The Mediterranean diet and cardiovascular disease

Since the 1950s, when Ancel Keys popularized the traditional Mediterranean diet, an immense accrual of large and valid studies, including prospective cohort studies, randomized controlled trials (RCT), and systematic reviews, have been conducted to investigate the potential health benefits related to this dietary pattern. The available evidence shows that the traditional Mediterranean diet represents a sustainable, healthy, and highly palatable pattern with a wide array of associated health benefits. In particular, its protective effects on cardiovascular disease have been supported by several consistent large RCTs, namely, the Lyon Diet-Heart Study, PREDIMED, PREDIMED-Plus and CORDIOPREV. The traditional Mediterranean diet is not a vegetarian diet, but it emphasizes the preferential consumption of minimally processed plant-based foods: fruits, vegetables, whole-grain cereals, legumes, and tree nuts. Its unique components-different from other healthy, plant-based, food patterns-are extra-virgin olive oil as the main source of fat (keeping a high monounsaturated-to-saturated fat ratio), a high consumption of tree nuts, and low-to-moderate consumption of red wine with meals. However, the inclusion of an alcoholic beverage in a healthy diet is becoming increasingly controversial. An ongoing RCT, the University of Navarra Alumni Trialist Initiative (UNATI), aims to answer this question in 10 000 drinkers. In addition to conventional epidemiologic studies, metabolomics techniques have been applied to assess the role of adherence to the Mediterranean diet and to better understand the mechanisms involved in the protection afforded by this interesting dietary pattern. In this review, we update the available scientific evidence.