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- Sprache: Englisch
Implementing the Mediterranean Diet Implementing the Mediterranean Diet: Nutrition in Practice and Public Health situates this 'gold standard' of diets within the wider food environment by bridging the gap between the evidence-based health benefits of the Mediterranean diet and its implementation. The text explores the many approaches that can be used by health professionals to help consumers adopt this healthy eating pattern, as well as the barriers encountered with implementing this diet at home and in the wider environment. It also considers sustainable food and farming practices, and national food strategies. A one-stop resource for food and health professionals, this seminal text demonstrates the full range of benefits that the Mediterranean diet can bring to society. This ground-breaking book: * Gives an in-depth review of the effectiveness of the Mediterranean diet in disease prevention and the management of chronic diseases * Contextualises the diet within the food environment, showing why the whole dietary pattern and minimizing the consumption of highly processed foods are both so important * Shows how to implement the Mediterranean diet, motivating and guiding consumers to make the transition * Addresses the practical and behavioural barriers to food choice in terms of taste, cost, variety, convenience and animal welfare concerns Implementing the Mediterranean Diet is a must-have resource for advanced undergraduate and postgraduate students in the food sciences, and for healthcare professionals such as dietitians, nutritionists, GPs, and health workers, especially those working in non-Mediterranean, high-income countries.
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Veröffentlichungsjahr: 2022
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Table of Contents
Cover
Title Page
Copyright Page
Preface
Acknowledgements
Contributors
Abbreviations
PART 1: THE EVIDENCE BASE FOR THE MEDITERRANEAN DIET
CHAPTER 1: The Med Diet in Healthcare and Disease Prevention
1.1 DISEASE PREVENTION AND HEALTHY DIETS
1.2 THE MEDITERRANEAN DIET
1.3 ACHIEVING DIETARY CHANGE
1.4 HEALTHCARE PROFESSIONALS
1.5 REASONS FOR OPTIMISM
1.6 CONCLUSION
REFERENCES
CHAPTER 2: Overview of the Med Diet
2.1 FOOD COMPOSITION
2.2 DIETARY DIVERSITY
2.3 PROCESSED FOODS
2.4 NUTRIENT COMPOSITION
2.5 MEALS
2.6 SNACKS
2.7 OTHER LIFESTYLE FACTORS
REFERENCES
CHAPTER 3: Epidemiological Evidence – Assessment
3.1 MEASURING ADHERENCE
3.2 TYPES OF STUDIES
REFERENCES
CHAPTER 4: Epidemiological Evidence – Health Outcomes
4.1 OVERVIEWS
4.2 CARDIOMETABOLIC DISORDERS
4.3 CARDIOVASCULAR DISEASE
4.4 OBESITY
4.5 TYPE 2 DIABETES
4.6 METABOLIC SYNDROME
4.7 NON‐ALCOHOLIC FATTY LIVER DISEASE
4.8 CANCER
4.9 COGNITIVE DISORDERS
4.10 STRESS
4.11 DEPRESSION
4.12 ALL‐CAUSE MORTALITY
4.13 RHEUMATOID ARTHRITIS
4.14 DIFFERENCES BETWEEN MEDITERRANEAN AND NON‐MEDITERRANEAN COUNTRIES
REFERENCES
CHAPTER 5: How the Med Diet Works
5.1 MACRONUTRIENTS
5.2 MICRONUTRIENTS AND PHYTOCHEMICALS
5.3 CORE PATHOGENIC RISK STATES
5.4 CORE RISK STATES AND IMPLICATIONS FOR CONSUMING THE MED DIET
5.5 SUMMARY – CORE RISK STATES AND IMPLICATIONS FOR IMPLEMENTING THE MED DIET
REFERENCES
CHAPTER 6: Foods of the Med Diet
6.1 IMPORTANCE OF THE WHOLE DIET
6.2 EXTRA VIRGIN OLIVE OIL
6.3 FRUIT AND VEGETABLES
6.4 PULSES
6.5 CEREALS
6.6 NUTS AND SEEDS
6.7 CULINARY HERBS AND SPICES
6.8 DAIRY PRODUCTS
6.9 EGGS
6.10 MEAT
6.11 SEAFOOD
6.12 ALCOHOL/WINE
REFERENCES
CHAPTER 7: The Med Diet Compared to Other Mainstream Diets
7.1 MED DIET VARIANTS
7.2 OTHER MAINSTREAM DIETS
REFERENCES
PART 2: IMPLEMENTING A MEDITERRANEAN DIET
CHAPTER 8: Personal Barriers and Enablers to Consuming a Med Diet
8.1 GROUPS WITH HIGHER ADHERENCE TO THE MED DIET
8.2 BARRIERS AND ENABLERS IN NON‐MEDITERRANEAN POPULATIONS
8.3 GENERAL BEHAVIOURAL APPROACHES TO DIETARY CHANGE
8.4 MED DIET INTERVENTION STUDIES
8.5 ADDITIONAL TYPES OF SUPPORT
8.6 DIGITAL TECHNOLOGIES
REFERENCES
CHAPTER 9: Enhancing Consumption of Foods in the Med Diet – General Considerations
9.1 APPETITE
9.2 FOOD CHOICE
9.3 TASTE
9.4 COST
9.5 CONVENIENCE
9.6 VARIETY
9.7 HEALTH
9.8 ENVIRONMENTAL AND ANIMAL WELFARE ISSUES
REFERENCES
CHAPTER 10: Enhancing Consumption of Foods in the Med Diet
10.1 EVOO
10.2 FRUIT AND VEGETABLES
10.3 CEREALS
10.4 PULSES
10.5 SEAFOOD
10.6 DAIRY
10.7 MEAT
10.8 ALCOHOL/RED WINE
REFERENCES
CHAPTER 11: The Med Diet in the Home
11.1 HOME COOKING
11.2 PRACTICAL ASPECTS
11.3 FOOD WASTE
REFERENCES
CHAPTER 12: The Med Diet in the Food Environment
12.1 FOOD ENVIRONMENT
12.2 THE HOME ENVIRONMENT
12.3 THE RETAIL ENVIRONMENT
12.4 OPTIONS FOR CONSUMERS
12.5 INSTITUTIONAL CATERING AND FOOD EDUCATION
12.6 MEDIA
REFERENCES
CHAPTER 13: The Med Diet in Primary Healthcare
13.1 PROVISION OF FREE MED FOODS
13.2 DELIVERING DIETARY ADVICE
13.3 PRIMARY HEALTHCARE PROFESSIONALS
13.4 RESOURCES FOR PROFESSIONALS
REFERENCES
CHAPTER 14: Case Studies
14.1 CASE STUDY 1 – THE MEDITERRANEAN DIET IN A PRIMARY CARE AND PUBLIC ENVIRONMENT
14.2 CASE STUDY 2 – ENHANCING RISK MANAGEMENT IN THE NHS HEALTH CHECKS PROGRAMME WITH WEB‐BASED ADVICE ON THE MED DIET – A FEASIBILITY STUDY
14.3 CASE STUDY 3 – POLICIES AND GOVERNANCE: LEARNING FROM FRANCE
REFERENCES
CHAPTER 15: The Med Diet as Part of a Sustainable Food and Farming System
15.1 FOOD SYSTEMS AND THE ENVIRONMENT
15.2 THE MED DIET AND THE ENVIRONMENT
15.3 THE MED DIET AS A SUSTAINABLE DIET
15.4 THE MED DIET AND SUSTAINABLE FARMING – RESILIENCE
15.5 THE MED DIET AND SUSTAINABLE FARMING – FUTURE DIRECTIONS
15.6 SUSTAINABILITY AND THE CONSUMER
REFERENCES
CHAPTER 16: Governance and the Med Diet
16.1 INTRODUCTION
16.2 GOVERNANCE IN NUTRITION
16.3 TOP‐DOWN AND BOTTOM‐UP STRATEGIES
16.4 EXAMPLES OF STRATEGIES FOR INCREASING IMPLEMENTATION OF THE MED DIET
REFERENCES
Index
End User License Agreement
List of Tables
Chapter 2
TABLE 2.1 Some dietary sources of fibre in the Med diet.
TABLE 2.2 Glycaemic index of some high‐carbohydrate foods.
TABLE 2.3 Protein content of foods.
TABLE 2.4 Typical foods in a traditional Cretan Mediterranean diet consumed...
Chapter 3
TABLE 3.1 Mediterranean diet scores.
Chapter 4
TABLE 4.1 Summary of the evidence for health outcomes with adherence to a M...
TABLE 4.2 Cardiodiabesity health outcomes from adherence to Med diet [3].
Chapter 5
TABLE 5.1 Associations between oxidative stress, chronic low‐grade inflamma...
TABLE 5.2 Proinflammatory and anti‐inflammatory foods and nutrients.
Chapter 6
TABLE 6.1 Major phenolic compounds in olive oils.
TABLE 6.2 Fruit and veg and the risk of various cancers as assessed by WCRF...
TABLE 6.3 Fruits and vegetables and their composition.
TABLE 6.4 Wholegrain and refined grain foods.
TABLE 6.5 Medium‐chain fatty acid (MCFA) content of cow, sheep and goat mil...
TABLE 6.6 Omega‐3 fat content of fish commonly consumed in the UK.
Chapter 7
TABLE 7.1 Comparison between a Med diet pyramid and the UK Eatwell Guide.
TABLE 7.2 Nutrient composition of the Med diet compared with the Western di...
TABLE 7.3 The NOVA food classification system.
Chapter 8
TABLE 8.1 Perceived barriers and enablers to adopting a Med diet in non‐Med...
TABLE 8.2 MINDSPACE framework for behaviour change.
TABLE 8.3 Selected Med diet intervention studies in non‐Mediterranean count...
TABLE 8.4 Key aspects contributing to high compliance with a Med diet patte...
Chapter 9
TABLE 9.1 A suggested healthy meal sequence for a Med diet based on satiati...
TABLE 9.2 Examples of bitter compounds found in Med diet foods.
TABLE 9.3 Costs of home‐made versus ready‐made Mediterranean meals.
TABLE 9.4 Reasons parents reported buying prepackaged processed meals.
Chapter 10
TABLE 10.1 The beneficial Mediterranean meat eating pattern.
Chapter 11
TABLE 11.1 Variables influencing outcomes of cookery classes.
TABLE 11.2 General meal plan for med diet.
TABLE 11.3 Sample weekly meal plan.
TABLE 11.4 Examples of foods in the Western diet to replace with Med diet f...
Chapter 15
TABLE 15.1 Environmental impacts of contemporary Western agriculture.
TABLE 15.2 Ten priorities for an EU Farm to Fork strategy [37].
Chapter 16
TABLE 16.1 Policy areas in population‐wide adoption of a Med diet.
List of Illustrations
Chapter 1
FIGURE 1.1 Risk factors for disability in England for men and women combined...
FIGURE 1.2 Variation of the Mediterranean Adequacy Index (MAI) in various co...
Chapter 2
FIGURE 2.1 Mediterranean diet pyramid.
Chapter 3
FIGURE 3.1 Hierarchy of study designs in nutritional epidemiology. RCT, rand...
Chapter 4
FIGURE 4.1 The interconnectedness of obesity, cardiovascular disease (CVD), ...
FIGURE 4.2 Combined incident cardiovascular disease (myocardial infarction, ...
FIGURE 4.3 Summary of meta‐analysis of observational studies on Mediterranea...
Chapter 5
FIGURE 5.1 Inter‐relationship between core pathogenic risk states that predi...
FIGURE 5.2 Proposed mechanisms for how the Western diet alters susceptibilit...
Chapter 6
FIGURE 6.1 Constituents of whole wheat grains. ALA, alpha‐linolenic acid....
FIGURE 6.2 Association between baseline alcohol consumption with all cardiov...
FIGURE 6.3 Dose–response relationship between alcohol consumption and total ...
FIGURE 6.4 Multicountry analysis of the associations of baseline alcohol con...
FIGURE 6.5 Hazard ratios per 100 g/week higher than baseline alcohol consump...
Chapter 7
FIGURE 7.1 The Eatwell Guide [8] / © Crown copyright 2016, Open Government L...
FIGURE 7.2 Relationship between the Mediterranean diet and Western diet.
Chapter 9
FIGURE 9.1 Trends in consumption of ready meals and meat cuts in the UK [59]...
Chapter 11
FIGURE 11.1 Potential pathways to behaviour change from a cooking skills pro...
FIGURE 11.2 Conceptual model of the determinants and outcomes of home cookin...
Chapter 12
FIGURE 12.1 Biggest barriers to eating more healthily.
FIGURE 12.2 Google trends data for the UK for the popularity of the search t...
Chapter 13
FIGURE 13.1 Mediterranean diet Eatwell Guide.
Chapter 14
FIGURE 14.1 ‘Eat, Move’ (
Manger, Bouger
).
FIGURE 14.2 Nutri‐Score label.
Chapter 15
FIGURE 15.1 The four sustainable dimensions of the Mediterranean diet.
FIGURE 15.2 Basic cycle between farm animals and crops.
Chapter 16
FIGURE 16.1 Nuffield Ladder of Intervention.
Part 2
FIGURE P2.1 The main determinants of health [2].
Guide
Cover Page
Title Page
Copyright Page
Preface
Acknowledgements
Contributors
Abbreviations
Table of Contents
Begin Reading
Index
WILEY END USER LICENSE AGREEMENT
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Implementing the Mediterranean Diet
Nutrition in Practice and Public Health
Richard Hoffman PhD RNutr FRSA
Associate Lecturer
University of Hertfordshire
UK
This first edition first published 2023© 2023 by John Wiley & Sons Ltd
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The right of Richard Hoffman to be identified as the author of this work has been asserted in accordance with law.
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Library of Congress Cataloging‐in‐Publication Data
Names: Hoffman, Richard, 1957– author.Title: Implementing the Mediterranean diet : nutrition in practice and public health / Richard Hoffman.Description: First edition. | Hoboken, NJ : Wiley‐Blackwell, 2023. | Includes bibliographical references and index.Identifiers: LCCN 2022029659 (print) | LCCN 2022029660 (ebook) | ISBN 9781119826712 (paperback) | ISBN 9781119826729 (adobe pdf) | ISBN 9781119826736 (epub)Subjects: MESH: Diet, Mediterranean | Diet, HealthyClassification: LCC RM222.2 (print) | LCC RM222.2 (ebook) | NLM WB 423 | DDC 613.2/5–dc23/eng/20220829LC record available at https://lccn.loc.gov/2022029659LC ebook record available at https://lccn.loc.gov/2022029660
Cover Design: WileyCover Images: © Ian Laker Photography/Getty Images; Solskin/Getty Images; Stevica Mrdja/Getty Images
Preface
There is now good evidence that the Mediterranean diet (Med diet) reduces the risk of a wide range of chronic diseases and can also help manage their symptoms. But progress in implementing this diet in the community lags far behind. This book attempts to bridge the gap between the evidence for the health benefits of the Med diet and its implementation. It is intended for advanced undergraduate and postgraduate students in the food sciences, and for healthcare professionals who give dietary advice on the Med diet, such as dietitians, nutritionists, GPs and health workers, especially those working in non‐Mediterranean high‐income countries. It summarises the many approaches that can be used by health professionals to help consumers surmount the obesogenic environment and to adopt this healthiest of eating patterns.
Part 1 discusses why the Med diet should be implemented, by:
summarising the evidence base for the effectiveness of the Med diet in disease prevention and in the management of chronic diseases, and the most likely mechanisms for this diet's benefits
explaining the importance of the whole dietary pattern and why minimising the consumption of highly processed foods is important.
Part 2 then goes on to discuss how to implement the Med diet and how to help motivate and guide consumers to make the transition from a Western dietary pattern to a Mediterranean dietary pattern. It:
addresses practical and behavioural barriers to food choice in the context of taste, cost, variety, convenience, health and environmental and animal welfare concerns
discusses how consumers can eat the correct balance of the main foods and food groups in the Med diet – extra virgin olive oil, vegetables, fruits, legumes, cereals, nuts, fish, dairy, meat and wine
situates the Med diet in the foodscape by discussing barriers to adopting this diet encountered in the home and the high street, such as negative influences from the media and fast food shops
provides lifestyle advice on shopping, the kitchen environment and eating together, and shows how the Mediterranean dietary pattern can be incorporated into daily life
considers the evidence base for the provision of the Med diet in primary care, dietetic practice and various community settings such as work canteens and care homes
concludes with a discussion of the wider benefits that a Med diet can bring to society, by considering this diet's place in a sustainable food and farming environment and in national food strategies.
Acknowledgements
I am extremely grateful to the University of Hertfordshire, UK, for all its support and resources.
I would also like to thank my wife, Marella, for all her help and encouragement.
Contributors
Chapter 14 Case Studies:
Dr Simon Poole, MB BS DRCOG, Cambridge, UKDr Mariette Gerber, MD, PhD, DSc Chercheur Honoraire INSERM, Expert ANSES
Abbreviations
AGE
Advanced glycation end‐product
AICR
American Institute for Cancer Research
ALA
Alpha‐linolenic acid
BAC
Blood alcohol concentration
BCAA
Branched chain amino acid
BMI
Body mass index
CHD
Coronary heart disease
CI
Confidence interval
COPD
Chronic obstructive pulmonary disease
CPG
Clinical practice guideline
CVD
Cardiovascular disease
DASH
Dietary Approaches to Stop Hypertension
DHA
Docosahexaenoic acid
EFSA
European Food Safety Authority
EPA
Eicosapentaenoic acid
EPIC
European Prospective Investigation Into Cancer
EVOO
Extra virgin olive oil
FA
Fatty acid
FFA
Free fatty acid
FFQ
Food frequency questionnaire
GHG
Greenhouse gases
GI
Glycaemic index
GL
Glycaemic load
HCA
Heterocyclic amine
HDL
High‐density lipoprotein
HFSS
High fat, sugar and salt
HIC
High‐income country
HPFS
Health Professionals Follow‐Up Study
HR
Hazard ratio
IGF1
Insulin‐like growth factor 1
LDL
Low‐density lipoprotein
LPS
Lipopolysaccharide
MCFA
Medium‐chain fatty acid
MCI
Mild cognitive impairment
MDS
Mediterranean diet score
Med diet
Mediterranean diet
MetS
Metabolic syndrome
MI
Myocardial infarction
MRP
Maillard reaction product
MUFA
Monounsaturated fatty acid
NAFLD
Non‐alcoholic fatty liver disease
NHS
National Health Service (UK)
NICE
National Institute for Health and Care Excellence
NuHS
Nurses' Health Study
PA
Physical activity
PAH
Polycyclic aromatic hydrocarbon
PUFA
Polyunsaturated fatty acid
RCT
Randomised control trial
RDA
Recommended daily allowance
RR
Relative risk
SACN
Scientific Advisory Committee on Nutrition
SCFA
Short‐chain fatty acid
SFA
Saturated fatty acid
SSB
Sugar‐sweetened beverage
TFA
Trans fatty acid
TMAO
Trimethylamine N‐oxide
UPF
Ultra‐processed food
WCRF
World Cancer Research Fund
PART 1THE EVIDENCE BASE FOR THE MEDITERRANEAN DIET
Part 1 summarises the epidemiological evidence for the Med diet. It then goes on to discuss possible mechanisms of action for the Med diet and how an understanding of these mechanisms can help guide optimal implementation of the Med diet. Part 1 concludes by looking at differences between the Med diet and other dietary patterns common in Western countries, especially the Western diet.
CHAPTER 1The Med Diet in Healthcare and Disease Prevention
1.1 Disease Prevention and Healthy Diets
1.1.1 Plant‐based Diets
1.2 The Mediterranean Diet
1.2.1 The Importance of Understanding How the Med Diet Works
1.3 Achieving Dietary Change
1.4 Healthcare Professionals
1.5 Reasons for Optimism
1.6 Conclusion
References
This chapter discusses the importance of placing greater emphasis on disease prevention, with particular reference to dietary advice around the Med diet. It also discusses how an understanding of how the Med diet works can shed light on how best to implement this diet.
1.1 DISEASE PREVENTION AND HEALTHY DIETS
The strain on health services from diseases that should be being prevented is now reaching crisis point. There is increasing support for the view that prevention is key to tackling the huge worldwide surge in chronic diseases. Prevention campaigns give people the knowledge, tools and support they need to better manage their health and are essential if we are to manage the epidemic of chronic diseases [1]. And yet of the £130 billion spent on the NHS every year (excluding COVID spending), 95% is still spent on treating illness, with just 5% going towards prevention [2]. A good example of the need for prevention is the great difficulty most people find in permanently losing weight once acquired, and hence the massive burden from obesity‐related diseases [3].
FIGURE 1.1 Risk factors for disability in England for men and women combined. Risk is expressed as the proportion of all years lost to disability – disability‐adjusted life‐years (DALYs). Risk factors are calculated independently of each other and so cannot be summed together.
Source:[5] / with permission of Elsevier.
Poor diet has now overtaken smoking to become the top global contributor to morbidity and mortality from chronic diseases [4], including in many high‐income countries (HICs) such as England [5] (Figure 1.1). The typical diet in HICs is the Western diet, characterised by excessive quantities of meat and other animal products, refined grains and highly processed foods (junk foods) – many of which fall within the recently described category of ultra‐processed foods (UPFs). UPFs are made from highly refined ingredients and are designed to be hyperpalatable. This can make it difficult to restrict intake to acceptable levels, and so these products can incite binge eating [6]. Not surprisingly, there is now good evidence that consuming high levels of UPFs is strongly associated with an increased risk of obesity [7]. Consuming a Western diet frequently leads not only to overconsumption of calorie‐rich macronutrients (carbohydrates and fat), but also to underconsumption of micronutrients (vitamins and minerals), phytochemicals and fibre. The result is consumers who are ‘overfed and undernourished’.
1.1.1 Plant‐Based Diets
To transition away from a Western diet, there is widespread consensus from the mainstream scientific community that a healthier diet is one based on ‘minimally processed foods close to nature’ [8]. In Michael Pollan's famous aphorism: ‘Eat food. Not too much. Mostly plants’.1 Advice to eat mostly plant foods and to keep it natural has been a consistent message from nutrition scientists for many years.
Evidence suggests that plant‐based dietary patterns, with their higher consumption of vegetables, fruits, legumes, nuts, whole grains, unsaturated oils, fish and lean meat or poultry (when meat is included), are associated with a decreased risk of all‐cause mortality. These healthy patterns are low in red and processed meat, high‐fat dairy and refined carbohydrates or sweets. Some of these dietary patterns also include alcoholic beverages in moderation [9].
1.2 THE MEDITERRANEAN DIET
The Mediterranean diet (Med diet) is one of several healthy, plant‐based, semi‐vegetarian dietary patterns that incorporate most of these recommendations. Others include the ‘prudent’ diet and the ‘flexitarian’ diet. The Med diet differs from these two patterns by explicitly recommending extra virgin olive oil (EVOO) as the main source of added fat and by recognising moderate amounts of alcohol consumption (mainly red wine) as being an acceptable accompaniment to the main meal of the day. Both of these foods are considered as healthful components of a Med diet.
The Med diet – also sometimes called the Mediterranean dietary pattern – often implies not just its food composition, but also how those foods are prepared and the social setting in which they are eaten. This is an important distinction between the Med diet and other healthy plant‐based diets. As noted by Dr Antonio Trichopoulou, a leading authority on the Med diet, ‘It would have been impossible to consume the high quantities of vegetables and legumes, which characterize the Mediterranean diet, were it not for olive oil that is traditionally used in the preparation of these dishes’. So although much of the guidance about implementing a Med diet relates to increasing various plant foods and restricting animal foods, there is evidence that a far greater emphasis should be given to food preparation and consumption [10]. Recommended consumption of fruit and vegetables in the Med diet is not just ‘five a day’, it is five a day the Med diet way.
1.2.1 The Importance of Understanding How the Med Diet Works
The increasing understanding of how the Med diet works is shedding light on why it is important to consider not only the foods themselves but also the way they are consumed. For example, consuming a Med diet is now known to suppress key early pathogenic stages associated with chronic diseases, such as oxidative stress, chronic low‐grade inflammation and insulin resistance. Since oxidative stress and inflammation rise during the postprandial period, it is important to ensure that foods high in antioxidants are present during this postprandial period. A second example relates to the way a Western diet ‘opposes’ a Med diet. In contrast to the Med diet, the Western diet increases oxidative stress and inflammatory response. So this highlights the importance not only of enhancing adherence to a Med diet but also, at the same time, of reducing consumption of the proinflammatory foods associated with a Western diet. These examples show how a mechanistic understanding has important practical implications for the implementation of the Med diet.
1.3 ACHIEVING DIETARY CHANGE
A healthy diet is nutritious and sustaining. So it is unfortunate that so many people instead are choosing to eat a diet that is likely to substantially increase their personal risk of morbidity and mortality due to chronic disease. One explanation for this is that the general public still considerably underestimates the risks of developing a chronic disease that comes from eating a poor diet [11]. There are many reasons for this, such as the difficulty in public health campaigns of expressing health risk to the public in a meaningful way. Also, there is often scepticism about dietary advice. Although eating a healthy diet should be a simple message, disentangling the unhealthy aspects of eating from the overall diet has proven to be more complicated. Consumers are confused by the broad spectrum of views on which foods are permissible as part of a healthy diet. Also concerning are the perceived or actual contradictions in dietary information provided by the media. Much of the confusion is generated by the many vested interests competing to influence what we eat. Against this backdrop of confusion and lack of knowledge, the junk food industry is still able to play its hand with relative impunity.
Although the Med diet is widely perceived as tasty and healthy, there are many diverse reasons why people still shun it. There can be practical barriers, such as perceived cost and the perceived time and expertise needed for food preparation. Some of the practical barriers to understanding the benefits and ways of cooking are addressed in the many cookery books, websites and other resources on the Med diet. But providing accurate practical information may at best be only a small part of the optimal way of engaging people. Even when the risks from eating a poor diet are understood, there is still frequently a gap between what is known and what is done. Crucially, lack of implementation often arises because of deep‐seated habits that make behaviour change difficult. Hence, it is often more important to support behaviour changes than it is to discuss specific facts about nutrition or food preparation.
1.4 HEALTHCARE PROFESSIONALS
Healthcare professionals are key players for widening implementation of the Med diet. However, some primary healthcare professionals are hesitant about offering dietary advice [12]. Some GPs, for example, may be unwilling to offer nutrition advice because they feel they lack the necessary knowledge to confidently discuss these issues with their patients [13]. Or they may feel that there are contradictions in existing recommendations [14]. This can relate to scepticism about dietary advice or because the data is seen as being insufficiently rigorous or as being contradictory [15]. Also, healthcare professionals may feel they have received insufficient training and expertise on the Med diet. Even some dietitians believe they do not have enough resources to support their clients in implementing the Med diet [16, 17].
Professional health bodies can help in building up resources to facilitate greater implementation of the Med diet. And now, based on a judgement of the extensive evidence base, many health bodies – such as those representing cardiovascular disease (CVD), type 2 diabetes and dementia – have endorsed the Med diet, including the American Heart Association [18] and European Society of Cardiology [19]. Also helping to bridge the gap between the evidence base and professional practice are various clinical practice guidelines that recommend the Med diet for prevention and/or disease management.
1.5 REASONS FOR OPTIMISM
In most Mediterranean countries, the traditional diet is being replaced at an alarming rate by the Western diet. On the other hand, there is increasing interest in the Med diet in some non‐Mediterranean countries. This has been demonstrated by comparing changes between the periods 1961–1965 and 2004–2011 in adherence to the Med diet (using a metric called the Mediterranean Adequacy Index) (Figure 1.2). In contrast to the large decrease in adherence in Greece and some other Mediterranean countries, a few North European countries, including the UK, have seen a small increase in adherence. This can probably partly be attributed not only to its exceptional health benefits but also to its wide range of easy‐to‐prepare and tasty dishes.
Interest in the Med diet is often more prevalent in more advantaged socioeconomic groups and there is a particularly urgent need to persuade the less advantaged to eat more plant‐based diets based on natural foods. There are some signs that this may be possible. In the UK, the traditional British meal is losing its appeal, and many are now more open to new cuisines [21]. This interest in healthy diets provides a ‘window of opportunity’ for fundamental dietary change in countries such as the UK. Several preconditions for dietary change have been met [22]. These are defined as: (i) a clearly defined problem – namely how best to provide healthy and sustainably produced food, (ii) a range of policy solutions being offered, and (iii) an array of stakeholders and the national mood influencing the political climate. Hence, there is a real opportunity for dietary change.
But tempering this optimism is the current trend towards a new generation of junk foods, epitomised by UPFs. Perhaps the healthy eating lobby needs to take a leaf out of the junk food industry's book. This industry has clearly demonstrated that emphasising pleasure is the best way to sell its products, and so, it has been argued, the health sector should also embrace this approach [23]. The tasty Med diet can justifiably be presented as moving towards a new pleasurable way of eating and not as moving away from a previously more pleasurable activity. The inclusion of animal products in the Med diet, including some meat, also makes it a more acceptable and realistic option for many people than meat‐free vegetarian or vegan diets. Moderation, maintaining variety and gradual changes are key to facilitating a transition from a Western diet to a Med diet.
FIGURE 1.2 Variation of the Mediterranean Adequacy Index (MAI) in various countries between the periods of 1961–1965 and 2004–2011.
Source: [20] / with permission of Springer Nature.
1.6 CONCLUSION
Dietary change is a transition, and so to be successful it will require both weaning consumers off excessive consumption of unhealthy foods and creating a taste for healthier alternatives. This means addressing the barriers – personal, social and cultural – that hinder consumers from switching to a healthier diet.
Not only does choosing a Western diet rather than a Med diet greatly increase personal risk of morbidity and mortality, it also comes with substantial avoidable medical costs to society [24, 25]. There is now ample evidence to suggest that the Med diet is probably one of the closest things we have to a panacea for preventing the epidemic in chronic diseases. So a strong argument can be made that the priorities, and indeed obligations, in public health nutrition should be shifting away from evidence gathering. They should instead be moving more towards developing and implementing policies that help and encourage those who wish to adopt the Med diet [26]. Dietitians, nutritionists, GPs and other healthcare professionals are well placed to play a key role and this book provides tools to help achieve this.
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Note
1
From his seminal book
In Defence of Food
.
