Mediterranean diet, avoid dementia

How should you protect your heart? When it comes to diet vs drugs, which do you choose?

How Effective Are Drugs for the Heart?

Drug companies get excited when their medications reduce the risk of something (heart attacks, strokes, death) by 30% or 40%. When they accomplish a relative risk reduction in that neighborhood, the FDA frequently approves the drugs and the companies advertise them like crazy on TV and in magazines. As a result, doctors prescribe such drugs in huge quantities and patients think of them as a lifeline to good health.

When a diet performs equally well, it is often ignored or forgotten because there is no one to beat the drum for food as medicine.

The Story of a Statin:

If you don’t believe us, just get inside our time machine. Several years ago the maker of the best-selling drug in America (Lipitor, AKA atorvastatin) created ads that proclaimed:

In patients with multiple risk factors for heart disease, LIPITOR REDUCES RISK OF HEART ATTACK BY 36%*…”

On the surface, this seemed fabulous. A lot of people would love to reduce their risk of a heart attack by a third. They might interpret this to mean that out of 100 people, Lipitor would protect 36 from having a heart attack. Those would indeed be impressive odds.

But the asterisk told a different story. In fine print the ad went on to explain:

“That means in a large clinical study, 3 percent of patients taking a sugar pill or placebo had a heart attack compared to 2 percent of patients taking Lipitor.”

What this means is that if 100 people took the drug and 100 people took the placebo, there would be 2 heart attacks among Lipitor users and 3 among placebo takers-just 1 fewer heart attack over the course of the study (which actually had many more people and ran longer than a single year). In other words, 99 people out of 100 who took the drug did not get any obvious heart attack protection. All of a sudden, the odds don’t seem as appealing as a 36 percent relative reduction in risk.

Diet vs Drugs:

Around the same time there was a book review published in the New England Journal of Medicine (“Nutrition in the Prevention and Treatment of Disease,” May 30, 2002) that noted:

“two fish meals a week are as effective as statins in preventing death among patients with cardiac disease.”

We’re not sure how many doctors prescribed fish instead of statins, but during the last two decades more than $130 billion has been spent on Lipitor alone (not counting lovastatin, pravastatin or simvastatin, and several other statin-type cholesterol-lowering drugs).

The Mediterranean Diet:

What if we told you that the Mediterranean diet is just as good? Would you believe us? Would you believe the research?

A study published in the New England Journal of Medicine (Feb. 25, 2013) reports that people at high risk for heart disease can lower their likelihood of having a heart attack, stroke or dying prematurely from cardiovascular causes by switching from their “normal” diet to a Mediterranean diet. The relative risk reduction was about 30%. The investigators were so impressed with the results that they stopped the study after nearly five years (one year earlier than planned). The results were so beneficial that they felt it would be unethical to keep people on their normal diets instead of the Mediterranean diets. They also felt compelled to announce their findings to the world.


Here is what they did. Roughly 7,500 people in Spain were recruited to participate in the PREDIMED trial (PREvencion con DIeta MEDiterranea). Although none had clear signs of cardiovascular disease at the start of the study (Oct. 1, 2003), they were all at substantial risk. They were between 55 and 80 years of age and had at least three of the following problems: type 2 diabetes, hypertension, high LDL cholesterol levels, low HDL cholesterol levels, overweight or cigarette use.

At the start of the study the subjects were randomized to either:

  • A Mediterranean diet with lots of extra-virgin olive oil (a minimum of 4 tablespoons daily, up to a liter weekly). It also included fish (3 times/wk) and legumes (3 times/wk). Drinkers were allowed at least a glass of wine a day. Carbs from baked goods were discouraged.
  • A Mediterranean diet as above, but instead of olive oil the volunteers were instructed to eat a large handful of nuts a day (30 grams of nuts daily containing 15 g of walnuts, 7.5 g of hazelnuts & 7.5 g almonds)
  • A low-fat control diet that allowed carbohydrates like sodas and baked goods

The Conclusions:

Here are the conclusions of the authors in their own words:

“Our results compare favorably with those of the Women’s Health Initiative Dietary Modification Trial, wherein a low-fat dietary approach resulted in no cardiovascular benefit. Salient components of the Mediterranean diet reportedly associated with better survival include moderate consumption of ethanol (mostly from wine), low consumption of meat and meat products, and high consumption of vegetables, fruits, nuts, legumes, fish, and olive oil. Perhaps there is a synergy among the nutrient-rich foods included in the Mediterranean diet that fosters favorable changes in intermediate pathways of cardiometabolic risk, such as blood lipids, insulin sensitivity, resistance to oxidation, inflammation, and vasoreactivity [blood vessel flexibility].”

Bottom Line:

Lowering fat consumption does not improve health outcomes. In fact, the advice of the American Heart Association to reduce fat and substitute polyunsaturated vegetable oils (such as safflower oil) may be counterproductive (see this link to a previous post to understand why).

Consuming more olive oil and nuts were among the most likely causes for the improved outcomes of the Mediterranean diet.

This was a primary prevention trial. That means that none of the participants had diagnosed heart disease at the start of the study. Statins have not been shown to lower heart attacks, strokes or prevent death in a similar population.

More Evidence on Diet vs Drugs for Heart Disease:

Statins are effective in lowering such events in people who have already experienced a heart attack (a secondary prevention trial), but the drugs have not performed as well as the Mediterranean diet in otherwise healthy people who are at high risk for problems down the road.

We’re not in any way discouraging people from taking statins if their physicians insist that they are necessary. They do help prevent second heart attacks! What we are sharing, however, is the good news that a Mediterranean diet is at least as good, if not better, than statins in the primary prevention of heart attacks, strokes or premature death in high-risk individuals.

Since the first results of the PREDIMED trial were reported, there have been many other studies showing benefit from the Mediterranean diet. People following this eating pattern reduce their chances of breast cancer, retinopathy, cognitive decline, depression and diabetes. Recent research from Italy showed that those whose diets were closest to the traditional Mediterranean pattern were 37 percent less likely to die of heart disease than those whose diets were less healthful.

How Can You Eat Mediterranean Style?

Would you like to know more about the “nuts and bolts” of a Mediterranean diet? We have included the nitty-gritty details in our book, Quick & Handy Home Remedies from The People’s Pharmacy. You will learn about the best protein sources (besides fish) and which vegetables and fruits are ideal. You will also get practical low-carb dietary suggestions that will be very helpful in planning your grocery shopping expeditions. In addition, there are breakfast, lunch and dinner recipes that follow a Mediterranean diet approach.

Should you desire even more recipes for good health, you may want to take a look at our book, Recipes and Remedies from The People’s Pharmacy. We asked some of the country’s leading nutrition experts to share their recipes with our readers and radio show listeners.

Walter Willet, MD, DrPH, is Chairman of the Department of Nutrition at Harvard School of Public Health. He sharesd his wife’s “Lentil Nut Loaf with Red Pepper Sauce.” Lentils are legumes, highly valued in the Mediterranean Diet.

Christopher Gardner, PhD is a Stanford University nutrition guru. He also offered a great legume recipe: “Lentil and Roasted Bell Pepper Salad.” (You’ll find more great lentil recipes here. And you can listen to our radio show on healthful vegetarian eating here.)

Have you incorporated the Mediterranean diet into your daily meal plan? If so, share your favorites in the comments below. Do you consume 4 tablespoons of olive oil a day? Do you consume a handful of nuts? Let us know your secrets to good health!

This article was updated on 11/22/2016

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  1. Laura

    I’ve just been introduced to Avocado Oil. It is wonderful to taste, and I’m hoping it is very healthful as well. Do you have any info on it?

    • Terry Graedon

      Avocado oil is an excellent choice. It is rich in monounsaturated fatty acids, like olive oil, and also contains polyunsaturated fatty acids like vegetable oils. It is very useful for high-heat cooking like stir-frying. Enjoy.

  2. MJK

    The difference between this study and the claims of other diets is that this is a controlled study with a large number of subjects over a significant period of time. There are no similar studies and certainly no eveidence at this level of confidence that shows that other diets are as effective or more effective. If Anne has good evidence to the contrary, she needs to show it after making her statement that “There’s so much MORE evidence that eliminating the oil further enhances the effect of a plant-based diet.”
    This study used biomarkers showing that the subjects did follow the diet in addition to patient surveys. It is an impressive study that cannot be ignored.
    In addition, the end point of this study was stroke, heart attack, and death, not some level of lipids, BMI or other marker that may or may not have significance for health. And it was a study of at risk patients, not a random sample of everyone. Those patients, however, do have a lot in common with average Americans. 13% were smokers, the average BMI was 29, and all had a metabolic syndrome (Diabetes Mellitus, Dyslipidemia, Central Obesity, Increased Blood Pressure) which is very common in this country. No other study had the gravitas of this one when it comes to outcomes.
    The conclusion of this study is that physicians need to recommend the diet to patients who are at risk. This is not everyone, but one of the striking features of the diet is that weight gain did not seem to be a factor in the study. This may be a cultural issue (see above note on fast days, although the adherence to Catholic or Muslim customs is not that high in Europe) or it could be a factor of the diet. Sticking to this diet, as is true of any diet, is probably difficult but the study makes allowance for this with its 14 point survey. 11/14 is good enough for the patients studied.
    With such good evidence it makes more sense to try this way of eating (which it is and not so much a “diet”) than stricter and more regimented diets that have no evidence showing effectiveness and are much harder to follow in order to remain healthy (i.e. not die or have heart attacks and strokes.)
    Besides, unlimited chocolate, nuts and wine? How can you object?
    Dear MJK,
    We couldn’t have said it better. Thanks for such a thoughtful response.

  3. REH

    Which is it? 1 liter/wk or 4 tbsp./day? These 2 quantities are not equivalent. My conversion chart indicates that 4 tbsp./day is 0.41 liter/wk (or less than 1/2 liter/wk).
    We took a LOT of flack for our reporting of the trial and we deserved it. We did not accurately report the trial protocol. So…here’s the deal:
    The investigators encouraged participants to consume 4 tablespoons of olive oil daily. They supplied the subjects 1 liter of olive oil a week. We now know (thanks to our vigilant listeners) that there are roughly 68 tablespoons in a liter. If you consumed 4 tablespoons a day for 30 days that would be 120 tablespoons. But the subjects were given roughly 272 tablespoons of olive oil in a month.
    The answer is that they were supposed to eat AT LEAST 4 tablespoons a day. They could have consumed more and in fact were encouraged to do so by getting the extra olive oil for free (an extra 152 tablespoons of olive oil each month).
    Sorry we did not get it exactly right on the radio.

  4. Ed C

    One tablespoon = .5 fl. oz.
    4 T/day = 2 oz/day = 14 oz/week, ~not~ a liter per week
    This is a huge discrepancy in statements on the radio program and in the web article. I am pretty confused here, because I am sure that I am not the only person out here who knows that there are two tablespoons in a fluid ounce and a liter is roughly equal to a quart, which is 32 ounces. So 4 T/day of EVOO would be less than half a liter per week? Am I wrong somehow?
    PEOPLE’S PHARMACY RESPONSE: Not wrong at all. That is why Gina Kolata kept stressing that 4 tablespoons daily is the MINIMUM they were to consume. They were provided with a liter each week as part of the study.

  5. JT

    What about Niaspan for the small particles? I have heard that it is the small particles, not the cholesterol that causes the blockages. Small particles, need to be large particles, to keep the arteries cleared. My doctor is big on this because it will increase the HDL and lower the triglycerides. You must also watch your diet and exercise as with the statins. Experts have found out it is the particle size that counts, not the LDL???

  6. Karen

    >In other words, lipid levels are almost always “better” after he low-carb diets than the low-fat diets. Go figure…
    OK, guys, You’re the professions. This is NOT a professional response. “Go figure?????” It’s been well known for 20 years in the low-carb world that the easiest way to lower blood fats is to eat fats; this is not “man bites dog,” and I don’t understand how that phrase fits this question.
    Why is “better” is quotations, anyway? Improved blood lipid levels are not “better.” They are better.

  7. CG

    I have been led to believe that Canola oil has the same health benefits as olive oil. Is this true?

  8. Peppy

    Are there similar studies comparing the Med. diet with the Ornish, Esselstyn or Fuhrman diets? They don’t allow unhealthy carbs or soda’s and encourage healthy carbs but two of them all no nuts, seeds or oils.
    Fuhrman does allow the healthy high fat plant foods and very little if any olive oil. Have these diets been shown to reduce heart attacks or repeat heart attacks at a higher percentage then the Med. diet? They claim they do but I haven’t seen the clinical studies. Have they been done?
    There are no long-term prospective studies that have measured outcomes such as heart attacks, strokes and mortality after 5 or 6 years on such a diet. The studies that have compared the low-fat diets with low-carb diets have produced “man-bites-dog” outcomes. In other words, lipid levels are almost always “better” after he low-carb diets than the low-fat diets. Go figure…

  9. DS

    Our local newspaper and county hospital are still very much into “LOW FAT” and always feature low fat recipes. It makes me want to scream. Until I got wise and started eating MORE FAT and MORE SALT, I got heavier and less healthy all the time. People here in Oklahoma are big and getting bigger, and I think the health industry is to blame.

  10. Karen

    >• Consuming more olive oil and nuts were among the most likely causes for the improved outcomes of the Mediterranean diet.
    Naseem Taleb also proposes that one of the ignored aspects of a real Med. diet is that it includes numerous fast days throughout the year, according to the various religious calendars, and therefore includes a significant component of caloric restriction.
    One more variable.

  11. Anne

    I’m an absolute believer in diet over drugs. Switching to a strictly plant-based, low SOS (salt, oil, sugar) diet has changed my life and brought back my health! However, the Mediterranean diet is successful in spite of, not because of, it’s inclusion of olive oil and some animal products such as fish. There’s so much MORE evidence that eliminating the oil further enhances the effect of a plant-based diet.

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