 wild greens and this pie was done with 14 greens and then we compared the flavonoid content of these green pies with other beverages which are considered and they are quite rich in flavonoids like red wine, black tea and apple juice. You can see the blue bar represented the flavonoid content of the green pie.

Slide 23

We chemically analysed another traditional Greek food, Pasteli, it has nuts, it’s a paste of sesame and honey, it’s free of cholesterol.

Slide 24

The yellow bar is the content in potassium and calcium which was discussed before and phosphorus is very, very, very high actually it’s a supplement, it’s a pill for calcium and phosphorous.

Slide 25

Then we chemically analysed a whole week of a Mediterranean menu and we found out that the inorganic constituents, as well as the vitamins, as well as the macronutrients, were fully in accordance with the European Commission Daily recommendations.

Slide 26

Again, it’s the variety. We compared the flavonoid intake between the Netherlands and Greece and you see that the flavonoid intake comes from too many sources in the Greek Mediterranean diet. In the Netherlands it comes mainly from tea, onions and apples. But because we have in our gastronomy, let’s say in our traditional foods we’re using many herbs and spices I mean the sources of flavonoids and vitamins in organic material is much more diverse and this is one of the secrets I think of the Mediterranean diet. So, I want to give you an example, for example, of how calcium is contributed by a green pie of Chalkidiki another area of Greece. It contains wild sea-beet, corn poppies, spinach, leeks, spring onions, dried onion, dill, flour, extra virgin oil, semolina, corn starch, salt, pepper and water. All these things little by little in the end this traditional food is a rich source of calcium.
Again, a very simple food from Santorini island, it’s a magnificent island a Greek island. The traditional food of Santorini is fava. Fava does not contain any flavone, flavonol, flavan 3 but if you add capers it becomes very, very rich in flavonoids this simple humble food, fava.

Slide 27

So, as Hippocrates said ‘Let food be the medicine and medicine be the food’.

Slide 28

A philosopher who was born in Asia Minor 200 before Socrates, he visited Athens, Sicily, he might have come to Spain too, I don’t know he said that ‘God did not reveal everything to mankind from the beginning but people researching as we do discover with time the better.’

Slide 29

I think that the Mediterranean can help us do that. Thanks for your attention.

Slide 30

Chairman: Thank you for your nice presentation. Thank you for defining to us what the Mediterranean diet means. The problem that we have here in Spain that we always speak about our Mediterranean diet but we don’t know if we really have a Mediterranean diet. When you published in the New England Journal of Medicine the study about the Mediterranean diet, you presented 23.000 people that were studied but what is the proportion of that population that were rural instead of urban because I think the diet is quite different. We cannot say….

Prof. Trichopoulou: Thank you very much for this question the Greek EPIC arm, the Greek EPIC study refers to 28.000 Greeks all over Greece. To a certain degree it’s a representative sample of the Greek adult population but may I tell you that the younger generation doesn’t follow the Mediterranean diet. It’s the older generation that follows the Mediterranean diet that’s why I said that in 10, 20 years, if we don’t react, all this diet will be lost forever.

Question: First of all, I appreciated so much your conference, congratulations. My question concerns, is it only the Mediterranean diet or what does the lifestyle of these people have to do with it? I would like your reflection.

Prof. Trichopoulou: Thank you very, very much but I was respecting time, the 20 minutes allotted to me and I didn’t want to expand on that but as you will see in our nutrition guidelines, we have this homunculus it’s physical activity. Physical activity is very important and at the time in the 60s we were walking a lot and then as Professor De Alvaro mentioned before but I didn’t mention in my presentation, recently we published a paper in which we found out that siesta is beneficial and this is part of the Mediterranean diet. Also a more relaxing attitude, yes. But in our studies, in our statistical analysis we take into account physical activities as confounders, so it doesn’t influence our results because we excluded from our statistical analysis the influence of physical activity but not for siesta.

Chairman: Anymore questions? Yes please.

Question: You’re doing some speculations on the individual components that can be involved in the positive effect suspected for the Mediterranean diet on the public health. The flavonoids and other antioxidants are commonly associated with this sort of speculation but you know that probably something that is not related with something individual is the complex as you said in your presentation because if we expect that flavonoids as antioxidants can do something, we are probably on the wrong side because their concentration is always very low. Even if you consider their metabolites and everything you cannot go over 4 µmol in the circulation. So you must suspect that vitamin C and other antioxidants may contribute much better than those components but what is the magic mixture in terms of the most beautiful contribution to the effect t of the Mediterranean diet? What do you think is the right combination? I mean the ‘5 a day’ for instance, is a sort of interpretation of what is the healthy concept of the diet. A lot of fruit, a lot of vegetables and so on. But the Mediterranean diet goes far beyond that concept to other kinds of food, other kinds of nutrients that are associated with not just vegetables and fruit. Do you understand what I mean? Oil, fat something that is mostly associated with calories and so with the risk of obesity. So, what’s the combination’? What’s the balance between all these aspects?

Prof. Trichopoulou: Well, you raised several questions and I thank you very much for that. Originally the Mediterranean diet as I mentioned in the 60s as it was considered by Ansel Keys was a low saturated fat diet. In the course of the years this has been expanded to olive oil and to the composition and for many years emphasis was given to olive oil. If you ask me if there is a magic bullet in the Mediterranean diet that is olive oil but extra virgin olive oil. Olive oil has two micro components. Then when we start with the Mediterraneans trying to preserve our culture and our habits which were good for health, whatever we touched with the Mediterranean diet or olive oil is protected and we said no this is not feasible. Let’s try to find what else. Taling about the ‘5 a day’, in the Mediterranean we are far above ‘5 a day’ and personally I have repeatedly said to all Health Organisations if we say ‘5 a day’ then you reduce fruit and vegetables in the Mediterranean region. That’s why last year in Denmark they increased 5 and more and they said that 7 is the optimal. So when I presented flavonoids not because I am a believer of that there is no strict scientific evidence for the flavonoids. First of all because the combination might be a combination of several antioxidants, might be pre-oxidants but in order to provide, to explain myself trying to say come on, it’s not so simple, it’s the pattern which counts, we don’t know. Look at what all those foods what they offer, what they contribute because we like to simplify things and say take these pills because they have these flavonoids or take this because it has this mineral. We create a magic bullet and there was a lot of interest in this calcium process and I was thinking well all these vitamins which we are providing what are they doing in our population if we give pills. But if you give food, you give them in the right combination and proportion. I’m sorry I don’t know if I have explained myself but I totally agree with your views. Yes.

Chairman: Well, thank you. Are there any more questions? Then we can close the session. Thank you very much for your presentation. Thank you all very much for coming.