May 2012 Issue

The Mediterranean Diet — A Practical Guide to Shopping, Menu Ideas, and Recipes
By Sharon Palmer, RD
Today’s Dietitian
Vol. 14 No. 5 P. 30

The evidence on the Mediterranean diet’s health benefits is compelling, but it doesn’t do much good if clients don’t understand how to apply this eating style to their own dinner plates. Today’s Dietitian provides all the resources you need to help clients translate this dietary pattern into a practical method of eating for life.

There’s something special about the diets of people who live in the countries along the Mediterranean Sea. In fact, they’ve been the subject of intensive research for more than 50 years, ever since Ancel Keys first organized his legendary, post-World War II Seven Countries Study, a state-of-the-art research project for its time.

The first study to explore associations among diet, risk, and disease across contrasting populations, Keys and his colleagues looked at the health outcomes of nearly 13,000 middle-aged men in the United States, Japan, Italy, Greece, the Netherlands, Finland, and then-Yugoslavia. They discovered that men from Crete experienced lower cardiovascular disease rates than their counterparts in other countries—a link researchers attributed to these men’s postwar “poor” diet, which emphasized fruits, vegetables, grains, beans, and fish.

In an addendum to the Seven Countries Study, Keys’ research team gave the “low-coronary-risk male” living on the Isle of Crete the following description:

He is a shepherd or small farmer, a beekeeper or fisherman, or a tender of olives or vines. He walks to work daily and labors in the soft light of his Greek isle, midst the droning of crickets and the bray of distant donkeys, in the peace of his land. … His midday, main meal is of eggplant, with large livery mushrooms, crisp vegetables, and country bread dipped in the nectar that is golden Cretan olive oil. Once a week there is a bit of lamb, naturally spiced from grazing in thyme-filled pastures. Once a week there is chicken. Twice a week there is fish fresh from the sea. Other meals are hot dishes of legumes seasoned with meats and condiments. The main dish is followed by a tangy salad, then by dates, Turkish sweets, nuts, or succulent fresh fruits. A sharp local wine completes this varied and savory cuisine. This living pattern, repeated six days a week, is climaxed by a happy Saturday evening. The ritual family dinner is followed by relaxing fellowship with peers. Festivity builds to a passionate midnight dance under the brilliant moon in the field circle where the grain of the region is winnowed. … He is handsome, rugged, kindly—and virile. His is the lowest heart-attack risk, the lowest death rate, and the greatest life expectancy in the Western world.

Land of Health Benefits
The nutrition research world spent the next 50 years accumulating evidence on the remarkable health outcomes associated with the Mediterranean style of eating, which includes increased life span, improved brain function, better eye health, lower risk of certain cancers, decreased risk of heart disease and diabetes, lower levels of blood pressure and LDL cholesterol, protection against Alzheimer’s and Parkinson’s diseases, improved rheumatoid arthritis, better fertility, and a greater chance of delivering a healthier baby.

“There’s overwhelming evidence confirming that the Mediterranean diet lowers the risk of heart disease and diabetes; the evidence is very clear and compelling,” says Dariush Mozaffarian, MD, DrPH, an associate professor at the Harvard School of Public Health who conducts research in the field of diet and cardiovascular health. Indeed, cardiovascular disease reduction has been one of the most consistent findings related to the Mediterranean diet. In the European Prospective Investigation Into Cancer and Nutrition cohort study, published April 2005 in the Archives of Internal Medicine, higher adherence to the Mediterranean diet was linked with a 27% lower mortality rate among people with prevalent coronary heart disease.

Research on other health benefits is mounting. “There’s pretty good evidence that the Mediterranean diet lowers stroke risk and perhaps cognitive decline, and other vascular conditions. There’s growing evidence linking the Mediterranean diet to weight control,” Mozaffarian adds.

A major factor behind the benefits of this diet may be its influence on inflammation and oxidative stress, which is at the root of chronic disease. The diet also is relatively high in total fat, but more than one-half of the fat comes from monounsaturated fats; the saturated fat levels are low. In addition, the dietary pattern’s high intake of whole plant foods boosts fiber, mineral, vitamin, and phytochemical levels.

Researchers from Italy’s National Institute for Food and Nutrition Research studied the diets of 131 healthy adults, rating them for overall adherence to a traditional Mediterranean diet. They found that those with greater adherence had higher levels of circulating carotenoids, as well as vitamin A and vitamin E; improved levels of endogenous antioxidants, and higher levels of anti-inflammatory biomarkers. The researchers concluded in a November 2011 issue of Nutrition Journal that the Mediterranean dietary pattern is associated with significant amelioration of multiple risk factors, including a better cardiovascular risk profile, reduced oxidative stress, and inflammation modulation.

Portrait of a Healthful Diet
The beauty of the Mediterranean diet is that it’s based on an entire dietary pattern, not particular foods and nutrients. “We have more information on the diet pattern rather than individual components of the diet,” Mozaffarian says. “The most important things in the diet seem to be the relatively high amount of minimally processed foods, such as fruits, vegetables, nuts, and whole grains; the use of dairy and fish; and the high amount of healthful fats from vegetable oils. And there are benefits from what they’re not eating, such as highly processed and refined carbohydrates, processed meats, trans fats in processed foods, and sugar-sweetened beverages.”

Here are several features of the Mediterranean diet that have been identified:

Grains, vegetables, and fruits are eaten at most meals. Including these plant foods that are high in vitamins, minerals, energy, antioxidants, and fiber promotes optimal health and weight control. The majority of grains are consumed in their whole, minimally processed form and include wheat, oats, rice, rye, barley, and corn. Vegetables provide satiety and key nutrients, which are amplified with the addition of olive oil. Whole, unsweetened fresh fruits are included regularly.

Olives/olive oil is the principal fat. Olives are eaten whole, used in cooking, and used for flavoring dishes. Olive oil is the main source of dietary fat used in cooking, baking, and preparing salads and vegetables.

Nuts, beans, legumes, and seeds are essential foods. These whole foods not only provide healthful fats, protein, and fiber to the diet, they infuse flavor and texture into dishes.

Herbs and spices are used liberally. Adding flavors and aroma to foods, these plant seasonings reduce the need for added salt as well as boost health-promoting antioxidants in the diet.

Cheese and yogurt are eaten often. In low to moderate amounts, cheese and yogurt may be important for bone and heart health.

Fish and shellfish are important protein sources. Omega-3–rich fish such as tuna, herring, sardines, salmon, and bream, and mussels, clams, and shrimp are consumed frequently.

Eggs are included regularly. Good sources of high-quality protein, eggs are used in place of meat in traditional dishes.

Meats are eaten in small portions. Small amounts of lean meats are consumed, along with moderate portions of poultry, which is lower in saturated fats.

Sweets are consumed in small amounts. Fruits are a regular treat, while small servings of sweetened desserts are consumed less frequently.

Wine is consumed often but in moderation. Up to one 5-oz glass of wine per day for women and up to two 5-oz glasses for men is considered moderate.

Water is the primary beverage. Essential for life and proper hydration, adequate water intake makes a positive contribution to health, well-being, and energy levels.

Portion size is under control. Meats, sweets, wine, poultry, and eggs are consumed in small to moderate portions.

Moderation is key. The dietary pattern includes a balanced approach to enjoying foods, such as wine, treats, and meats in moderation.

Daily physical activity is important. From strenuous exercise such as running to leisurely activities such as walking and housework, activity is included daily.

Meals are enjoyed in the company of others. Food, drinks, and meals are enjoyed and savored among family and friends.

Transporting This Diet Around the World
It’s clear that people around the world can benefit from adopting the principles of the Mediterranean diet. They may follow a traditional diet from a specific region, but the overall dietary pattern can be assimilated elsewhere. Mozaffarian reports that benefits have been found when other populations follow the diet. “Compared to other dietary patterns, the Mediterranean diet has been tested in numerous prospective cohort studies and in trials of risk markers, in which consumption of these diet patterns is consistently linked to lower cardiovascular disease risk,” he says.

To bring the Mediterranean diet home to your clients and patients, “RDs need to first understand the entirety of the Mediterranean lifestyle so they can put eating, activity, and family in the right balance,” says Connie Diekman, MEd, RD, LD, FADA, director of university nutrition at Washington University in St Louis, past president of the Academy of Nutrition and Dietetics, and author of The Everything Mediterranean Diet Book. “Second, they need to have useful tips for their clients to help them implement recipe changes. And finally, they need to help clients [allot] more time to eat, think about what they’re eating, and view food as a part of their life, not a quick grab.”

Bringing This Diet Into Your Kitchen
Of course, a major part of the Mediterranean diet is introducing this delicious, minimally processed way of eating into the kitchen, which can be a barrier for today’s cooking-challenged consumers. Chef David Shalleck, founder of VOLOCHEF Culinary Solutions, a culinary production company, and author of the culinary travel memoir Mediterranean Summer, wants to believe that Mediterranean cooking is within everyone’s reach “because it’s so simple. Perhaps barriers to technique are merely ambivalence for success in the kitchen or that the concept of cooking is daunting. Under a halo of goodness, incorporating the idea of Mediterranean cooking is easy. As this pertains to technique, it’s only a matter of great ‘how-to’ showing and then practice on the user side to build comfort and confidence in the kitchen.”

Indeed, the Mediterranean culinary style is anything but complex—it’s based on preparing fresh, seasonal foods such as grains, vegetables, legumes, and seafood with a simple touch of olive oil, citrus, herbs, and spices. Often, vegetables are sautéed with a drizzle of olive oil and garlic, fresh vegetables are tossed into simple salads, and legumes and grains are steamed with herbs and spices. Shalleck says fish frequently is cooked using a “slow and moist heat method, like simmering in some sort of flavored liquid or sauce; baking with aromatics, extra-virgin olive oil, a splash of dry white wine, or fresh lemon juice; and of course, there’s grilling and griddling too.”

Thankfully, more and more culinary resources are available for people who want to learn how to incorporate a Mediterranean cooking style into their kitchens. Oldways, a nonprofit organization dedicated to educating people about healthful, traditional diets such as the Mediterranean diet, has developed many resources to help teach people about a Mediterranean culinary style. Shalleck suggests people “sign up to receive the Oldways Mediterranean Foods Alliance newsletter [] and check out the wealth of information on the Oldways site.

“There also are numerous authors as well [who have written about the Mediterranean diet],” Shalleck continues. “Out of the gate, I’d read The New Mediterranean Diet Cookbook by Nancy Harmon Jenkins.” And there are scores of Mediterranean culinary classes—in the states and abroad—as well as blogs, books, and websites focused on promoting these cooking skills.

Strategies for Success
Wondering how you can best promote the Mediterranean diet? Our experts contributed their top 11 tips for helping people transform their meals.

1. Boost fruits and veggies. Diekman suggests that the first place people can start is by adding more fruits and veggies to their current recipes. “Boost veggies in chili, soups, and casseroles. Add fruits to cereal, snack on dried fruit and nuts, top fish with fruit chutneys, or add it to salads.”

2. Switch to olive oil. Of course, making the switch to olive oil as your primary cooking oil is an easy fix, but Diekman suggests clients reserve extra-virgin olive oil for salad dressings, due to its strong flavor and volatile nature, and use a more stable oil, such as canola oil, for baking. And remember to go easy on the olive oil; each tablespoonful contains 124 calories, which can add up quickly. “Dress, don’t drown, your salad,” Shalleck says.

3. Choose seafood more often. The Mediterranean countries, perched on the sea, enjoy a bounty of local fish, which is why it’s a significant part of their traditional diet. You can do the same thing at home by choosing fish and seafood available in your own region. Cynthia Harriman, director of food and nutrition strategies at Oldways, suggests clients put it on their menu at least twice each week.

4. Serve petite portions of meats. Don’t feature a big hunk of meat as the center of the plate. “[Make] meat portion sizes more as a player and less as a hero,” Shalleck says.

5. Turn to whole grains. Feature healthful, whole grains in your meals every day. “Make up a batch of whole grains—brown rice, wheat berries, farro, quinoa, or whatever you enjoy—and use a little every day as a side dish at dinner or in a salad or with chopped vegetables and dressing for lunch,” Harriman says.

“Discover flavorful whole wheat breads,” Shalleck adds.

6. Munch on nuts and seeds every day. Just a handful of nuts and seeds, such as almonds, walnuts, pistachios, pumpkin seeds, and sesame seeds, can add flavor, satiety, and healthful fats to your diet.

7. Leave room for legumes. Encourage clients to include them several times per week. Mediterranean favorites include chickpeas, cannelloni beans, borlotti beans, lentils, and fava beans, Shalleck says.

8. Spice it up! “Use fresh or dried spices and herbs instead of salt to add pizzazz to your food,” Harriman suggests. Shalleck also recommends seasoning food with citrus and dried chilis. Other Mediterranean spices he suggests include fennel seeds; herbes de Provence (a French seasoning blend that includes marjoram, thyme, rosemary, and fennel); oregano; and whole, grated nutmeg.

9. Savor your food. A large part of the Mediterranean lifestyle is simply enjoying your meals—it’s a mindful eating approach at its best. “Turn off the TV and taste each bite. Relax and savor your meals in the company of others,” Harriman recommends telling clients.

10. Eat desserts without guilt. Who needs decadent treats when clients can enjoy Mediterranean-style desserts? Here are a few of Shalleck’s suggestions: cheese with fruit; fresh fruit with a couple biscotti; sorbet and gelato with minimal adornments; and dark chocolate with low- or no-fat dairy.

11. Enjoy wine in moderation (if you drink). “Spanish Tempranillo grape-based wines, French Rhône and Provence wines, the wonderful reds from Piedmont and Tuscany, and the food-friendly reds from the Campania region in southern Italy will cover just about the entire repertoire of hearty Mediterranean Rim cooking,” Shalleck says.

— Sharon Palmer, RD, is a contributing editor at Today’s Dietitian, a freelance food and nutrition writer in southern California, and author of the forthcoming book The Plant-Powered Diet.


Look for the Med Mark
Developed by Oldways as an easily identifiable symbol on food packages, clients can find the Med Mark symbol on more than 150 healthful, Mediterranean food products (


A Mediterranean Shopping List
Suggest clients take this shopping list with them the next time they go to the supermarket. The list includes minimally processed foods that can easily promote a Mediterranean diet pattern.

Fish and shellfish: Clams, crab, halibut, lobster, mussels, salmon, scallops, shrimp, sole, tilapia, trout, tuna

Fruits (fresh, dried, frozen, or canned without sugar): apples, bananas, berries, cherries, citrus, dates, figs, grapes, melons, nectarines, peaches, pears, pomegranates

Vegetables (fresh, frozen, or canned without salt): artichokes, asparagus, avocados, beets, bell peppers, broccoli, Brussels sprouts, cabbage, carrots, celery, corn (sweet yellow), cucumbers, eggplant, fennel, green beans, green leafy vegetables, lettuce, mushrooms, olives, onions, peas, potatoes, radishes, squash, tomatoes, turnips

Grains: barley, brown rice, buckwheat, bulgur, couscous, faro, kamut, oatmeal, polenta, quinoa, wheat berries, whole grain, stone-ground breads, rolls, tortillas, and pasta

Legumes, nuts, and seeds: almonds, black-eyed peas, cashews, chickpeas (garbanzo beans), hazelnuts, kidney beans, lentils, lima beans, pecans, pine nuts, pistachios, sesame seeds, sunflower seeds, split peas, walnuts

Herbs and spices (fresh or dried): basil, chili powder, chilies, cinnamon, cloves, cumin, dill, garlic, ginger, fennel seed, marjoram, mint, nutmeg, oregano, parsley, pepper (black or red), rosemary, saffron, sage, tarragon, thyme

Dairy products: low-fat milk, low-fat yogurt, reduced-fat cheese

Oils: canola, extra-virgin olive, grapeseed, and sesame


Pasta e Fagioli

Serves 8

This traditional Italian soup is very hearty and satisfying, loaded with pasta, beans, and vegetables. You can use whatever vegetables you’d like, or try red beans instead of white. Small pasta shapes such as ditalini or macaroni work well in this soup.

2 T extra-virgin olive oil
1/8 lb (about 3 slices) pancetta, chopped
2 fresh sprigs rosemary
1 fresh sprig thyme
2 dried bay leaves
1 medium onion, finely chopped
1 small carrot, finely chopped
1 rib celery, finely chopped
4 large garlic cloves, minced
Coarse salt and pepper
Two 15-oz cans cannellini (white) beans
1 cup canned tomato sauce or canned crushed tomatoes
2 cups water
1 quart low-sodium chicken stock
6 oz ditalini pasta
Grated Parmesan or Romano cheese for serving

1. Heat a stock pot over medium high heat and add oil and pancetta. Brown the pancetta bits lightly, and add herb stems, bay leaves, chopped vegetables, and garlic. Season with salt and pepper. Add the beans, tomato sauce, water, and stock to pot and raise heat to high.

2. Bring soup to a rapid boil and add the pasta. Reduce heat to medium and cook soup, stirring occasionally, 6 to 8 minutes or until pasta is cooked al dente. The rosemary and thyme leaves will separate from stems as soup cooks—just remove the stems and bay leaves from soup after turning off heat. Let soup rest and begin to cool for a few minutes. Serve in deep soup bowls with cheese on top.

Nutrient Analysis per serving
Calories: 278; Protein: 12 g; Fat: 8 g; Sat fat: 2 g; Carbohydrates: 42 g; Fiber: 7 g; Sodium: 389 mg

Recipe courtesy of Sara Talcott for Oldways


Halibut in Crazy Water (Pesce in Acqua Pazza)

Serves 4

From the region of Campania and a classic of Neapolitan cooking, this recipe is all about a great piece of fish cooked in a wonderfully simple way. Since the list is short, using great ingredients is paramount. At the beginning of the cooking, everything in the pan is fairly dry, but by the time the fish is cooked, there will be a simmering bath of acqua pazza—crazy water! This is a perfect way to cook halibut and other flaky fish such as snapper, grouper, or bass. Use vine-ripened tomatoes that aren’t too soft. And by rinsing off the capers, you’ll get seasoning from the capers, not the flavor of the brine. Serve with roasted or steamed potatoes.

Four 6-oz pieces skinless halibut fillet
Fine sea salt
Freshly cracked black pepper
2 large garlic cloves, peeled
2 T extra virgin olive oil, plus a little for drizzling
11/4 lbs ripe, firm tomatoes, seeded and cut into 3/8-inch dices (about 2 cups)
11/2 T finely chopped Italian parsley
1 T drained capers, rinsed and finely minced

1. Season the fish on both sides with salt and pepper. Lightly crush the garlic cloves and put them in a sauté pan. (The pan should be large enough to hold all the fish and some of the tomatoes in between in a single layer.)

2. Add the olive oil and heat over medium heat. When the garlic starts to sizzle, gently shake and tilt the pan so the cloves are immersed and sizzling at one side of the pan in a pool of the oil. As the cloves start to turn golden, lay the pan flat on the burner so the oil covers the entire surface.

3. Place the fish in the pan, skin side down. Tilt the pan so you can spoon some of the garlic oil over the exposed side of the fish. Season the tomatoes with salt and pepper. Add the tomatoes and parsley, evenly distributing them over the entire surface of the fish and in between the fillets. Cover and lower the heat so the pan juices come to a slow, even boil. Add the capers 2 to 3 minutes later so their flavor won’t overpower the rest of the dish. Continue to simmer until the fish is opaque and slightly firm, 3 to 4 minutes.

4. Transfer the fish with a thin slotted spatula to warm plates or a serving platter. Using a perforated spoon, place the tomatoes over the fish, then with a regular spoon, place some of the residual “crazy water” in the pan over the fish and enough on the dish or platter to serve it in a shallow pool. Finish with a drizzle of olive oil. Serve subito (immediately)!

Nutritional Analysis per Serving
Calories: 278; Carbohydrates: 7 g; Fat: 11 g; Cholesterol: 54 mg; Protein: 37 g; Sodium: 169 mg; Fiber: 2 g; Sat Fat: 2 g

Recipe courtesy of Chef David Shalleck, adapted from the book Mediterranean Summer