Every day

• • Main meals should contain three basic elements, which can also be found throughout the day:

  • – Cereals: one or two servings per meal in the form of bread, pasta, rice, couscous and others. Preferably whole grain, since processing normally removes fibre and some valuable nutrients (Mg, Fe, vitamins, etc.)⁽Reference Slavin¹⁷⁾.

  • – Vegetables: two or more servings per meal. In order to ensure vitamin and mineral daily intakes, at least one of the servings should be consumed raw (one meal/d)⁽Reference Tang, Zirpoli and Guru¹⁸⁾.

  • – Fruit: one or two servings per meal, as the most frequently chosen dessert. The concept of ‘variety in colours and textures’ is highlighted, in the case of fruit and vegetables, in order to ensure a wide variety of antioxidants and protective compounds⁽Reference Khoo, Prasad and Kong¹⁹⁾.

• • A daily intake of 1·5–2 l of water (equivalent to six to eight glasses) should be guaranteed. Proper hydration is essential to maintaining the corporal water equilibrium, although needs may vary among people due to age, physical activity, personal circumstances and weather conditions. It should be consumed freely, bottled or from the tap, when hygienic circumstances allow it. In addition to water, sugar-free herbal infusions and tea, and low-sodium and low-fat broths may help to complete the requirements.

• • Dairy products should be present in moderate amounts (two servings per day), with a preference for low-fat dairy, traditionally in the form of yoghurt, cheese and other fermented dairy products. Although their richness in Ca is important for bone and heart health, dairy products can be a major source of saturated fat⁽Reference Ascherio²⁰⁾.

• • Olive oil is located at the centre of the pyramid; it should be the principal source of dietary lipids because of its high nutritional quality (especially extra virgin olive oil). Its unique composition gives it a high resistance to elevated temperatures, and it is recommended for both cooking⁽Reference Casal, Malheiro and Sendas²¹⁾ and dressings. Olive oil has been reported to be inversely associated with some cancers and is known to positively affect blood lipids and cardiovascular systems⁽Reference Bertuzzi, Tavani and Negri^22–Reference Pelucchi, Bosetti and Negri²⁶⁾. This may be related to its high content of monounsaturated oleic acids and abundance of antioxidant compounds, which are primarily present in virgin olive oil⁽Reference Corona, Spencer and Dessì²⁷⁾. Traditionally, vegetables and other plant foods are cooked with olive oil, thus amplifying their nutritional value.

• • Olives, nuts and seeds are good sources of healthy lipids, proteins, vitamins, minerals and fibre⁽Reference Sabaté, Ros and Salas-Salvadó²⁸⁾. A reasonable consumption of olives, nuts and seeds (such as a handful) make for a healthy snack choice.

• • Spices, herbs, garlic and onions are a good way to introduce a variety of flavours and palatability to dishes and allow for a reduction in salt use, as salt is one of the main contributing factors to the development of hypertension among predisposed individuals⁽²⁹⁾. Herbs and spices are good sources of micronutrients and antioxidant compounds and also contribute to the regional identities of Mediterranean dishes.

• • Respecting religious and social beliefs, a moderate consumption of wine and other fermented beverages during meals (one glass per day for women and two glasses per day for men, as a generic reference) is present in the MDP⁽Reference Mink, Scrafford and Barraj^30–Reference Vilavalur, Otani and Singal³²⁾.

Weekly

Consumption of a variety of plant- and animal-origin proteins is recommended. Traditional Mediterranean dishes do not usually have animal-origin protein foods as the main ingredient but rather as a source of flavour.

• • Fish and shellfish (two or more servings), white meat (two servings) and eggs (two to four servings) are good sources of animal protein. Fish, white meat (poultry, turkey, rabbit, etc.) and eggs provide high-quality protein. Fish and shellfish are a good source of healthy protein and lipids. Varied consumption (of oily fish, lean fish and shellfish) is recommended. Fish (especially those high in lipids) and shellfish consumption has been reported to reduce the risk of CHD and they have anti-inflammatory properties due to their content of long chain n-3 PUFA⁽Reference Kris-Etherton, Harris and Appel^33, Reference Simopoulos³⁴⁾. White meat is also a good source of lean protein without the high levels of saturated fat found in some red meat cuts. Egg consumption, including those used in cooking as well as baking, should be between two and four times per week.

• • Consumption of red meat (less than two servings, preferably lean cuts) and processed meats (less than one serving) should be small in both quantity and frequency as the intake of such meats has been consistently associated with some chronic diseases (cancers and CHD)⁽Reference Micha, Wallace and Mozaffarian^{35, 36)}.

• • The combination of legumes (more than two servings) and cereals is a healthy plant protein and lipid source that should be considered as a meat alternative⁽Reference Rochfort and Panozzo^37, Reference Bazzano, He and Ogden³⁸⁾.

• • Potatoes are also included on the weekly level (three or fewer servings per week, preferably fresh), as they are a part of many traditional recipes with meat and fish. They should be consumed in moderation⁽Reference Mozaffarian, Hao and Rimm³⁹⁾ as they have a high glycaemic index⁽Reference Willett, Manson and Liu⁴⁰⁾ and are most commonly prepared fried.

Occasionally

In the top vertex of the pyramid are the foods rich in sugars and unhealthy fats (sweets). Sugar, candies, pastries and beverages such as sweetened fruit juices and soft drinks should be consumed in small amounts and set aside for special occasions. These foods are energy dense and are likely to contribute to weight gain⁽Reference Mozaffarian, Hao and Rimm³⁹⁾. Simple sugars, which are abundant in sweets, pastries, fruit juices and soft drinks, have been associated with an increased occurrence of tooth decay⁽³⁶⁾.

Moderation

Serving sizes should be based on frugality and moderation, to adapt the urban and modern lifestyles to energy needs. This aspect is emphasised due to the major public health challenge of obesity. The portion sizes of the foods represented at the bottom should be larger and consumed frequently as they provide satiety along with moderate amounts of energy, and those foods at the upper levels should be consumed in smaller amounts and less frequently due to their high fat and simple sugar contents. Serving sizes should reflect autochthonous peculiarities and local habits, thus adapting to the specific realities of each country and region.

Socialisation

The conviviality aspect is important for the social and cultural value of the meal beyond nutritional aspects. In this sense, several factors related to food (understood as a social fact) must be kept in mind, such as culinary activities, knowledge transmitted from generation to generation and time devoted to meals related to the daily pace of life. All these aspects contribute to generating or strengthening sociability, communication and the identity of communities. Sharing food in the company of family and friends around the table represents social support and a sense of community⁽Reference Medina⁴¹⁾. The pleasure associated with the conviviality of meals may positively affect food behaviours, and in return, health status⁽Reference De Garine⁴²⁾.

Culinary activities

The development of culinary activities such as cooking, making crafts, the organisation of domestic space and other techniques associated with food is basic for the social reproduction of the identity of each particular culture⁽Reference Heine¹⁰⁾. Thus, devoting enough time and space for such culinary activities is stressed, giving account to their role in everyday meals, celebrations and religious festivals in every culture.

Physical activity

Regular practice of moderate physical activity (at least 30 min throughout the day) serves as a basic complement to the diet by balancing energy intake, maintaining healthy body weight and providing many other health benefits⁽³⁶⁾. Physical activity not only involves sports such as football, dancing, jogging, cycling, etc. but also walking, taking the stairs v. the lift, housework, gardening, etc. Practising leisure activities outdoors⁽Reference Thompson, Boddy and Stein⁴³⁾, and preferably with others, makes them more enjoyable and strengthens the sense of community.

Adequate rest

Resting during the day (nap) as well as adequate night sleep is also part of a healthy and balanced lifestyle. Scientific evidence has shown that a short rest after eating is a healthy and traditional Mediterranean habit that helps promote a balanced lifestyle⁽Reference Ficca, Axelsson and Mollicone⁴⁴⁾. An after-meal nap is an increasingly widespread habit in Mediterranean countries and throughout Europe.

Seasonality

The preference for seasonal, fresh and minimally processed foods may in most cases maximise the content of protective nutrients and substances in the diet. Currently and due to the modern lifestyle, the consumption of fresh foods is being substituted by other processed foods. However, progress in modern technology minimises nutrient loss and offers healthy alternatives⁽Reference Sizer and Whitney⁴⁵⁾. Especially in the case of fresh products, several factors influence their nutritional value: the growing methods used, the specific variety chosen, ripeness when harvested, post-harvest handling, storage, extent and type of processing, and the distance transported⁽⁴⁶⁾. Thus, all the decisions and practices along the food system – from seed to table – affect the nutrient content of foods.

Traditional, local, eco-friendly and biodiverse products

Taking into account the traditional, local, eco-friendly and biodiverse products whenever possible contributes to the preservation of Mediterranean landscapes and sea. The MD should be understood not only as a set of foods but also a cultural model incorporating the whole food chain: the way foods are selected, produced, processed and distributed to the consumers^(13, Reference Serra-Majem⁴⁷⁾. Moreover, the MD, as a plant-centred dietary pattern, further contributes to the preservation of the environment, as it implies a reduction in animal consumption and therefore production compared to Western patterns and, consequently, lowered demands on soil, water and energy resources⁽Reference Gussow^48, Reference Stehfest, Bouwman and Van Vuuren⁴⁹⁾. All these items express the sustainable character of the MD in an increasingly globalised world⁽Reference Serra-Majem^{47, 50,} Reference Gussow and Clancy⁵¹⁾.

The MD is an example of a sustainable pattern in which agricultural biodiversity plays an important role⁽Reference Serra-Majem^47, Reference Gussow and Clancy⁵¹⁾. The variety both among and within species contributes to differences in appearance and taste, as well as micronutrient and phytochemical content⁽⁴⁶⁾. However, when making varietal decisions, durability (for instance, to withstand long-distance transport) is sometimes being prioritised over taste and nutritional quality⁽Reference Goldman, Kader and Heintz⁵²⁾. The large number of endemic species and landscape diversification (cultivated areas, grassland or forest and land use changes over time) that contribute to the biodiversity of the territories bordering the Mediterranean make this area a hot spot of global diversity⁽Reference Myers, Mittermeier and Mittermeier⁵³⁾. In this sense, agricultural biodiversity provides food variety of plant and animal food products from wild and domesticated sources⁽Reference Trichopoulou, Vasilopoulou and Hollman⁵⁴⁾ that foster the nutritional guidelines⁽Reference Johns and Sthapit⁵⁵⁾.

The consumption of local and eco-friendly foods has been associated with health and environmental preservation in several ways⁽⁵⁰⁾. First, although there is still no unanimous international consensus on the differences in nutrient content between eco-friendly and conventional products⁽Reference Dangour, Dodhia and Hayter⁵⁶⁾, some literature surveys of nutritional and sanitary aspects of eco-friendly (organic) foods^(57, Reference Lairon⁵⁸⁾ have reported some higher nutrient contents and marginal pesticide residue contaminations. Second, locally grown and harvested foods are normally given more time to ripen. Third, local food products normally have less distance to travel, thus promoting energy saving and reducing pollution, having a lower contribution to climate change and greenhouse gas emissions if compared to long-travelling food products⁽Reference Carlsson-Kanyama and González⁵⁹⁾. Moreover, by buying local foods, farmers are encouraged to diversify their crops and decrease their vulnerability to pests⁽⁵⁰⁾. Finally, the consumption of local foods contributes to improving local economies⁽Reference Horrigan, Lawrence and Walker⁶⁰⁾.

Traditional knowledge and practices developed through daily observation, interaction within rural communities, transfer production, procurement and consumption techniques and activities are locally transmitted from generation to generation⁽Reference Contreras¹¹⁾. All those elements ensure positive, responsible, sustainable and healthy behaviours⁽Reference Gussow^{48, 50,} Reference Johns and Sthapit⁵⁵⁾ while reproducing the Intangible Cultural Heritage of the Mediterranean Diet⁽¹³⁾. The modernisation process, including sociocultural changes and new technologies, has transformed food production and threatens sustainable orders of life, such as local foodstuffs and environmental biodiversity. Thus, countries, communities and cultures that maintain their own traditional food systems are better able to conserve local food specialities with a corresponding diversity of crop varieties and animal breeds^(50, Reference Burlingame and Dernini⁶¹⁾.