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Mediterranean diet pyramid today. Science and cultural updates

  • Anna Bach-Faig (a1), Elliot M Berry (a2), Denis Lairon (a3), Joan Reguant (a1), Antonia Trichopoulou (a4), Sandro Dernini (a5) (a6), F Xavier Medina (a7), Maurizio Battino (a8), Rekia Belahsen (a9), Gemma Miranda (a1) and Lluís Serra-Majem (a1) (a10)...



To present the Mediterranean diet (MD) pyramid: a lifestyle for today.


A new graphic representation has been conceived as a simplified main frame to be adapted to the different nutritional and socio-economic contexts of the Mediterranean region. This review gathers updated recommendations considering the lifestyle, dietary, sociocultural, environmental and health challenges that the current Mediterranean populations are facing.

Setting and Subjects

Mediterranean region and its populations.


Many innovations have arisen since previous graphical representations of the MD. First, the concept of composition of the ‘main meals’ is introduced to reinforce the plant-based core of the dietary pattern. Second, frugality and moderation is emphasised because of the major public health challenge of obesity. Third, qualitative cultural and lifestyle elements are taken into account, such as conviviality, culinary activities, physical activity and adequate rest, along with proportion and frequency recommendations of food consumption. These innovations are made without omitting other items associated with the production, selection, processing and consumption of foods, such as seasonality, biodiversity, and traditional, local and eco-friendly products.


Adopting a healthy lifestyle and preserving cultural elements should be considered in order to acquire all the benefits from the MD and preserve this cultural heritage. Considering the acknowledgment of the MD as an Intangible Cultural Heritage of Humanity by UNESCO (2010), and taking into account its contribution to health and general well-being, we hope to contribute to a much better adherence to this healthy dietary pattern and its way of life with this new graphic representation.


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1.Keys, A, Menotti, A, Karvonen, MJ et al. (1986) The diet and 15-year death rate in the Seven Countries Study. Am J Epidemiol 124, 903915.
2.Trichopoulou, A (2004) Traditional Mediterranean diet and longevity in the elderly: a review. Public Health Nutr 7, 943947.
3.Serra-Majem, L, Roman, B & Estruch, R (2006) Scientific evidence of interventions using the Mediterranean diet: a systematic review. Nutr Rev 64, Suppl. 1, S27S47.
4.Sofi, F, Cesari, F, Abbate, R et al. (2008) Adherence to Mediterranean diet and health status: meta-analysis. BMJ 337, a1344.
5.Benetou, V, Trichopoulou, A, Orfanos, P et al. (2008) Greek EPIC cohort. Conformity to traditional Mediterranean diet and cancer incidence: the Greek EPIC cohort. Br J Cancer 99, 191195.
6.Meydani, M (2005) A Mediterranean-style diet and metabolic syndrome. Nutr Rev 63, 312314.
7.Willett, WC, Sacks, F, Trichopoulou, A et al. (1995) Mediterranean diet pyramid: a cultural model for healthy eating. Am J Clin Nutr 61, Suppl. 6, 1402S1406S.
8.Trichopoulou, A, Ocurrís-Blazos, A, Wahlqvist, ML et al. (1995) Diet and overall survival in elderly people. BMJ 311, 14571460.
9.Reguant-Aleix, J, Arbore, R, Bach-Faig, A et al. (2009) Mediterranean diet: an intangible cultural heritage. Public Health Nutr 12, 15911594.
10.Heine, P (1994) Middle Eastern food. The anthropologists’ perspective. In La alimentación en las culturas islámicas, pp. 159167 [M Marín and D Saines, editors]. Madrid: Agencia Española de Cooperación Internacional.
11.Contreras, J (1993) Antropología de la alimentación, p. 9. Madrid: Ediciones de la Universidad Complutense.
12.UNESCO (2003) Convention for the Safeguarding of the Intangible Cultural Heritage. (accessed April 2011).
13.UNESCO (2010) Representative List of the Intangible Cultural Heritage of Humanity. (accessed April 2011).
14.Serra-Majem, L, Bes-Rastrollo, M, Román-Viñas, B et al. (2009) Dietary patterns and nutritional adequacy in a Mediterranean country. Br J Nutr 101, Suppl. 2, S21S28.
15.Buckland, G, Bach-Faig, A & Serra-Majem, L (2008) Obesity and the Mediterranean diet: a systematic review of observational and intervention studies. Obes Rev 9, 582593.
16.Centro internacional de altos estudios agronómicos mediterráneos (editors) (2008) Evolución del consumo y de la alimentación. In Terramed: el futuro del sector agroalimentario en el mediterráneo, pp. 157180. Madrid: Ministerio de Medio Ambiente y Medio Rural y Marino.
17.Slavin, J (2004) Whole grains and human health. Nutr Res Rev 17, 99110.
18.Tang, L, Zirpoli, GR, Guru, K et al. (2008) Consumption of raw cruciferous vegetables is inversely associated with bladder cancer risk. Cancer Epidemiol Biomarkers Prev 17, 938944.
19.Khoo, HE, Prasad, KN, Kong, KW et al. (2001) Carotenoids and their isomers: color pigments in fruits and vegetables. Molecules 16, 17101738.
20.Ascherio, A (2002) Epidemiological studies on dietary fats and coronary heart disease. Am J Med 113, Suppl. 9B, 9S12S.
21.Casal, S, Malheiro, R & Sendas, A (2010) Olive oil stability under deep-frying conditions. Food Chem Toxicol 48, 29722979.
22.Bertuzzi, M, Tavani, A, Negri, E et al. (2002) Olive oil consumption and risk of non-fatal myocardial infarction in Italy. Int J Epidemiol 31, 12741277.
23.Pérez-Jiménez, F, Lista, JD, Pérez-Martínez, P et al. (2006) Olive oil and haemostasis: a review on its healthy effects. Public Health Nutr 9, 10831088.
24.La Vecchia, C (2009) Association between Mediterranean dietary patterns and cancer risk: review. Nutr Rev 67, Suppl. 1, S126S129.
25.Castañer, O, Fitó, M, López-Sabater, MC et al. (2011) The effect of olive oil polyphenols on antibodies against oxidized LDL. A randomized clinical trial. Clin Nutr (Epublication ahead of print version).
26.Pelucchi, C, Bosetti, C, Negri, E et al. (2011) Olive oil and cancer risk: an update of epidemiological findings through 2010. Curr Pharm Des 17, 805812.
27.Corona, G, Spencer, JP & Dessì, MA (2009) Extra virgin olive oil phenolics: absorption, metabolism, and biological activities in the GI tract: review. Toxicol Ind Health 25, 285293.
28.Sabaté, J, Ros, E & Salas-Salvadó, J (2006) Nuts: nutrition and health outcomes. Preface. Br J Nutr 96, Suppl. 2, S1S2.
29.World Health Organization (2004) Global Strategy on Diet, Physical Activity and Health. The Fifty-seventh World Health Assembly, Resolution WHA57. Geneva: WHO; available at
30.Mink, PJ, Scrafford, CG, Barraj, LM et al. (2007) Flavonoid intake and cardiovascular disease mortality: a prospective study in postmenopausal women. Am J Clin Nutr 85, 895909.
31.Pasten, C & Grenett, H (2006) Wine, fibrinolysis and health. Rev Med Chil 134, 10401048.
32.Vilavalur, R, Otani, H, Singal, PK et al. (2006) Significance of wine and resveratrol in cardiovascular disease: French paradox revisited. Exp Clin Cardiol 11, 217225.
33.Kris-Etherton, PM, Harris, WS & Appel, LJ (2002) American Heart Association. Nutrition Committee. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Circulation 106, 27472757.
34.Simopoulos, AP (2006) Evolutionary aspects of diet, the omega-6/omega 3-ratio and genetic variation. Biomed Pharmacother 60, 502507.
35.Micha, R, Wallace, SK & Mozaffarian, D (2010) Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus: a systematic review and meta-analysis. Circulation 121, 22712283.
36.World Health Organization (2003) Diet, Nutrition and the Prevention of Chronic Diseases. Joint WHO/FAO Expert Consultation. WHO Technical Report Series no. 916. Geneva: WHO.
37.Rochfort, S & Panozzo, J (2007) Phytochemicals for health, the role of pulses. J Agric Food Chem 55, 79817994.
38.Bazzano, L, He, J, Ogden, L et al. (2001) Legume consumption and risk of coronary heart disease in US men and women: NHANES I Epidemiologic Follow-up Study. Arch Int Med 161, 25732578.
39.Mozaffarian, D, Hao, T, Rimm, EB et al. (2011) Changes in diet and lifestyle and long-term weight gain in women and men. New Engl J Med 364, 23922404.
40.Willett, W, Manson, J & Liu, S (2002) Glycemic index, glycemic load, and risk of type 2 diabetes. Am J Clin Nutr 76, Suppl. 1, 274S280S.
41.Medina, FX (1996) Dieta y comportamientos alimentarios en el contexto mediterráneo. In La alimentación mediterránea. Historia, cultura, nutrición, p. 42 [FX Medina, editor]. Barcelona: Icaria.
42.De Garine, I (1993) La dieta mediterránea en el conjunto de los sistemas alimentarios. In Antropología de la alimentación: ensayos sobre la dieta mediterránea, pp. 926 [I González Turmo and P Romero Solís, editors]. Sevilla: Junta de Andalucía, Fundación Machado.
43.Thompson, J, Boddy, K, Stein, K et al. (2011) Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environ Sci Technol 45, 17611772.
44.Ficca, G, Axelsson, J, Mollicone, DJ et al. (2010) Naps, cognition and performance. Sleep Med Rev 14, 249258.
45.Sizer, F & Whitney, E (2000) Food Safety and Food technology. In Nutrition concepts and controversies, pp. 507545 [A Williams, J Wood and C Winter, editors]. Belmont: Wadsworth, Thomson Learning.
46.Harvard Medical School, Center for Health and the Global Environment (2010) Healthy and sustainable food. (accessed May 2011).
47.Serra-Majem, L (2010) Nutrición comunitaria y sostenibilidad: concepto y evidencias. Revista Española de Nutrición Comunitaria 16, 3540.
48.Gussow, JD (1995) Mediterranean diets: are they environmentally responsible? Am J Clin Nutr 61, Suppl. 6, 1383S1389S.
49.Stehfest, E, Bouwman, L, Van Vuuren, DP et al. (2009) Climate benefits of changing diet. Climatic Change 95, 83102.
50.Food and Agricultural Organization (2010) Biodiversity in Sustainable Diets. Technical Workshop Report. Rome: FAO; available at
51.Gussow, JD & Clancy, KL (1986) Dietary guidelines for sustainability. J Nutr Educ 18, 15.
52.Goldman, IL, Kader, AA & Heintz, C (1999) Influence of production, handling, and storage on Phytonutrient content of food. Nutr Rev 57, 9 Pt 2, S46S52.
53.Myers, N, Mittermeier, RA, Mittermeier, CG et al. (2000) Biodiversity hotspots for conservation priorities. Nature 24, 853858.
54.Trichopoulou, A, Vasilopoulou, E, Hollman, P et al. (2000) Nutritional composition and flavonoid content of edible wild greens and green pies: a potential rich source of antioxidant nutrients in the Mediterranean diet. Food Chem 70, 319323.
55.Johns, T & Sthapit, BR (2004) Biocultural diversity in the sustainability of developing-country food systems. Food Nutr Bull 25, 143155.
56.Dangour, AD, Dodhia, SK, Hayter, A et al. (2009) Nutritional quality of organic foods: a systematic review. Am J Clin Nutr 90, 680685.
57.Food Standards Agency (2009) Comparison of Composition (Nutrients and Other Substances) of Organically and Conventionally Produced Foodstuffs: A Systematic Review of Available Literature. London, UK: FSA; available at
58.Lairon, D (2010) Nutritional quality and safety of organic food. A review. Agron Sustain Dev 30, 3341.
59.Carlsson-Kanyama, A & González, AD (2009) Potential contributions of food consumption patterns to climate change. Am J Clin Nutr 89, Suppl. 5, 1704S1709S.
60.Horrigan, L, Lawrence, RS & Walker, P (2002) How sustainable agriculture can address the environmental and human health harms of industrial agriculture. Environ Health Perspect 110, 445456.
61.Burlingame, B & Dernini, S (2011) Sustainable diets: the Mediterranean diet as an example. Public Health Nutr 14, Suppl. 1, 22852287.
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