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Rapid Responses: Rapid Responses published:
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Low number of new cases of diabetes.
- Edoardo Cervoni (31 May 2008)
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Physical activity in the SUN cohort participants
- Miguel A. Martinez-Gonzalez (1 June 2008)
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Does a healthy diet have a be Mediterranean?
- Paula J Whittaker (3 June 2008)
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Diet?
- Alexander Jablanczy (3 June 2008)
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Diabetes,diet and blood rheology.
- Leslie O Simpson (4 June 2008)
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The "Gorilla Diet"
- Charles Savona-Ventura (4 June 2008)
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Mediterranean eating pattern is possible for all.
- Carole A. Bartolotto (11 June 2008)
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It is more correct to consider all three groups of the prospective cohort study together. Still the conclusion will not change.
- Arya K Kumarasena, none (12 June 2008)
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Diet parallel of Mediterranean eating pattern
- Nan Li (13 June 2008)
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Re: Diet?
- Alexander Jablanczy (16 June 2008)
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Re: The "Gorilla Diet"
- Alexander Jablanczy (16 June 2008)
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Med diet and the agrofood industry
- Guy-Andre Pelouze (18 June 2008)
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protein and mediterranean diet
- edwin n wardle (20 June 2008)
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Cultural transitions, context, and adhering to a Mediterranean diet
- Sylvia S. Barton (28 June 2008)
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Results outside the lab
- Erlon O. de Abreu Silva, Aline Marcadenti, Nutritionist (8 August 2008)
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Toronto study
- Alex Jablánczy (21 December 2008)
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Edoardo Cervoni, ENT Specialist Southport Institute Anti-Aging Medicine, 70 Leyland Road, Southport, PR9 9JA
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It comes hardly as a surprise that the number of new cases of diabetes was small, despite the follow-up of several thousand people for over four years. The partecipants were infact either young or relatively young. As the Authors admit, this is a major drawback. I also would like to have more information about the amount and type of physical exercise of the partecipants, if the this type of data should be available. The analysis is very elegant and I am looking forward to see the results of a longer follow-up. Competing interests: None declared |
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Miguel A. Martinez-Gonzalez, Professor of Epidemiology and Chair University of NAVARRA. Pamplona, E31080
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The total leisure-time energy expenditure (METS-h/week) of the SUN cohort participants according to their categories of adherence to the Mediterranean dietary score are shown in table 1 of our on-line paper (1). The means (standard deviations) were: 24.1 (23.4); 29.3 (26.2); and 36.4 (29.2) METs-h/week, respectively for successive categories of adherence to the Mediterranean score. The following 7 activities (in this order) explained 82 percent of the total weekly METs-h/week of leisure-time physical activity among our participants: walking, competitive running, mountain hiking, jogging, calisthenics, cycling, and tennis (or other racket sports). Among men, the same 7 activities explained 83% of total METs-h/week. Among women, the following 7 activities (in this order) explained 86% of total METS-h/week: walking, mountain hiking, calisthenics, aerobics, jogging, swimming, and skiing. The average (standard deviations) METS-h/week of leisure-time physical activity were 33.1 (25.3) among men and 26.6 (20.3) among women. Further information about physical activity in the SUN cohort can be found in two previously published papers by our group (2,3). 1. Martínez-González MA, Fuente-Arrillaga CD, Nunez-Cordoba JM, Basterra-Gortari FJ, Beunza JJ, Vazquez Z, Benito S, Tortosa A, Bes- Rastrollo M. Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study. BMJ. 2008 May 29. [Epub ahead of print] 2. Sanchez-Villegas A, Ara I, Guillén-Grima F, Bes-Rastrollo M, Varo- Cenarruzabeitia JJ, Martínez-González MA. Physical activity, sedentary index, and mental disorders in the SUN cohort study. Med Sci Sports Exerc 2008;40:827-34. 3. Martínez-González MA, López-Fontana C, Varo JJ, Sánchez-Villegas A, Martinez JA. Validation of the Spanish version of the physical activity questionnaire used in the Nurses' Health Study and the Health Professionals' Follow-up Study. Public Health Nutr 2005;8:920-7. Competing interests: None declared |
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Paula J Whittaker, Specialist Registrar in Public Health Manchester PCT M21 9WN
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The cohort study by Martinez-Gonzalez et al was reviewed at our public health department’s journal club[1]. This raised some issues about the applicability of the findings to a UK population. The authors assert that the Mediterranean diet is highly palatable, and people are likely to comply with it. In the UK, this diet is expensive and not easily accessible. The authors do acknowledge that the Indian diabetes prevention programme reduced the incidence of diabetes using a plant based diet[2]. So a diabetes- and CHD-preventing diet does not necessarily have to be a Mediterranean diet. In multicultural societies such as the UK, it may be more successful to advise people how they can adjust they’re chosen diet to make it healthier rather than asking them to radically change their eating habits. I assume that the Spanish participants in Martinez-Gonzalez’s study were brought up on a Mediterranean diet. It would be interesting to see how quickly the benefits of the diet emerged if applied to a UK population eating a traditional Western diet. The results of this study do support a dose-response benefit of eating a healthy diet, including increasing benefits from fruit and vegetables over and above the 5-a-day we are advised to eat. References 1. Martinez-Gonzalez MA et al. Adherence to Mediterrenean diet and risk of developing diabetes: prospective cohort study. BMJ, doi:10.1136/bmj.39561.501007.BE (published 29 May 2008) 2. Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V. The Indian diabetes prevention programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006;49:289-97. Competing interests: None declared |
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Alexander Jablanczy, MD GP office
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I cringe at any medical advice and worse a supposedly informative articulate article which uses the well nigh meaningless term diet. Not much better nor any more specific if the adjective Mediterranean is added. It is analogous to saying that someone is on a medication. Really? In a medical journal someone is on medication? How odd. Obviously the amount and types of food must be precisely identified. Even the star words vegetables and fruit are meaningless, In some contexts potato is a vegetable in others it isnt. Does this Mediterranean include a diet eating ten pounds of potatoes a day? Or none at all? How about twenty bananas Euro crooked or strait ones? Or twenty five delicious apples. Or a pound of avocadoes? How can you prescribe something without stating precisely what it is and the amount. The same is true about the equally meaningless fluffy fuzzy term exercise or worse the vogue term workout? Does ten minutes or two hours of vigorous ping pong qualify? Etc. So all the highfaluting statistical mumbo jumbo becomes risible twaddle without precision and accurate meaningful information. Competing interests: None declared |
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Leslie O Simpson, retired medical research worker Dunedin, New Zealand, 9077
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The interesting article by Martinez-Gonzalez et al regarding the health benefits arising from the Mediterranean diet could have been improved by a contribution from any of the Spanish groups working in the field of blood rheology. It would have been informative to have had data concerning blood viscosity and red cell deformability prior to and after the development of diabetes. Both type 1 and type 2 diabetes share the common feature of altered red cell morphology and reduced red cell deformability, and it is very likely that the high content of olive oil in the diet would improve red cell deformability. Furthermore, it is known that the low intensity physical activity in which participants engaged, would lower blood viscosity. As age was a confounding factor, it is worth noting that in 1998 Ajmani and Rifkind (1) discussed the haemorheological changes which occur during human aging. In the abstract it was stated, " The rise in fibrinogen, blood viscosity, plasma viscosity, red cell rigidity, fibrin degradation products and early activation of the coagulation system are some of the prominent findings. It is generally agreed that a rise in blood viscosity factors leads to a state of hypoperfusion which results in impaired microcirculation." Thus it seems unlikely that an understanding of the associations between diet and disease will be achieved without taking cognisance of the importance of associated changes in the flow properties of blood. Reference. Ajmani RS, Rifkind JM. Hemorheological changes during human aging. Gerontology 1998;44:111-20. Competing interests: None declared |
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Charles Savona-Ventura, Professor of Obstetrics & Gynaecology University of Malta
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The current Mediterranean diet is today too modified by Northern European and American influences to be closely defined and adhered too. This makes any comparative studies very difficult unless the actual diet is clearly defined and detailed. I prefer to consider the ideal diet to be that enjoyed by our "wildlife cousins" - the gorilla. One of the best and worst episodes in human evolution was the Neolithic Period where man developed farming and changed his diet to a grain-based one. It was the best episode in his development because farming gave communities a surplus of food that allowed them to develop technology and culture. However, man's biology is poorly adapted to deal with a diet that is highly dependant on refined grain products. The increased availability of highly-refined grain-product foods that increasingly feature in the day-to-day diet - consider pasta and bread - places a massive strain on modern man's carbohydrate metabolism and predisposes to the increasing problem of metabolic syndrome. Carbohydrates are essential in our diet, but emphasis should be made on obtaining this mainly from fruit and vegatables rather than depending on highly refined grain products. Grain products on the market should be required to include the percentage fibre on the packaging. Competing interests: None declared |
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Carole A. Bartolotto, Healthcare consultant and RD 01101
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Hello, I am responding to some of the rapid responses to this article regarding how difficult it is to stick to this diet in the UK and potentially other areas/countries. This type of diet has been applied to many population groups (Indian, Austrailian, French, Western Europe) and could also be applied to a UK population. The key is to focus on the basic principles of the diet such as: choose the healthier oils such as olive or canola, eat a lot of fruits and vegetables (6 to 10 servings per day). limit red meat to ideally 1 to 2 times a month, eat fatty fish 2 times a week, choose chicken and beans as protein sources, choose whole grains and have fruit in place of other desserts. Thses ideas can be applied to most population groups. It is the principles of the diet and not eating "Mediterranean" foods that is most important. Sincerely, Carole Bartolotto, MA, RD Competing interests: None declared |
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Arya K Kumarasena, Consultant/Director 85 ,Braybrroke ,place colombo2,Sri Lanka, none
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As mentioned in the paper it self even among those in the lowest category of adherence to the diet , the estimated mean daily absolute consumption of olive oil, vegetables, fruits, cereals and legumes can be considered as healthy according to accepted standards[1]. On the other hand working back from the table 2 reveals that the data of only 9 (low, score 0-2), 22 (medium, score 3-6) and 2 (high, score 7-9) persons in three groups were available for analysis. Total number of events mentioned in the paper is also 33 (9+22+2) after removing other type of diabetic patients and cases without sufficient data. It is to be noted that without having sufficient number of events standard statistical concepts become meaningless. As an example incident rate ratio adjustments for age and sex (95% CI) is not meaningful for high score group which had only 2 events. Even after considering most of the 21 persons with insufficient data ( even all of them) as type 2 diabetic patients total number of reported cases will not exceed (33+21) 54 . As (54 events from 13,380 participants in 4.4 years or 58918 participant years) the event rate of 0.92 per 1000 person years is still quite low, the main conclusion of the paper is confirmed by its findings. Reference 1. M Á Martínez-González, C de la Fuente-Arrillaga, J M Nunez- Cordoba, F J Basterra-Gortari, J J Beunza, Z Vazquez, S Benito, A Tortosa, and M Bes-Rastrollo Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study BMJ 2008; 0: bmj.39561.501007.BEv1 Competing interests: None declared |
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Nan Li, MD, PhD Shanghai, China
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The current modified Mediterranean diet is referred to eating pattern rich in olive oil, vegetables, fruits, nuts, cereals, legumes, and fish but relatively low in meat and moderate in dairy products. Obviously, olive oil is a peculiarity of the region. It is not yet popular in other areas and relative expensive, for example, in China. On the other hand, high intake of vegetables, fruits, nuts, cereals, legumes and fish and low intake of red meat and dairy products are also the features of Asian diet. Similar to virgin olive oil, plant oils such as rape oil or sesame oil in Chinese diet is also a major source of monounsaturated fat. Therefore, Asian diet especially Chinese diet is similar to Mediterranean diet in essence, although it is not fully studied yet. From this cohort study, we still can not conclude which of the components in Mediterranean diet is more important in reducing type 2 diabetes. Thus, Asian diet or Chinese diet, which is economic and popular, seems promising and demands more trials for the benefit of local population. Competing interests: None declared |
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Alexander Jablanczy, MD medical office
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I am not sure what happened here, the details of the diet were inaccessible to me at least previously or was my cri du coeur heard and the article was rewritten to include a very extensive almost fully adequate and informative disquisition on the precise meaning of the Mediterranean diet. Muchos gracias. I would like to amuse the readership and the authors with two instances from popular classical literature. One from Xenophon the other from Julius Caesar. During the Anabasis after the defeat of the Persians or Medes the Athenians and other Greeks when supplies were running low were reduced to eating mainly struthoi--that is, ostriches--which they ate with great disgust and murmurs of mutiny. They didn't mind skirmishes and strategems and constant fear of ambush travelling through enemy or hostile territory but eating meat as a staple, now that was too much like barbarians. Similarly during all the wars of Julius Caesar this one specifically in Gaul he never ever had to face mutiny of his troops. The only time that occurred was not during near defeat or retreat or privations or other dangers but when the frumentum ran out. His legions marched on grain the British call corn but elsewhere called wheat or cereals and peas. The reason for their mutiny was the same as the grumbling of Xenophon's men, they were reduced to eating beef and other meat like the barbarians of Gaul and Britain. In Britain Julius Caesar makes note of the odd diet of the islanders keeping ducks geese chickens and other small game and fowl as pets but mainly relying on cattle for food. How odd. So the two great civilizations of antiquity were both overwhelmingly vegetarian eating mainly wheat and peas and considering meat a last resort before starvation perhaps consuming cattle horses sheep pigs only as holiday or sacrificial fare. Of course wine and olive oil were already major staple foods. Tasting song birds would supply only a minimal caloric intake. Competing interests: None declared |
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Alexander Jablanczy, MD office
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I fully agree with including our primate ancestors-cousins in the dietary discussion. But what is lacking is the actual mention of what the gorillas eat. My understanding is that they almost exclusively eat the stem of one green plant ie the equivalent of broccoli or rhubarb or asparagus. Chimpanzees on the other hand are mostly fruit eaters. Rarely they catch a bird or an insect and will devour it. The most interesting are the more distant baboons. They eat everything grubs worms dirt roots stems bark. Except the ones around a Nairobi five star hotel where they have hit the dump feasting on leftovers of fried chicken and lemon meringue pie. What is instructive about these baboons is that their blood cholesterol in the wild is 1 but on this hotel garbage leftovers it rises to 3. And the weight of the dominant males from 150 lb to 400 lb. No word if they are diabetic or have MIs. Competing interests: None declared |
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Guy-Andre Pelouze, MD Institut de Recherche Clinique, 64000 Pau France
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It is of great interest to read that med diet is difficult to follow in UK for several reasons--namely, availability, prices and taste of med nutrients. Except for taste, it seems to me that these obstacles are the same on the continent, especially in urban areas either in med countries or other non med countries even Spain. To explain that one must describe the main obstacle to consuming a med diet and which is widely underestimated in the comments. The production of agriculture and breeding were so deeply transformed since WWII, that our food environment is completely different. We don't eat grassfed meat but processed products made of cornfed sedentary obese animals heavily transformed by heating, mincing, mixing, sterilising and so on. Wild meat is below 10% of fat and crops are now > 25% fat. We know that processed meat and saturated fats are a recognised factor for colon cancer and other chronic diseases. We don't eat the same ceareals because they are now products made of refined corn or wheat, high temperature cooked, sugared, mixed with trans fats, with added multivitamins. Consumption of high GI foods and fructose is clearly associated with D2. We don't eat the same olive oil because med populations consume olives, non refined olive oil and a lot of wild greens or crops naturally rich in alphalinoleic acid. Instead at best we buy white salads like the iceberg one which is depleted in phytonutrients and alphalinoleic acid and we pour on it sunflower oil which is pure W6 linoleic acid. Consequently a dramatic change has occurred in the W6/W3 ratio of PUFA which is in favor of inflammation--a common final way of chronic diseases. We don't eat the same dairy products because more than 80% of them are sugared, flash pasteurised, and made with milk from cow fed cornstarch... These kind of examples are endless. But the question is: Why do we consume these foods? Is it a clear choice or a mandatory buying in the different supermarkets which sell the same industrialised products? Clearly the anwer is: the agrofood industry and the low cost of goods transportation (at least until oil reach new unsustainable prices) had standardised food in a way which is not compatible with our genome. It is impossible for our genome to adapt in only fifty years... Med diet for all demands a change in agriculture and breeding. The recent policies toward more sustainable and energy efficient farming are in favor of the med diet. Other changes need to occur and it seems to me that medicine must take charge of them. Competing interests: None declared |
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edwin n wardle, retired physician Baldock Herts SG7 6SY
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The impressive report on reduction of diabetes risk by consuming a mediterranean diet might worry some persons owing to its low protein. However Azadbakht et al[1] have recently reported how a soy protein diet will similarly reduce the development of nephropathy in type2 DM patients. Thus one might boost the protein content of the Spanish diet by the addition of soy proteins as tofu,soy nuts,soy milk etc. Azadbakht L, Atabak S, Esmaillzadeh A. Soy protein intake,cardiorenal indices and C-reactive protein in type 2 diabetes with nephropathy. Diabetes Care 2008;31;648-654 Competing interests: None declared |
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Sylvia S. Barton, Associate Professor, RN, PhD, Faculty of Nursing University of Alberta, Edmonton, Alberta, T6G 2G3
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Considering the empirical context of diabetes related to high rates has led scholars to articulate a health promotion and illness prevention mandate. It is considered a way to challenge environmental, social, and lifestyle factors that influence diabetes health, including increased fat intake, reduced physical activity, and an inherited susceptible genotype. A focus on adhering to a Mediterranean diet to reduce the risk of developing diabetes is an important one, not only in terms of an area worthy of further research, but in relation to cultural transitions from traditional to modern ways of living. Associated with environmental changes that are affecting a global society, obesity, fasting blood glucose, insulin concentrations, lack of exercise, and diet are all risk factor determinants for the development of diabetes. Investigations into the mechanisms by which diet and exercise may prevent diabetes will increase an understanding of insulin resistance. The variation in high rates of diabetes among different ethnic groups, especially indigenous populations, requires more research. As studies continue to unravel the epidemiological features of diabetes, concerns related to the provision of diabetes programs of care that do not benefit people of different ethnic backgrounds remain disconcerting. The extent to which the major protective characteristics – a high intake of fibre, a high intake of vegetable fat, a low intake of trans fatty acids, and a moderate intake of alcohol – could be adapted to meet the needs of different ethnic groups, as seen in the Mediterranean and Indian food patterns, is worthy of consideration. Adherence to these dietary characteristics might provide common ground for community-based screening and primary prevention programs to increase their effectiveness. This information is desired in order to form a basis for determining how the health of an ethnic group living in one country compares with the health of ethnic groups living with diabetes in other countries. Such comparative information could increase our dietary understanding of how social, political, and cultural contexts influence diabetes health. Competing interests: None declared |
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Erlon O. de Abreu Silva, MD Instituto de Cardiologia do Rio Grande do Sul; Porto Alegre, Brazil, 90620-001, Aline Marcadenti, Nutritionist
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In the cohort published by Martínez-González et al.(1), adherence to a Mediterranean diet was associated with a reduced risk of diabetes. Several studies compared different diets and their potential benefits. The DIRECT trial (2), concluded that Mediterranean and low- carbohydrate diets are effective options to low-fat diet. However, some considerations must be made. Despite the relatively long follow-up and large number of subjects, the limitations of the study – as the food-frequency and physical activity questionnaires, the labeled and color-coded separation of food – imply in potential bias and loss of effectiveness, respectively. This faces the DIRECT trial against the same “some efficacy, low effectiveness” problem seen in previous studies of this kind. So, taking into account the higher rate of adherence and the better overall metabolic effects described in the DIRECT trial, the previously demonstrated cardiovascular benefits, and the evidence of protection fot incidente of diabetes, it seems that the Mediterranean diet is a more beneficial, feasible and efficient in the daily clinical practice- not only in laboratory – option References 1 - Martínez-González MA, Fuente-Arrillaga C de la, Nunez-Cordoba JM, et al. Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study BMJ 2008; 336: 1348-1351 2 -Shai I, Schwarzfuchs D, Henkin Y, et al. Weight loss with a low- carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008 Jul 17;359(3):229-41. Competing interests: None declared |
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Alex Jablánczy, MD office
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There is a study published recently Dec 21st comparing bean legume and nut they dont mention seeds as they should have versus grain whole grain oatmeal etc. There was also another study a few days ago comparing olive oil walnuts and oatbran. This was erroneaous as it's not the oatbran but the whole oatmeal that has been found to reduce cholesterol. Both studies found walnuts to be the most recent miracle food, one preventing or controlling diabetes the other reducing LDL. It seems the Italians even use walnut oil in cooking I dont know how. So this to me reinforces the breakfast I have been advocating for decades. OATMEAL Walnuts Flax seed and blueberries if unavailable substitute raisins. Absolutely no brown sugar which isnt brown sugar anyway but coloured white sugar, and absolutely no milk. Why? It contains lactose and galactose which you dont need nor sucrose if you are diabetic obese hypertensive or have heart disease. Green and black tea with nothing. That's it. The above diets both the successes and the failures omit the two most salient important factors. It is not what you eat but what you don't eat that matters. What matters is that you dont eat junk food meaning anything with added sugar salt fat additives and processed to death. So that eliminates sugar cookies cakes ice cream candy milk cream pop juices alcohol except minimal dry red wine and ham bacon sausage salami wieners hot dogs chicken pork beef. Minimal meat is acceptable and some fish. Dairy only if fermented as in buttermilk but watch the salt content as well in cottage cheese if hypertensive avoid both. That leaves plain yoghurt and only one cheese I found without added salt Bocconcini tre stelle. And of course all the dark green vegetables as spinach romaine lettuce dandelion etc and a few fruits. The salad with olive oil of course. That would be the ideal DM MI Ca prevention diet at this time to my knowledge. The second factor is alas amount. One quarter or one half what most obese diabetics eat. On quarter to lose weight one half to maintain it. If you go to three quarters you gain all the weight back. So I had to reduce even my perfect breakfast from a large bowl to a very small one. Competing interests: nil |
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