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International Consensus Statement
Prof. Gerd Assmann,
Institute of Arteriosclerosis Research, Münster, Germany
Prof. Guy de Backer,
Department of Public Health, Ziekenhuis Ghent, Belgium
Prof. Sebastiano Bagnara,
Institute of Psychology, National Research Council, Rome, Italy
Prof. John Betteridge,
Department of Medicine, Thorn Institute, Middlesex Hospital, UK
Prof. Gaetano Crepaldi,
Institute of Internal Medicine, University of Padua, Italy
Prof. Arturo Fernandez-Cruz,
Institute of Internal Medicine, University Hospital San Carlos, Madrid, Spain
Dr. John Godtfredsen,
Department of Cardiology, University Hospital, Herlev, Denmark
Prof. Bernard Jacotot,
Department of Internal Medicine, INSERM, Creteil, France
Prof. Rodolfo Paoletti,
Institute of Pharmacological Sciences, University Of Milan, Italy
Prof. Serge Renaud,
Department of Research, INSERM, Bordeaux, France
Prof. Giorgio Ricci,
Institute of Systematic Medical Therapy, University La Sapienza, Rome, Italy
Prof. Evangelista Rocha,
Department of Cardiology, Medical University of Lisbon, Portugal
Dr. Elke Trautwein,
Institute of Human Nutrition and Food Sciences, University of Kiel, Germany
Prof. Gian Carlo Urbinati,
Institute of Systematic Medical Therapy, University La Sapienza, Rome Italy
Prof. Gregorio Varela,
Department of Nutrition and Bromatology, Complutense University, Madrid, Spain
Prof. Christine Williams,
Department of Food Science and Technology, University of Reading, UK
At a meeting convened by the European Commission at the Italian National
Research Council in Rome, 11 April 1997, European nutrition, cardiology,
lipidology and public health specialists gathered to reach a health consensus
on olive oil and the Mediterranean diet.
They agreed that there is strong evidence that a Mediterranean-style diet,
in which olive oil is the principal source of fat, contributes to the
prevention of cardio-vascular risk factors, such as dyslipidaemia,
hypertension, diabetes and obesity, and therefore, in the primary and
secondary prevention of coronary heart disease. In addition, there is
evidence suggesting that the Mediterranean diet plays a preventive role
against some cancers.
In this consensus statement, the major evidence for the health benefits of the Mediterranean diet is detailed, the mechanisms by which its components are believed to contribute to the benefits are stated, and the role of the Mediterranean diet in the prevention of diseases is pointed out.
A working definition of the traditional Mediterranean diet is described as follows:
| The traditional (European) Mediterranean diet is characterised by an abundance of plant foods such as bread, pasta, vegetables, salad, legumes, fruit, nuts; olive oil as the principal source of fat; low to moderate amounts of fish, poultry, dairy products and eggs; only little amounts of red meat; low to moderate amounts of wine, normally consumed with meals. This diet is low in saturated fatty acids, rich in carbohydrate and fibre, and has a high content of monounsaturated fatty acids. These are primarily derived from olive oil. |
Recommendations are made to develop practical measures to
Targets for this information campaign include the food industry (including supermarkets, manufacturers, caterers), governments, consumers, public health departments, schools, the media, hospital doctors and GPs.
1.1 Biochemical and clinical studies and a number of large European and US population studies have shown beyond doubt that a high-fat diet, rich in saturated fatty acids (SFA), as is common in most Western and Northern European countries, raises atherogenic LDL cholesterol and thus is causally related to high incidence of CHD (1-3).
1.2 In contrast, a diet rich in complex carbohydrates and fibre and whose fat source is primarily monounsaturated fatty acids (MUFA), as found in the olive oil-rich Mediterranean-style diet as can be found in Southern Europe, lowers LDL cholesterol and is associated with a low incidence of CHD (1-3).
1.3 Intervention studies with "soft end-points", such as serum lipid levels, indirectly support the health benefits of the Mediterranean-style diet (4). In addition, many controlled dietary studies show that diets rich in monounsaturated fatty acids lead to a reduction of total and low-density lipoprotein (LDL) cholesterol as compared to diets very rich in saturated fatty acids (5,6).
1.4 The traditional Mediterranean-style diet has been shown to predispose to a lower blood pressure compared with typical Western diets (7,8).
1.5 Cross-cultural comparisons and studies on vegetarians show that a high intake of complex carbohydrate and dietary fibre such as found in the Mediterranean diet, and the low intake of SFA have beneficial effects that could lower the risk of diabetes (8-11).
1.6 Epidemiological data show a strong inverse relationship between carbohydrate intake and relative body weight (12). Due to its high content of complex carbohydrates, the Mediterranean-style diet has, on average, a lower energy content than a high-fat diet which makes it suitable for the prevention of obesity.
1.7 Epidemiological studies provide evidence that in Southern European countries, where a Mediterranean-style diet is consumed, colon cancer incidence is low compared with Northern European countries (13-16).
1.8 Epidemiological evidence shows that a high intake of fruit and vegetables, particularly raw vegetables, protects against cancers at different sites, especially those of the digestive and respiratory tracts and the hormone related cancers (17-21).
1.9 The major features of the Mediterranean-style diet are consistent with important findings which indicate reductions in the incidence of cancer at a number of important sites (22-25).
2.0 What are the mechanisms by which olive oil exerts its beneficial effect on health?
2.1 The major fatty acid of olive oil is oleic acid, a monounsaturated
fatty acid (55-83% of total fatty acids). Olive oil contains further
saturated fatty acids (range: 8-14%), polyunsaturated fatty acids (range: 4-20%),
and other important minor constituents, particularly antioxidants, such as
vitamin E and polyphenols.
The beneficial health effects of olive oil are due to both its high content
of monounsaturated fatty acids and its high content of antioxidative substances.
When substituted for serum cholesterol-elevating saturated fatty acids,
monounsaturated fatty acids - as contained in olive oil - reduce total
and LDL cholesterol concentrations without reducing the levels of HDL
cholesterol, thus leading to favourable changes in the serum lipid
profile and possibly to changes in the physico-chemical properties of
lipoproteins. In this way, olive oil with its high monounsaturated fatty
acid content may contribute to the prevention and management of
hypercholesterolaemia (LDL), a dominant risk factor for the development of
atherosclerosis, and to the prevention of CHD.
The consumption of olive oil increases the intake of monounsaturated fatty
acids without any significant elevation of SFA, and simultaneously ensures
an appropriate intake of the essential polyunsaturated fatty acids.
3.0 What role could olive oil and the Mediterranean-style diet play in the prevention of CHD?
3.1 The adoption of a Mediterranean-style diet, with olive oil as a principal source of dietary fat, within the recommended limits of total fat intake, will play an important role in providing a dietary shield for people's health. The beneficial effect of olive oil on the risk of CHD is mostly due to its favourable effects on blood lipids, including their oxidizability.
3.2 The Lyon Diet Heart Study in patients recovering from heart attack showed a Mediterranean-style diet resembling that in Crete, high in monounsaturated fatty acids, even when adapted to a Western population, protects against CHD better than other recommended linoleic-acid rich diets for such patients (26,27).
3.3 The Mediterranean-style diet provides an excellent example of a tasty and healthy diet which, if preserved in countries where it is traditional and if adopted throughout Europe, will contribute to reducing the risk of CHD, both in primary and secondary prevention, and possibly also cancer, diabetes, obesity and hypertension.
3.4 Hospital clinicians, public health doctors, nurses, dietitians and primary health care workers have a duty to advise their patients on strategies for healthy living. Stopping smoking, taking regular exercise and a healthy diet (such as a low fat Mediterranean-style diet comprising olive oil) are a sensible approach for all individuals.
4.0 What actions should be recommended to promote the adoption of a healthier diet?
4.1 The scientific evidence is sufficient to justify a campaign of focused action to influence policy makers in governments, health authorities, primary and secondary care physicians, health educationalists, the media, nutritionists, caterers, schools and the public to accept the benefits of olive oil and the principles of the Mediterranean diet and make it more of a part of the national diet of all countries.
4.2 Promote health education through advertising, TV, workshops, school programmes, etc. to get the message across.
4.3 On the basis of existing guidelines (28-30), the principles of the Mediterranean diet as a recommended dietary habit should be referred to more explicitly.
4.4 Each country should develop an action plan for change that includes the promotion of the Mediterranean-style diet, and introduction of more fruit and vegetables in the preparation of its own traditional products.
4.5 Ensure the availability of the ingredients for the Mediterranean-style diet containing, in particular, olive oil, fruit, vegetables, and fish and that food preparers and manufacturers, whether professional or the general public, have access to them and know how to use them.
4.6 Involve the food industry in implementing the changes through collaboration with government, consumer groups and researchers.