38 CLINICAL FOCUS
38 CLINICAL FOCUS
31 OCTOBER 2025 ausdoc. com. au
| THE | DIABETES & WEIGHT MANAGEMENT SPECIAL
Therapy Update
A Mediterranean approach to diet
Diet
Dr Evangeline Mantzioris is an accredited practising dietitian, senior lecturer and program director of the Bachelor of Nutrition and food sciences program at the University of SA.
Dr Anthony Villani is an accredited practising dietitian, senior lecturer and program co-ordinator of the Bachelor of Dietetics program at the University of the Sunshine Coast, Queensland.
Multiple factors are likely to account for the potential benefits for this approach, which encompass cardiometabolic and mental health, and healthy ageing.
THE Mediterranean diet is a dietary pattern based on the eating habits and traditional foods from the olive-growing regions of the Mediterranean basin before the mid-1960s. 1 While there is no single Mediterranean diet, it is broadly described as a plant-based dietary pattern that is rich in healthy fats, dietary fibre, vitamins, minerals and antioxidants, and low in saturated fat and sodium. 2
The Mediterranean diet was first noticed by US physiologist Professor Ancel Keys while on sabbatical leave in Italy. He noticed the distinctly different dietary pattern, and the very low rates of CVD. From these observations, he commenced the famous Seven Countries Study, which explored the impact of diet and lifestyle on CVD risk in almost 12,000 healthy men, aged 40-59 from seven countries: US, Japan, Finland, Italy, Netherlands, Yugoslavia, and Greece( Crete). 3 Results of this pioneering study showed that higher saturated fat intake was associated with higher CVD-related mortality. Interestingly, the Cretan cohort had the lowest rates of CVD and cancer, despite low socioeconomic status, poor access to healthcare, low education and high smoking rates. Notably, their diet was about 40 % fat, significantly higher than other countries. This study was among the first to suggest that the type of fat( in this case, monounsaturated fats from extra virgin olive oil) may be more important for cardiovascular health than the total amount of fat consumed. However, as an observational study, it could not establish
direct causal links between health outcomes and dietary adherence.
Following on from the Seven Countries Study, the definition of the Mediterranean diet has been refined from the traditional dietary pattern that was first observed in the Cretan cohort. Nevertheless, the true identity of a Mediterranean diet is difficult to define as it varies by country and time. For example, the Mediterranean basin spans over 20 countries in Europe, Africa and Asia, each with unique dietary patterns, religious beliefs and cultures. Thus, there is no single‘ Mediterranean diet’. Although often described as a‘ diet’ in the scientific literature, the Mediterranean diet is more correctly recognisable as a‘ whole lifestyle’ approach, which also incorporates time-honoured behaviours, including harvesting, traditional culinary techniques, regular physical activity, frugality and conviviality. 4 Regardless of how the Mediterranean diet has been defined over several decades, it is characterised by a high intake of vegetables, fruits, nuts, legumes, unprocessed cereals, daily use of extra virgin olive oil; moderate consumption of fish, shellfish and fermented dairy products( cheese and yogurt); low consumption of meat and meat products, processed cereals, sweets, vegetable oils and butter; and the consumption of red wine, typically during meals only. 5
Over the past several decades, the Mediterranean diet has been extensively investigated with respect to reductions in chronic disease risk and to support
The diet is more correctly recognisable as a‘ whole lifestyle’ approach, which also incorporates time-honoured behaviours.
healthy ageing. These findings are summarised below.
Cardiometabolic benefits
One of the largest clinical trials to be published, the PREvención con DIeta MEDiterránea( PREDIMED) study, included over 7000 middle-aged and older adults( 55-80 years of age) at risk of CVD. The study identified a 30 % risk reduction in major cardiovascular events over a five-year period in participants at high risk of CVD when assigned to either a Mediterranean diet supplemented with additional extra virgin olive oil( at least four tablespoons / day) or nuts( 30g / day), compared with those assigned to a standard low-fat control diet. 6 Furthermore, after four years of follow-up, participants assigned to either of the two Mediterranean diets, without caloric restriction, had
NEED TO KNOW
The Mediterranean diet is broadly described as a plant-based dietary pattern characterised by a high intake of vegetables, fruits, nuts, legumes and unprocessed cereals, and the daily use of extra virgin olive oil. It is rich in healthy fats, dietary fibre, vitamins, minerals and antioxidants, and low in saturated fat and sodium. It is low in red meat and processed foods.
The Mediterranean diet has been extensively investigated with respect to reductions in chronic disease risk and to support healthy ageing. This includes the prevention and management of CVD, overweight and obesity, type 2 diabetes, metabolic syndrome, depression, cognitive decline and physical health.
Its benefits are related to the anti-inflammatory potential of the diet, reductions in oxidative stress and a higher intake of antioxidants.
The Mediterranean diet can be adhered to in Australia, however many patients require dietary counselling to support compliance.
a 40 % and 18 % reduction, respectively, in the incidence of type 2 diabetes compared with those in the low-fat control diet. 7 Following on from the PREDIMED study, the PREDIMED-Plus lifestyle intervention evaluated the long-term cardiovascular benefits from a calorie-restricted Mediterranean diet intervention combined with physical activity promotion and behaviour modification in over 600 middle-aged adults with overweight and obesity and metabolic syndrome. After 12 months, participants allocated to the PREDIMED-Plus lifestyle intervention( compared with standard education on an ad libitum Mediterranean diet used in the original PREDIMED study) experienced greater improvements in CVD risk factors including waist circumference, fasting glucose, insulin sensitivity and blood lipid profiles. 8
Improved cardiometabolic benefits are also observed independent of a calorie-restricted Mediterranean diet. For example, in a sample of 180 participants with overweight and metabolic syndrome, after two years of following a Mediterranean diet intervention without calorie restriction( compared with a standard healthy diet consistent with typical dietary guidelines), participants experienced significant reductions in body weight, waist circumference, blood pressure, fasting blood glucose levels, insulin, total cholesterol and triglycerides as well as significant increases in HDL cholesterol and improved endothelial function. 9 In patients with type 2 diabetes, improvements in glycaemic control have also been noted, independent of changes in body weight. For example, an Australian clinical trial showed that a 12-week ad libitum Mediterranean diet