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About
PREDIMED
STUDY
The study “Primary prevention of cardiovascular disease with Mediterranean
diets: the PREDIMED trial” was published in the February 2013 issue of the
New England Journal of Medicine. This is one of the world’s leading medical
journals; it is owned and published by the Massachusetts Medical Society,
and its most recent impact factor is 53.
Study
in
Spain
The multidisciplinary team of the PREDIMED study gathered outstanding research
groups involved in nutrition and cardiovascular risk in Spain. There were 16 groups
distributed in 7 autonomous communities in Spain, which were formed by university researchers, hospital clinicians, primary care physicians, nutritionists and epidemiologists
working in various public institutions.
The creation of the PREDIMED1 team meant the union of a wide group of Spanish investigators able to compete with those of the rest of Europe or the USA. Within this context, a coordinated project was designed to study the effects of the Mediterranean diet
on the primary prevention of cardiovascular diseases. The project started in October
2003 and recruited more than 7,000 asymptomatic participants at high cardiovascular
risk, who followed for an average period of 5 years. Its main outcome was incident
cardiovascular disease, secondary outcomes were all cause mortality and incidence of
other chronic diseases, and tertiary outcomes were changes in risk biomarkers.
The team of the PREDIMED study was coordinated by Dr. Ramón Estruch from Hospital
Clínic, University of Barcelona, Spain, who also leads the groups included in CIBERobn.
The leader of Network RD 06/0045, which provided funding for the remaining
PREDIMED partners, was Dr. Miguel Ángel Martínez-González, from the University of
Navarra, Spain.
PREDIMED is the acronym of a long-term nutritional intervention study that assessed
the efficacy of the Mediterranean diet in the primary prevention of cardiovascular diseases, the complete title of which is “Effects of the Mediterranean diet on the primary
prevention of cardiovascular diseases”.
with
7.000
asymptomatic
participants at high
cardiovascular risk
16
groups distributed
in 7 autonomous
communities in Spain
Primary prevention of cardiovascular
disease with Mediterranean diets:
the PREDIMED trial.
1
PREDIMED was launched in 2003 thanks to a grant from Instituto de Salud Carlos III (ISCIII) of the Spanish Health Ministry, the Thematic Network of Cooperative Investigation G03/140. The study was supported by
two additional ISCIII initiatives, CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn) and Network RD
06/0045. PREDIMED could not have started with out the generous donation of supplemental foods: extra-virgin
olive oil (Hojiblanca S.A. and Patrimonio Comunal Olivarero, Spain), walnuts (California Walnut Commission,
Sacramento, California, USA), almonds (Borges S.A., Reus, Spain) and hazelnuts (Morella Nuts, Reus, Spain).
3
The study was a large randomized clinical trial of dietary intervention in persons at high
risk of cardiovascular disease. The main objective was to evaluate whether the Mediterranean diet supplemented with extra-virgin olive oil or tree nuts prevents cardiovascular
diseases (cardiovascular death, myocardial infarction and/or stroke), by comparison
with a low-fat diet. As secondary variables, the preventive efficacy of the Mediterranean
diet was also assessed on all-cause mortality and incidence of heart failure, diabetes,
cancer, dementia and other neurodegenerative diseases. The trial was registered in the
London-based Current Controlled Trials register with ISRCTN number 35739639.
In a multicenter, randomized, controlled clinical trial, 7,447 participants (55
to 80 years old; women, 57%) at high risk of cardiovascular disease, but no
cardiovascular disease at enrolment, were randomized to one of three diets:
1) Mediterranean diet supplemented with extra-virgin olive oil; 2) Mediterranean diet supplemented with mixed nuts, or 3) a low-fat control diet (advice
to reduce dietary fat). Participants received quarterly individual and group
educational sessions and, depending on group assignment, free provisions of
extra-virgin olive oil, mixed nuts (almonds, hazelnuts and walnuts), or small
non-food gifts. The primary end point was the rate of major cardiovascular
events (myocardial infarction, stroke and cardiovascular death).
The PREDIMED intervention focused on diet, not on other lifestyle components; therefore the results answer the matter on whether the Med diet is undeniably cardio protective.
The PREDIMED trial obtained relevant information for public health use because the
nutritional intervention was undertaken in free-living persons who receive information,
motivation, support and empowerment to modify their food habits in a real-life context,
i.e., they continued buying their foods and cooking their meals. Such an intervention
provided a real life scenario that could be easily applied to public health policies. Given that the palatability of meals is significant to ensure compliance, the PREDIMED
protocol included quarterly visits and delivery of shopping lists, menus, and recipes to
participants in the three study groups.
The main focus of the PREDIMED Study was to change the dietary pattern instead of
focusing on changes in macronutrients. As opposed to the control diet, total fat intake
for the two Mediterranean diet groups was ad libitum (a high fat intake was allowed, as
long as most of the fat was derived from fatty fish and vegetable sources, particularly
olive oil and nuts). There were no specific energy restrictions for any of the study groups.
Acceptance of the intervention protocol increased because no specific caloric
restriction was imposed and participants in the two Med Diets were allowed
ad libitum fat intake, whether it came from olive oil, nuts, other plant sources
or fatty fish.
Effects of the
Mediterranean
diet on the primary
prevention of
cardiovascular
diseases
4
CARDIOVASCULAR
DISEASES (CVDs)
KEY FACTS
• An estimated 17.3 million people died from CVDs in 2008.
• Over 80% of CVD deaths take place in low- and middle-income countries.
• By 2030 more than 23 million people will die annually from CVDs.
According to the World Health Organization (WHO) cardiovascular diseases (CVDs) are
a group of disorders of the heart and blood vessels, including:
•
•
•
•
Coronary heart disease - disease of the blood vessels supplying the heart muscle;
Cerebrovascular disease - disease of the blood vessels supplying the brain;
Peripheral arterial disease - disease of blood vessels supplying the arms and legs;
Rheumatic heart disease - damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria;
• Congenital heart disease - malformations of heart structure existing at birth;
• Deep vein thrombosis and pulmonary embolism - blood clots in the leg veins, which
can dislodge and move to the heart and lungs.
Heart attacks and strokes are usually keen events and are mostly caused by an obstruction that prevents blood from flowing to the heart or brain. The most common motive for
this is an increase of fatty deposits on the internal walls of the blood vessels. Strokes can
also be caused by bleeding from a blood vessel in the brain or from blood clots.
Key Facts
• CVDs are the number one cause of death globally: more people die annually from
CVDs than from any other cause 2.
• An estimated 17.3 million people died from CVDs in 2008, representing 30% of all
global deaths. Of these deaths, an estimated 7.3 million were due to coronary heart
disease and 6.2 million were due to stroke 3.
• Low- and middle-income countries are disproportionally affected: over 80% of
CVD deaths take place in low- and middle-income countries and occur almost
equally in men and women.
• The number of people who die from CVDs, mainly from heart disease and stroke,
will increase to reach 23.3 million by 2030. CVDs are projected to remain the single
leading cause of death 4.
• Most cardiovascular diseases can be prevented by addressing risk factors such as
tobacco, unhealthy diet, obesity, physical inactivity, high blood pressure, diabetes
and raised lipids.
• 9.4 million deaths each year, or 16.5% of all deaths can be attributed to high blood
pressure 5. This includes 51% of deaths due to stroke and 45% of deaths due to
coronary heart disease 6.
Global status report on noncommunicable diseases 2010. Geneva, World Health Organization, 2011.
Global atlas on cardiovascular disease prevention and control. Geneva, World Health Organization, 2011.
4
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med,
2006, 3(11):e442.
5
Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H et al. A comparative risk assessment of
burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a
systematic analysis for the Global Burden of Disease Study 2010. Lancet, 2012, 380(9859):2224–2260.
6
The global burden of disease: 2004 update. Geneva, World Health Organization, 2008.
2
3
5
CARDIOVASCULAR DISEASES (CVDs):
RISK STATISTICS
• Cardiovascular risk factors such as hypertension, diabetes and hyperlipidaemia cluster together and are major risk factors for
strokes and heart attacks.
• To prevent heart attacks and strokes, the total cardiovascular risk needs to be reduced by lowering all modifiable risk factors.
• The risk of cardiovascular events is two to threefold higher in people with diabetes and the risk is disproportionately higher in women.
• Hypercholesterolaemia is a major cardiovascular risk factor. There is continuous association between total cholesterol and cardiovascular risk.
• Lowering cholesterol in people with moderate-high cardiovascular risk prevents heart attacks and strokes.
There is a considerable body of evidence regarding the nutritional background of atherosclerosis in general and coronary heart disease
in particular. High dietary intakes of saturated fat, trans-fat cholesterol and salt, and low intake of fruits, vegetables and fish increase
the risk of CVD.
Obesity is a cardiovascular risk factor closely linked to diet and physical inactivity. Obesity results when there is an imbalance between
energy intake in the diet and energy expenditure.
Approximately 16 million (1.0%) DALYs (Disability Adjusted Life Years) and 1.7 million (2.8%) of deaths worldwide are
attributable to low fruit and vegetable consumption.
Source: “Avoiding heart attacks and strokes don’t be a victim - protect yourself”, World Health Organization, Geneva, c2005.
6
CVD PREVENTION
AND CONTROL:
PREDIMED STUDY
NEW RULES
Statistical analysis showed that compared to those following the control (low-fat) diet,
participants on the Mediterranean diet with extra-virgin olive oil were 30% less likely
to experience a cardiovascular event, and those on the Mediterranean diet with nuts
were 28% less likely.
“... the results of the PREDIMED trial are of utmost importance because they
convincingly demonstrate that a high vegetable fat dietary pattern is superior
to a low-fat diet for cardiovascular prevention.” 7 Dr. Ramón Estruch, Hospital
Clinic, Barcelona, Spain, Leader and Co-author of PREDIMED Study.
PREDIMED Study findings are consistent with those of prior observational studies
of the cardiovascular protective effects of the Mediterranean diet, olive oil and nuts;
smaller trials assessing effects on traditional cardiovascular risk factors and novel risk
factors, such as markers of oxidation, inflammation, and endothelial dysfunction; and
studies of conditions associated with high cardiovascular risk -namely, the metabolic
syndrome and diabetes. The results of the PREDIMED Study might explain, in part,
the lower cardiovascular mortality incidence in Mediterranean countries compared to
northern European countries or the United States.
The risk of stroke was reduced significantly in the two Mediterranean-diet
groups. This is consistent with epidemiologic studies that have showed an inverse
association between the Mediterranean diet, olive-oil and nut consumption and
incident stroke.
The two Mediterranean diet groups achieved good adherence to the intervention
based on self-reported intakes and blood biomarker measurements. The results of an
interim analysis prompted stopping the trial after a median follow-up of 4.8 years. A
major cardiovascular event occurred in 288 participants. Individuals in the Mediterranean diet with virgin olive oil group (96 events) and the tree nuts group (83 events) had
respectively a 30% and 28% less cardiovascular events and mortality than those in
the control low-fat diet; versus the control group (109 events). No diet-related adverse
effects or weight gain were reported during the trial.
In this trial, an energy-unrestricted Mediterranean diet supplemented with
either extra-virgin olive oil or nuts resulted in an absolute risk reduction of
approximately 3 major cardiovascular events per 1,000 person-years, for a relative risk reduction of approximately 30%, among high-risk persons who were
initially free of cardiovascular disease. These results support the benefits of
the Mediterranean diet for cardiovascular risk reduction.
PREDIMED results can be favourably compared 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 favourable changes
in intermediate pathways of cardio metabolic risk, such as blood lipids, insulin sensitivity, and resistance to oxidation, inflammation, and vasoreactivity.
7
PR Newswire press release issued on behalf of the California Walnut Commission on 25th February 2013.
7
CVD PREVENTION
AND CONTROL:
PREDIMED STUDY
NEW RULES
7,447 participants
Monitored during
4.8 years (average)
In conclusion, in this primary prevention trial, it is observed that an energy-unrestricted
Mediterranean diet, supplemented with extra-virgin olive oil or nuts, results in a substantial reduction in the risk of major cardiovascular events among persons at hish risk.
The results8 support the benefits of the Mediterranean diet for the primary prevention of cardiovascular disease.
Baseline Characteristics of the Study Participants
From October 2003 through June 2009, a total of 8,713 candidates were screened
for eligibility, and 7,447 were randomly assigned to one of the three study groups.
Participants were followed for a median of 4.8 years (interquartile range, 2.8 to 5.8).
After the initial assessment, 209 participants (2.8%) chose not to attend subsequent
visits, and their follow-up was based on reviews of medical records. By December
2010, a total of 523 participants (7.0%) had been lost to follow-up for 2 or more years.
Dropout rates were higher in the control group (11.3%) than in the Mediterranean-diet
groups (4.9%). As compared with participants who remained in the trial, those who
dropped out were younger (by 1.4 years), had a higher BMI (the weight in kilograms
divided by the square of the height in meters; by 0.4), a higher waist-to-weight ratio
(by 0.01), and a lower score for adherence to the Mediterranean diet (by 1.0 points on
the 14-item dietary screener) (P<0.05 for all comparisons).
Compliance with the Dietary Intervention
Participants in the three groups reported similar adherence to the Mediterranean diet at
baseline and similar food and nutrient intakes. During follow-up, scores on the 14-item
Mediterranean-diet screener increased for the participants in the two Mediterranean-diet groups. There were significant differences between these groups and the control
group in 12 of the 14 items at 3 years. Changes in objective biomarkers also indicated
good compliance with the dietary assignments.
Participants in the two Mediterranean-diet groups significantly increased weekly servings of fish (by 0.3 servings) and legumes (by 0.4 servings) in comparison with those in
the control group. In addition, participants assigned to a Mediterranean diet with extra-virgin olive oil and those assigned to a Mediterranean diet with tree nuts significantly
increased their consumption of extra-virgin olive oil (to 50 and 32 g per day, respectively) and tree nuts (to 0.9 and 6 servings per week, respectively). The main nutrient
changes in the Mediterranean-diet groups reflected the fat content and composition of
the supplemental foods. No relevant diet-related adverse effects were reported. There
was no significant difference in physical activity among the three groups.
As with many clinical trials, the observed rates of cardiovascular events were lower than anticipated, with
reduced statistical power to separately assess components of the primary end point. However, favourable
trends were seen for both stroke and myocardial infarction. Even though participants in the control group
received advice to reduce fat intake, changes in total fat were small and the largest differences at the end of
the trial were in the distribution of fat subtypes. The interventions were intended to improve the overall dietary
pattern, but the major between-group differences involved the supplemental items. Thus, extra-virgin olive oil
and nuts were probably responsible for most of the observed benefits of the Mediterranean diets. Differences
were also observed for fish and legumes but not for other food groups. The small between-group differences
in the diets during the trial are probably due to the facts that for most trial participants the baseline diet was
similar to the trial Mediterranean diet and that the control group was given recommendations for a healthy diet,
suggesting a potentially greater benefit of the Mediterranean diet as compared with Western diets.
8
8
Cardioprotective
effect
End Points
The median follow-up period was 4.8 years. A total of 288 primary-outcome events
occurred: 96 in the group assigned to a Mediterranean diet with extra-virgin olive oil
(3.8%), 83 in the group assigned to a Mediterranean diet with nuts (3.4%), and 109 in
the control group (4.4%). Taking into account the small differences in the accrual of
person-years among the three groups, the respective rates of the primary end point
were 8.1, 8.0, and 11.2 per 1,000 person-years.
The unadjusted hazard ratios were 0.70 (95% confidence interval [CI], 0.53 to 0.91)
for a Mediterranean diet with extra-virgin olive oil and 0.70 (95% CI, 0.53 to 0.94) for
a Mediterranean diet with nuts as compared with the control diet (P=0.015, by the
likelihood ratio test, for the overall effect of the intervention).
The results of multivariate analyses showed a similar protective effect of the two
Mediterranean diets versus the control diet with respect to the primary end point.
Regarding components of the primary end point, only the comparisons of stroke risk
reached statistical significance. The results of several sensitivity analyses were also
consistent with the findings of the primary analysis.
Subgroup Analyses
Reductions in disease risk in the two Mediterranean-diet groups as compared with
the control group were similar across the pre-specified subgroups. In addition, in order to take into account the protocol change in October 2006 whereby the intensity of
dietary intervention in the control group was increased, researchers compared hazard
ratios for the Mediterranean-diet groups (both groups merged vs. the control group)
before and after that date. Adjusted hazard ratios were 0.77 (95% CI, 0.59 to 1.00) for
participants recruited before October 2006 and 0.49 (95% CI, 0.26 to 0.92) for those
recruited thereafter (P=0.21 for interaction).
Limitations
PREDIMED study has the following limitations:
• The protocol for the control group was changed halfway through the trial. However,
scientists found no significant interaction between the period of trial enrolment (before vs. after the protocol change) and the benefit in the Mediterranean-diet groups.
• There were losses in the follow-up, predominantly in the control group, but
participants who dropped out had a worse cardiovascular risk profile at baseline
than those who remained in the study, suggesting a bias towards a benefit in the
control group.
• The generality of findings is limited because all participants lived in a Mediterranean
country and were at high cardiovascular risk; whether the results can be generalized
to persons at lower risk or to other settings requires further research.
9
Resources
for Health
Professionals
10
RESOURCES FOR
HEALTH PROFESSIONALS:
KEY MESSAGES
FROM PREDIMED
• A Mediterranean diet supplemented with either extra virgin olive oil or mixed nuts
may cut the risk of cardiovascular events by as much as 30% in subjects at high
risk of developing heart disease, as compared with people advised to eat a reduced-fat diet. 9
• Nuts are good sources of arginine, potassium, vitamin E, and other bioactive compounds. Consequently, the unique composition of nuts may help explain the beneficial effects observed in prospective cohorts and in short-term feeding trials.
• The PREDIMED study is the first large trial to randomize high-risk patients to receive nuts for cardiovascular prevention.
• Dr. Estruch highlights the importance of differentiating between different types of
fat. “Animal fat should be avoided,” he alleges, but “vegetable fats -extra virgin
olive oil and nuts- should be recommended [within] a healthy food pattern such as
the Mediterranean diet.” 10
• In Mediterranean diet groups supplemented with olive oil and nuts, the main end
point (myocardial infarction, stroke or cardiovascular death) was reduced by 30%
and 28% respectively, as compared with the control group.
• Individuals randomized to the Mediterranean diets were not told to reduce calories,
a major barrier to success in many dietary interventions, particularly the long-supported “low-fat” approach.
• Dr. Estruch emphasizes that “The standard American Heart Association (AHA) recommended diet should be modified to reflect these findings: fat is not the problem
with the American diet, we just eat the wrong types of fats.” 11
• Participants in the two Mediterranean-diet groups received either extra-virgin olive
oil (approximately 1 litre per week) or 30 g of mixed nuts per day (15 g of walnuts,
7.5 g of hazelnuts, and 7.5 g of almonds), and those in the control group received
small non-food gifts.
• Weight gain was not linked to the nuts-supplemented diet.
Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a Mediterranean
diet. N Engl J Med 2013; DOI: 10.1056/NEJMoa200303.
10,11
PR Newswire press release issued on behalf of the California Walnut Commission on 25th February 2013.
9
11
RESOURCES FOR HEALTH PROFESSIONALS:
THE BENEFITS OF MED DIET
The Mediterranean diet is identified as the traditional dietary pattern found in olive-growing areas of Crete, Greece, and Southern
Italy in the late 1950s and early 1960s. Its major characteristics
are: 1) a high consumption of grains, legumes, nuts, vegetables,
and fruits; 2) a relatively high-fat consumption (up to 40% of total
energy intake), mostly from monounsaturated fatty acids (MUFA),
which accounts for 20 percent or more of the total energy intake;
3) olive oil for culinary use and dressing of vegetables as the principal source of fat; 4) moderate to high fish consumption; 5) poultry and dairy products (usually as yogurt or cheese) consumed in
moderate to small amounts; 6) low consumption of red meats,
processed meats, and meat products; 7) moderate alcohol intake,
usually in the form of red wine consumed with meals.12
A meta analysis of more than 1.5 million healthy adults demonstrated that following a Med diet was associated with a reduced risk of
overall and cardiovascular mortality, a reduced incidence of cancer
and cancer mortality, and a reduced incidence of Parkinson’s and
Alzheimer’s diseases13. Healthy adults are therefore encouraged to
follow this diet for the prevention of major chronic diseases.
Surprisingly, a low incidence of coronary heart disease (CHD)
is found in some developed countries such as France, Spain,
Greece, Italy, and Portugal, leading to a higher life expectancy as
compared with Northern European countries or the USA14. The
Mediterranean food pattern has been the factor most frequently
invoked to explain this health advantage.
According to a 2008 study published in the British Medical Journal, the traditional Med diet provides substantial protection against
type 2 diabetes15. The study involved over 13,000 graduates from
the University of Navarra in Spain with no history of diabetes, who
were recruited between December 1999 and November 2007,
and whose dietary habits and health were subsequently tracked.
A high adherence to the diet was associated with an 83% relative
reduction in the risk of developing diabetes.
12
Costacou T, Bamia C, Ferrari P, Riboli E, Trichopoulos D, Trichopoulou A. Tracing the Mediterranean diet through principal components and cluster analyses in the Greek
population. Eur J Clin Nutr. 2003;57:1378-85
13
Sofi F, Cesari F, Abbate R, Gensini GF, Casini A. Adherence to Mediterranean diet and health status: meta-analysis. BMJ 2008;337:a1344
14
Tunstall-Pedoe H, Kuulasmaa K, Mahonen M, Tolonen H, Ruokokoski E, Amouyel P. Contribution of trends in survival and coronary-event rates to changes in coronary
heart disease mortality: 10-year results from 37 WHO MONICA project populations. Monitoring trends and determinants in cardiovascular disease. Lancet. 1999 May
8;353(9164):1547-57.
15
Martínez-González MA, de la Fuente-Arrillaga C, Nunez-Cordoba JM, et al. (June 2008). “Adherence to Mediterranean diet and risk of developing diabetes: prospective
cohort study”. BMJ 336 (7657): 1348–51. doi:10.1136/bmj.39561.501007.BE. PMC 2427084. PMID 18511765.
12
A 2008 study published in the New England Journal of Medicine
examined the effects of three diets: low-carb, low-fat, and Mediterranean. The study involved 322 participants and lasted for
two years. The low-carb and Mediterranean diet resulted in the
greatest weight loss, 5.4 kg (12 lbs) and 4.5 kg (10 lbs), respectively. The low-fat diet resulted in a loss of 3.2 kg (7 lbs). One
caution of the study is that 86% of the study participants were
men. The low-carb and Mediterranean diets produced similar
amounts of weight loss in the overall study results and in men. In
the remaining participants who were women, the Mediterranean
diet produced 3.8 kg (8.4 lbs) more weight loss on average than
the low-carb diet. However, the low-carb diet produced more
favourable changes in blood lipids16.
consumption and low meat intake, are more significantly associated with low risk of mortality than other components, such
as cereal and fish consumption. As part of the European Prospective Investigation into Cancer and Nutrition, researchers
followed more than 23,000 Greek men and women for 8.5 years
to see how various aspects of a Med diet affect mortality. Moderate alcohol consumption, high fruit and nut consumption, and
high legume consumption were also associated with lower risk
of mortality19. Med Diet, articulated into extensive lifestyles interventions in a clinical follow-up study, improves renal artery circulation, decreasing renal resistive index, even without significant
modifications of Insulin Resistance. This is a beneficial effect
and modifies the pathophysiology of essential hypertension20.
A meta-analysis published in the British Medical Journal in 2008
showed that following strictly the Mediterranean diet reduced
the risk of dying from cancer and cardiovascular disease, as well
as the risk of developing Parkinson’s and Alzheimer’s disease.
The results report 9%, 9%, and 6% reduction in overall, cardiovascular, and cancer mortality respectively. Additionally, a 13%
reduction in incidence of Parkinson’s and Alzheimer’s diseases
was expected provided strict adherence to the diet17. Furthermore, a 2007 study found that adherence to the Mediterranean
diet may affect not only risk of Alzheimer disease (AD) but also
subsequent disease course: Higher adherence to the Med diet
was associated with lower mortality due to AD18.
A 2011 meta-analysis published in the Journal of the American
College of Cardiology analyzed the results of 50 studies (35 clinical trials, 2 prospective and 13 cross-sectional) covering about
535,000 people to examine the effect of a Med diet on metabolic
syndrome. Researchers reported that the Med diet was associated with lower blood pressure, blood sugar, and triglycerides21.
A study published in the British Medical Journal in 2009 showed
that some components of the Med diet, such as high vegetable
A meta-analysis published in the American Journal of Clinical Nutrition in 2013 compared Mediterranean, vegan, vegetarian, low-glycemic index, low-carbohydrate, high-fiber, and
high-protein diets with control diets. The research concluded
that Mediterranean, low-carbohydrate, low-glycemic index, and
high-protein diets are effective in improving markers of risk for
cardiovascular disease and diabetes22.
16
Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, Golan R, Fraser D, Bolotin A, Vardi H, Tangi-Rozental O, Zuk-Ramot R, Sarusi B, Brickner D, Schwartz
Z, Sheiner E, Marko R, Katorza E, Thiery J, Fiedler GM, Blüher M, Stumvoll M, Stampfer MJ; Dietary Intervention Randomized Controlled Trial (DIRECT) Group. (July 17, 2008).
“Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet.”. N Engl J Med 359 (3): 229–241.
17
Sofi F, Cesari F, Abbate R, Gensini GF, Casini A (2008). “Adherence to Mediterranean diet and health status: meta-analysis”. BMJ (Clinical research ed.) 337 (sep11 2): a1344.
doi:10.1136/bmj.a1344. PMC 2533524. PMID 18786971.
18
Mediterranean diet and Alzheimer disease mortality - Scarmeas et al. 69 (11): 1084. Neurology. 2006-11-21. doi:10.1212/01.wnl.0000277320.50685.7c. Retrieved 2010-08-27.
19
A Trichopoulou, C Bamia, D Trichopoulos. “Anatomy of health effects of Mediterranean diet: Greek EPIC Prospective Cohort Study”. BMJ 2009; 338: b2337.
20
Trovato GM, Pirri C, Martines GF, Tonzuso A, Trovato F, Catalano D. (2010). “Lifestyle interventions, insulin resistance, and renal artery stiffness in essential hypertension.”. Clin
Exp Hypertens. 32 (5): 262–269.
21
Kastorini C-M, Milionis H, Esposito K, Giugliano D, Goudevenos J, Panagiotakos D. (2011). “The Effect of Mediterranean Diet on Metabolic Syndrome and its Components”.
Journal of the American College of Cardiology 57 (11): 1299–1313.
22
Ajala O., English P., Pinkney J. (2013). “Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes”. The American Journal of
Clinical Nutrition 97 (3): 505–516. doi:10.3945/ajcn.112.042457.
13
RESOURCES FOR HEALTH PROFESSIONALS:
SUPPLEMENT MED DIET WITH
A HANDFUL OF NUTS. WHY?
Major between-group differences involved the supplemental items. Therefore, extra-virgin olive oil and nuts were probably responsible for most of the observed benefits.
• Nuts are very high in fats (48-63 g/100 g of edible portion).
• Most nuts are rich in MUFA (mostly, oleic acid), while walnuts are high in PUFAs (linoleic and alpha-linolenic acids).
• The dietary fibre in nuts is high, ranging from 5 to 9% by
weight.
• Nuts are good sources of arginine, potassium, vitamin E,
and other bioactive compounds.
One-half the amount of nuts used in the nut-supplemented
group was made up of walnuts, which are rich in polyunsaturated fatty acids, particularly linoleic acid and alpha-linolenic
acid, plant-derived omega-3 fatty acid, and polyphenols. The
other half of the dose contained almonds and hazelnuts, both
rich in monounsaturated fatty acids and polyphenols. As for
extra virgin olive oil, in addition to being a rich source of monounsaturated fatty acids, it is also a good source of phenolic
antioxidants.
14
Therefore, the Mediterranean diet supplemented with virgin oil
was enriched in monounsaturated fatty acids and phenolic antioxidants, and the Mediterranean supplemented with nuts was
enriched in n-9, n-6, and n-3 polyunsaturated fatty acids, as
well as polyphenols. Although having the same general food
pattern of the Mediterranean diet, the two groups diverged in
the intake of two nutrients: monounsaturated fatty acids and
polyunsaturated fatty acids (including alpha-linolenic acid) that
are proven to be important in the prevention of cardiovascular
diseases, and might have different beneficial effects.
According to the PREDIMED study, an energy-unrestricted
Mediterranean diet supplemented with either extra-virgin olive
oil or nuts resulted in a total risk reduction of approximately 3 major cardiovascular events per 1,000 person-years, for
a relative risk reduction of approximately 30%, among highrisk persons who were initially free of cardiovascular disease.
These results support the benefits of tree nuts for cardiovascular risk reduction.
RESOURCES FOR HEALTH PROFESSIONALS:
SUPPLEMENT MED DIET WITH
A HANDFUL OF NUTS. TIPS
Although packed with unsaturated fatty acids, nuts are still wrongly perceived as fattening by some health professionals and individuals. Because of
this, it is particularly important to dismiss the fear of an eventual weight gain
that a person who is on a weight management program might have.
Scientific research points out that nuts increase satiety. For this reason, the PREDIMED
study suggests that nuts could be eaten anytime during the day except after dinner,
when food compensation in the next meal would not take place.
Here are some suggestions to add healthy nuts to your patient’s diet:
• Top hot or cold cereal with nuts for a nutritious and energy breakfast.
• Add a handful of nuts on top of yogurt.
• Add a handful of nuts on frozen yogurt.
• Use fat-free salad dressing and add nuts to salads.
• Use nuts to substitute croutons in salads or soups.
• Sprinkling chopped nuts to pasta dishes.
• Add nuts to bread, pancakes, waffles or muffins.
• Substituting the traditional milk for nutty milk: almond, cashew, etc.
• Opt for nuts for a tasty and healthy snack.
• Add crunchy taste to steamed veggies with a handful of nuts.
• Toast nuts to enhance the flavour. Bake for 5-10 minutes in a 350-degree oven.
• Opt for nuts in small bags for a great snack to take on the go or to the office.
15
OTHER PREDIMED
STUDY FINDINGS
SUMMARY
An analysis at baseline showed that adherence to Mediterranean diet was inversely
associated with prevalent diabetes, hypertension, dyslipidaemia and obesity23.
In the pilot study conducted in the first individuals randomized to the PREDIMED
study and followed by 3 months, both the olive-oil and the nuts groups showed reduced blood glucose levels, reduced systolic and diastolic blood pressure, and a
lower LDL:HDL cholesterol ratio, as well as reduced levels of oxidised LDL, and circulatory and cellular inflammation biomarkers compared to the low-fat diet24.
PREDIMED results after one year of follow-up showed that a Mediterranean diet rich
in olive oil or nuts protects against oxidative damage25.
The Mediterranean Diet supplemented with nuts was not
associated with a higher risk of weight gain.
Monitored data of non-diabetic participants showed that following either a Mediterranean pattern supplemented with nuts or olive oil resulted in a 50% reduction in
diabetes incidence, compared to the low-fat diet over four years.26
The Mediterranean Diet may be linked to a reduced cognitive impairment and a reduced progression of mild cognitive impairment to dementia27. PREDIMED data found
that individuals randomly assigned to a Mediterranean Diet supplemented with extra-virgin olive oil or mixed nuts for 6 years had better cognitive function than the
control group that followed a low-fat diet.
The study “Effects of Mediterranean diets on kidney function: a report from the PREDIMED trial”28 evaluated the effects of the three interventions on renal function after
1 year of follow-up using data of serum urea and creatinine concentrations, urinary
albumin-to-creatinine rations among other indicators. The results of this substudy
conclude that the 3 dietary interventions of the PREDIMED trial were associated with
improved kidney function.
23
Sánchez-Taínta A, et al. Adherence to a Mediterranean-type diet and reduced prevalence of clustered cardiovascular risk factors in a cohort of 3,204 high-risk patients. Eur J Cardiovasc Prev Rehabil. 2008;15(5):589-93.
24
Estruch R, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomised trial. Ann
Intern Med. 2006;145(1):1-11.
25
Fitó M, Guxens M, Corella D, Sáez G, Estruch R, de la Torre R, Francés F, Cabezas C, López-Sabater Mdel
C, Marrugat J, García-Arellano A, Arós F, Ruiz-Gutierrez V, Ros E, Salas-Salvadó J, Fiol M, Solá R, Covas MI;
PREDIMED Study Investigators. Effect of a traditional Mediterranean diet on lipoprotein oxidation: a randomized
controlled trial. Arch Intern Med. 2007 Jun 11;167(11):1195-203.
26
Salas-Salvadó J, et al. Reduction in the incidence of type 2 diabetes with the Mediterranean diet: results of the
PREDIMED-Reus nutrition intervention randomised trial. Diabetes Care. 2011;34(1):14-9.
27
Journal of Neurology Neurosurgery and Psychiatry
Source reference: Martinez-Gonzalez MA, et al “Mediterranean diet improves cognition: the PREDIMED-NAVARRA randomised trial” J Neurol Neurosurg Psych 2013; DOI: 10.1136/jnnp-2013-305153.
28
Dıaz-Lopez A, Bulló´ M, Martínez-Gonzalez MA, Guasch-Ferre M, Ros E, Basora J, Covas MI, del Carmen
Lopez-Sabater M, Salas-Salvado J; PREDIMED (Prevención con Dieta Mediterranea) Reus Study investigators:
Effects of Mediterranean diets on kidney function: A report from the PREDIMED trial. Am J
Kidney Dis 60: 380–389, 2012
16
OTHER PREDIMED
STUDY FINDINGS
EFFECT OF A MEDITERRANEAN
DIET ENRICHED WITH VIRGIN
OLIVE OIL OR MIXED NUTS ON
CLASSICAL RISK FACTORS OF
CARDIOVASCULAR DISEASE
In the pilot study conducted in the first individuals randomized to the PREDIMED
study and followed by 3 months, both the olive-oil and the nuts groups showed reduced classical cardiovascular risk factors.
Compared to the low-fat diet subjects, the researchers
found that both Mediterranean diets resulted in significant benefits for plasma glucose levels, insulin resistance
(in those non-diabetic participants) systolic and diastolic blood pressure and the ratio of total cholesterol to HDL
cholesterol.
The Med diet with extra olive oil was associated with decreases in plasma glucose
levels of 0.39 millimoles per litre, while the extra nuts Med diet was associated with
a decrease of 0.30 millimoles per litre. Systolic blood pressure decreased 5.9 mmHg
for the Med diet plus olive oil group, and 7.1 mmHg for the Med diet plus nuts group.
The ratio of total cholesterol to HDL cholesterol, reported to be the most specific lipid
risk factor for CVD, also decreased for both Med diet groups compared to the low-fat
group (reductions of 0.38 and 0.26 for the olive oil and nut groups, respectively). The
Med diet plus olive oil also produced significant reductions in the levels of C-reactive
protein, a pro-inflammatory protein linked to heart disease, and other inflammatory or
endothelial markers of cardiovascular disease.29
Estruch R, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomised trial. Ann
Intern Med. 2006;145(1):1-11.
29
17
OTHER PREDIMED
STUDY FINDINGS
OLIVE OIL, NUTS
AND OXIDATION
Olive oil, a rich source of monounsaturated fatty acids, is a main component of the
Mediterranean diet, and virgin olive oil retains all the lipophilic components of the fruit
and phenolic compounds with strong antioxidant and anti-inflammatory properties.
Tree nuts, which are common to the Mediterranean diet, also have a favorable fatty
acid profile and are a rich source of nutrients and other bioactive compounds, such
as fiber, phytosterols, folic acid, and antioxidants, which may beneficially influence
the risk for CHD through oxidation. Current evidence implicates oxidative damage as
part of the pathophysiological changes occurring in various diseases, such as coronary heart disease, cancer, neurodegenerative disease, and also aging, but as yet,
there are no randomized controlled intervention studies assessing the efficacy of the
Mediterranean diet on in vivo lipoprotein oxidation.
The PREDIMED study allowed investigators to test the hypothesis that oxidized LDL
might play a major role in atherosclerosis and cardiovascular disease.
After analyzing the preliminary 3-month data from approximately 125 patients in
each treatment arm, Maribel Covas and colleagues from the IMIM-Institut de Recerca del Hospital del Mar, Barcelona, Spain reported significant
reductions
in the amount of oxidized LDL cholesterol among those
randomized to the Mediterranean diet when compared
with those who ate just a low-fat diet .
30
This study clearly showed an antioxidant effect with a diet rich in monounsaturated
fatty acids, such as a diet rich in fruits and vegetables and supplemented with virgin
olive oil and nuts. According to Maribel Covas, the cardioprotective effects of the
Mediterranean diet are likely due to improving important cholesterol ratios, as well as
the effects on blood pressure and inflammation. This study, however, confirms previous hypotheses proposing an antioxidant effect with the popular diet.
In another substudy conducted on 110 females with metabolic syndrome recruited into the PREDIMED Study, it has been observed after 1-year of intervention that
urinary F2-IP decreased in all intervention groups; the decrease in MedDiet groups
reaching a borderline significance versus that of the control group31. Urinary 8-oxodG was also reduced in all groups, with a higher decrease in both MedDiet groups
versus the control group. That study concluded that the MedDiet reduces oxidative
damage to lipids and DNA in MetS (Metabolic syndrome) individuals. Data from this
study provide evidence to recommend the traditional MedDiet as a useful tool in the
management of MetS.
Fitó M, Guxens M, Corella D, Sáez G, Estruch R, de la Torre R, Francés F, Cabezas C, López-Sabater Mdel
C, Marrugat J, García-Arellano A, Arós F, Ruiz-Gutierrez V, Ros E, Salas-Salvadó J, Fiol M, Solá R, Covas MI;
PREDIMED Study Investigators. Effect of a traditional Mediterranean diet on lipoprotein oxidation: a randomized controlled trial. Arch Intern Med. 2007 Jun 11;167(11):1195-203.
31
Mitjavila MT, Fandos M, Salas-Salvadó J, Covas MI, Borrego S, Estruch R, Lamuela-Raventós R, Corella
D, Martínez-Gonzalez MÁ, Sánchez JM, Bulló M, Fitó M, Tormos C, Cerdá C, Casillas R, Moreno JJ, Iradi
A, Zaragoza C, Chaves J, Sáez GT. The Mediterranean diet improves the systemic lipid and DNA oxidative
damage in metabolic syndrome individuals. A randomized, controlled, trial. Clin Nutr. 2013 Apr;32(2):172-8.
30
18
EFFECTS ON
METABOLIC SYNDROME
A cross-sectional study conducted with 808 participants of the
Reus PREDIMED Centre, found an inverse association between
quartiles of adherence to the MedDiet (14-point score) and the
prevalence of MetS (Metabolic syndrome).32 After adjusting for
age, sex, total energy intake, smoking status and physical activity, participants with the highest score of adherence to the MedDiet (>/=9 points) had the lowest risk of having MetS compared
to those in the lowest quartile. Participants with the highest
MedDiet adherence had 47 and 54% lower odds of having low
HDL-c and hypertriglyceridemia MetS criteria, respectively, than
those in the lowest quartile. Some components of the MedDiet,
such as olive oil, legumes and red wine were associated with
lower prevalence of MetS.
A traditional Mediterranean diet enriched
with nuts could be a useful tool in the management of metabolic syndrome.
Another analysis published in Archives of Internal Medicine
looked specifically at the effect of the PREDIMED diets on metabolic syndrome status after intervention for one year. Metabolic
syndrome prevalence was significantly reduced, from 61.4% of
initial participants meeting the criteria, by 13.7% with the Mediterranean diet supplemented with nuts, non-significantly by
6.7% with the Mediterranean diet supplemented with olive oil,
and by just 2% for the low-fat control diet. Importantly, the main
metabolic syndrome component reduced by the nut diet was
waist circumference. As there were no body weight changes,
this finding suggests fat redistribution with nut consumption33.
Nut consumption was inversely associated
with the prevalence of general obesity, central obesity, Metabolic syndrome (MetS),
and diabetes in people with high cardiovascular risk.
The study “Cross-Sectional Assessment of Nut Consumption and
Obesity, Metabolic Syndrome and Other Cardiometabolic Risk
Factors: The PREDIMED Study”34 published in the PLOS ONE
Journal -an open access peer-reviewed scientific journal published
by the Public Library of Science- in early 2013, demonstrated that
in a Mediterranean population at high risk for CVD, the frequency
of nut consumption was inversely associated with obesity, MetS,
and diabetes prevalence.
In a cross-sectional study of 7,210 men and women (mean age,
67 years) a high frequency of nut consumption was inversely
associated with the prevalence of obesity, MetS35 and diabetes,
suggesting that nut consumption has protective effects on cardiometabolic risk. The suggested benefit on MetS was attributed
to a reduced frequency of abdominal obesity, but not of high fasting glucose, hypertension or atherogenic dyslipidemia.
Babio N, et al. Adherence to the Mediterranean diet and risk of metabolic syndrome and its components. Nutr Metab Cardiovasc Dis. 2009;19(8):563-70.
Salas-Salvadó J, et al. Effect of a Mediterranean diet supplemented with nuts on metabolic syndrome status: one-year results of the PREDMED randomised trial. Arch
Intern Med. 2008;168(22):2449-58.
34
Ibarrola-Jurado N, Bulló M, Guasch-Ferré M, et al. on behalf of the PREDIMED Study Investigators. Cross-Sectional Assessment of Nut Consumption and Obesity,
Metabolic Syndrome and Other Cardiometabolic Risk Factors: The PREDIMED Study. PLoS One. 2013 ;8:e57367.
35
MetS was defined by the harmonized ATPIII and IDF criteria. Diabetes and hypertension were assessed by clinical diagnosis and dyslipidemia (high triglycerides, low
HDL-cholesterol, and hypercholesterolemia) by lipid analyses. Nut consumption was assessed using a validated food frequency questionnaire and categorized as <1,
1-3, and >3 servings/wk. Control of confounding was done with multivariate logistic regression.
32
33
19
OTHER PREDIMED
STUDY FINDINGS
DIABETES
The study “Reduction in the Incidence of
Type 2 Diabetes With the Mediterranean
Diet Results of the PREDIMED-Reus nutrition intervention randomized trial”36 tested the effects of two Mediterranean diet
(MedDiet) interventions versus a low-fat
diet on incidence of diabetes.
Characteristically, the MedDiet is a highfat, high-unsaturated fat dietary pattern, a
feature that was maximized in the study
by the free provision of virgin olive oil (rich
in MUFAs) and mixed nuts (rich in MUFAs
and polyunsaturated fatty acids) to participants in the MedDiet groups.
The research was based on a three-group
randomized trial in 418 non-diabetic subjects, aged 55-80 years, recruited in one
center (PREDIMED-Reus, northeastern
Spain) of the PREDIMED study. Participants were randomly assigned to education on a low-fat diet (control group) or to
one of two Med Diets, supplemented with
either free virgin olive oil (1 liter/week) or
nuts (30 g/day). Diets were ad libitum, and
no advice on physical activity was given.
The main outcome was diabetes incidence diagnosed by the 2009 American
Diabetes Association criteria.
After a median follow-up of 4 years, diabetes incidence was 10.1% (95% CI 5.115.1), 11.0% (5.9-16.1), and 17.9% (11.424.4) in the Med Diet with olive oil group,
the Med Diet with nuts group, and the
control group, respectively. Multivariable
adjusted hazard ratios of diabetes were
0.49 (0.25-0.97) and 0.48 (0.24-0.96) in
the Med Diet supplemented with olive oil
and nuts groups, respectively, compared
with the control group. When the two Med
Diet groups were pooled and compared
diabetes incidence was reduced by 52%
(27-86). In all study arms, increased
with the control group,
adherence to the Med Diet was inversely associated with diabetes incidence.
Diabetes risk reduction occurred in the
absence of significant changes in body
weight or physical activity.
The results support the protective role of olive oil and
nuts against diabetes risk,
as both MedDiets were associated with
improved fasting glucose in diabetic
participants and decreased insulin resistance in those without diabetes after a
3-month follow-up, again in the absence
of weight loss.
Not enough evidence was found to support that a Mediterranean Diet is associated with lower levels of HbA1c in a subset
of 383 patients with T2DM, but PREDIMED results did suggest an inverse trend.
Future studies with larger sample size are
necessary.37
36
Salas-Salvadó J, Bulló M, Babio N, et al. on behalf
of the PREDIMED study investigators. Reduction in the
Incidence of Type 2-Diabetes with the Mediterranean
Diet: Results of the PREDIMED-Reus Nutrition Intervention Randomized Trial. Diabetes Care 2011;34:14-9.
37
Díez-Espino J, et al. Adherence to the Mediterranean
diet in patients with type 2 diabetes mellitus and HbA1c
level. Ann Nutr Metab. 2011;58(1):74-8.
20
ATHEROSCLEROSIS
PLAQUE
In a PREDIMED substudy conducted by the Navarra group (North of Spain)38 , changes in
mean intima-media thickness (IMT) of participants were measured ultrasonographically
in the far wall of bilateral common carotid arteries after one year. It has been shown
that MedDiets enhanced with virgin olive oil (VOO) or nuts were not effective in inducing ultrasonographic regression of carotid atherosclerosis after one year of intervention.
However, they were effective among subjects with elevated baseline IMT, suggesting
subclinical atherosclerosis may respond to dietary intervention within a relatively short time frame only among
subjects with a high initial atherosclerotic burden.
that
NUT INTAKE AND
MORTALITY RISK
PREDIMED researchers hypothesized that nut consumption would be strongly associated with mortality in the cohort of
the PREDIMED study, including older men and women at high cardiovascular risk.39 To this end, in this cohort researchers
longitudinally examined the association between the frequency of nut consumption at baseline and the risk of mortality at
the end of follow-up.
Researchers studied 7,216 men and women aged 55 to 80 years randomized to one of three interventions (Mediterranean diets supplemented with nuts or olive oil and control diet). Nut consumption was assessed at baseline and mortality
was ascertained by medical records and linkage to the National Death Index. Multivariable-adjusted Cox regression and
multivariable analyses with generalized estimating equation models were used to assess the association between yearly
repeated measurements of nut consumption and mortality.
During a median follow-up of 4.8 years, 323 total deaths, 81 cardiovascular deaths and 130 cancer deaths occurred.
Nut consumption was associated with a significantly reduced risk of all-cause mortality. Compared to non-consumers,
subjects consuming nuts >3 servings/week (32% of the cohort) had a 39% lower
mortality risk. A similar protective effect against cardiovascular and cancer mortality was observed. Participants
allocated to the Mediterranean diet with nuts group, who consumed nuts >3 servings/week at baseline, had the lowest
total mortality risk.
Increased frequency of nut consumption was associated with a significantly reduced
risk of mortality in a Mediterranean population at high cardiovascular risk.
Murie-Fernandez M, Irimia P, Toledo E, Martínez-Vila E, Buil-Cosiales P, Serrano-Martínez M, Ruiz-Gutiérrez V,
Ros E, Estruch R, Martínez-González MÁ; PREDIMED Investigators. Carotid intima-media thickness changes with
Mediterranean diet: a randomized trial (PREDIMED-Navarra). Atherosclerosis. 2011 Nov;219(1):158-62.
39
Guasch-Ferré M, Bulló M, Martínez-González MA, Ros E, Corella D, Estruch R, Fitó M, Arós F, Julia Wärnberg J,
Fiol M, Lapetra J et al, on behalf of the PREDIMED study group. Frequency of nut consumption and mortality risk
in the PREDIMED nutrition intervention trial. BMC Medicine 2013, 11:
38
21
OTHER PREDIMED
STUDY FINDINGS
COGNITIVE FUNCTION
low-fat control diet. The global cognitive performance was examined by Mini-Mental State Examination (MMSE) and Clock
Drawing Test (CDT) after 6.5 years of nutritional intervention.
After adjustment for sex, age, education, Apolipoprotein E genotype, family history of cognitive impairment/dementia, smoking,
physical activity, body mass index, hypertension, dyslipidaemia,
diabetes, alcohol and total energy intake, participants allocated
to the MedDiet+EVOO showed higher mean MMSE and CDT
scores with significant differences versus control. The adjusted
means of MMSE and CDT scores were also higher for participants allocated to the MedDiet+Nuts versus control (These results did not differ after controlling for incident depression).
The findings of the study showed that an
intervention with Med Diets enhanced with
either extra-virgin olive oil or nuts appears
to improve cognition compared with a lowfat diet.
A substudy of the larger PREDIMED trial published in the Journal of Neurology,
Neurosurgery & Psychiatry40, found that individuals randomly assigned to a Mediterranean diet supplemented with extra-virgin
olive oil or mixed nuts for six years had better cognitive function than control patients
who followed a low-fat diet.
Increased consumption of antioxidant-rich foods in general,
and polyphenols in particular, is associated with better cognitive
performance in elderly subjects at high cardiovascular risk. The
results reinforce the notion that Mediterranean diet components
might counteract age-related cognitive decline. Previous observational studies reported beneficial effects of the Mediterranean
diet (MedDiet) on cognitive function, but results were inconsistent. PREDIMED researchers assessed the effect on cognition of
a nutritional intervention using two Med Diet patterns in comparison with a low-fat control diet.
Researchers from the Navarra University assessed 522 participants at high vascular risk (44.6% men, age 74.6 ± 5.7 years
at cognitive evaluation) enrolled in the PREDIMED study, after a
nutritional intervention comparing two Med Diets (supplemented
with either extra-virgin olive oil (EVOO) or mixed nuts) versus a
Brain oxidative processes play a major role in age-related cognitive decline, thus consumption of antioxidant-rich foods might
help preserve cognition. PREDIMED researchers assessed whether consumption of antioxidant-rich foods in the Mediterranean diet
relates to cognitive function in the elderly. In 447 asymptomatic
subjects at high cardiovascular risk enrolled in the PREDIMED
study, investigators assessed food intake and cardiovascular risk
profile, and used neuropsychological tests to evaluate cognitive
function. They also measured urinary polyphenols as an objective
biomarker of intake. Associations between energy-adjusted food
consumption, urinary polyphenols, and cognitive scores were assessed by multiple linear regression models adjusted for potential
confounders. Consumption of some foods was independently related to better cognitive function.
Specific foods linked to various aspects of cognitive function
included: a) total olive oil consumption was associated with
improved immediate verbal memory, b) virgin olive oil and coffee were both associated with improvements in delayed verbal
memory, c) walnuts were associated with improved working
memory, and d) wine was associated with improved Mini-Mental
State Examination scores.
The authors conclude, “Increased consumption of antioxidant-rich foods in general and of polyphenols in particular is
associated with better cognitive performance in elderly subjects
at high cardiovascular risk. The results reinforce the notion that
Mediterranean diet components might counteract age-related
cognitive decline.” 41
40
Martínez-Lapiscina EH, Clavero P, Toledo E, Estruch R, Salas-Salvadó J, San Julián B, Sanchez-Tainta A, Ros E, Valls-Pedret C, Martinez-Gonzalez MA. Mediterranean
diet improves cognition: the PREDIMED-NAVARRA randomised trial. J Neurol Neurosurg Psychiatry. 2013 May 13. [Epub ahead of print] PubMed PMID: 23670794.
41
Valls-Pedret C, Lamuela-Raventós RM, Medina-Remón A, Quintana M, Corella D, Pintó X, Martínez-González MÁ, Estruch R, Ros E. Polyphenol-rich foods in the Mediterranean diet are associated with better cognitive function in elderly subjects at high cardiovascular risk. J Alzheimers Dis. 2012;29(4):773-82.
22
RENAL FUNCTION
Chronic kidney disease (CKD) is recognized as a major global public health problem.
It is defined as kidney damage usually signaled by the presence of albuminuria and/
or a reduced glomerular filtration rate. A substudy of the larger PREDIMED trial, the
study “Effects of Mediterranean diets on kidney function: a report from the PREDIMED trial,” evaluated the effects of the three interventions on kidney function42.
Researchers assessed 665 participants at high vascular risk recruited in one center
(PREDIMED-Reus, northeastern Spain) of the PREDIMED study, after one year a nutritional intervention comparing two MedDiets (a MedDiet supplemented with virgin
olive oil (VOO) and a MedDiet supplemented with mixed nuts) versus a low-fat control
diet. At baseline and after one year of follow-up, urinary albumin-to-creatinine ratio
(ACR) and the estimated glomerular filtration rate (eGFR), among other indicators,
were evaluated as two widely used measures for assessing kidney function.
After one-year of intervention, the three dietary approaches were associated with
improved kidney function, with similar average increases in eGFR, but no changes in
ACR ratios after adjustment for various confounders.
The results of this substudy conclude that the three dietary
interventions of the PREDIMED trial were associated with
improved kidney function. However, these findings do not support the
notion that the MedDiet has a beneficial effect on kidney function over and above
that recommended for a low-fat diet in elderly individuals at high cardiovascular risk.
Other epidemiological studies have appraised individual nutrients or foods and have
suggested that dietary intake of some macronutrients may be involved in the development of CKD. Hence, another analysis published in the Journal of Clinical Nutrition,
evaluated the associations between macronutrient intake and the prevalence of CKD
or microalbuminuria (MiA) in individuals at high cardiovascular risk43 .
This cross-sectional analysis, conducted in 2,123 nondiabetic individuals from the
PREDIMED study showed that a high intake of fiber was associated with a decreased
risk of CKD, while a high intake of n-6 PUFA was associated inversely with eGFR and
directly with CKD risk.
The findings of the study add new knowledge to the current scientific literature about the possible benefits that
high amounts of fiber or low amounts of n-6 PUFA in the
diet may have on kidney function.
Díaz-López A, Bulló M, Martínez-González MÁ, Guasch-Ferré M, Ros E, Basora J, Covas MI, del Carmen
López-Sabater M, Salas-Salvadó J; PREDIMED (Prevención con Dieta Mediterránea) Reus Study Investigators. Effects of Mediterranean diets on kidney function: a report from the PREDIMED trial. Am J Kidney Dis.
2012 Sep;60(3):380-9.
43
Díaz-López A, Bulló M, Basora J, Martínez-González MÁ, Guasch-Ferré M, Estruch R, Wärnberg J, Serra-Majem L, Arós F, Lapetra J, Ros E, Pintó X, Covas MI, Salas-Salvadó J. Cross-sectional associations between macronutrient intake and chronic kidney disease in a population at high cardiovascular risk. Clin Nutr.
2013 Aug;32(4):606-12.
42
23
OTHER PREDIMED
STUDY FINDINGS
EFFECTS ON
INFLAMMATORY MARKERS
The effects of virgin olive oil and nuts, as key
foods of the Mediterranean diet, on inflammatory biomarkers related to atherosclerosis.
Inflammation has been pointed out as a mechanism underlying
cardiovascular risk and potentially modulated by diet.
PREDIMED research demonstrated that adherence to the Mediterranean diet supplemented with nuts or olive oil is associated with
reduced cardiovascular risk. A cross-sectional analysis conducted
on 772 subjects reported that those subjects with the highest consumption of nuts and virgin olive oil showed the lowest circulating
concentrations of VCAM-1, ICAM-1, IL-6 and CRP 44.
Later, in two sub-studies 45 -46 of the PREDIMED, researchers analyzed the effects at three months of two Med-Diet interventions
supplemented with either virgin olive oil (VOO) or nuts compared
with a control low-fat diet (LFD). In both studies, Med-Diets supplemented with nuts or olive oil showed an anti-inflammatory
effect reducing serum C-reactive protein, Interleukin-6 (IL6) and
endothelial and monocytary adhesion molecules and chemok-
ines (P < 0.05; all), whereas these parameters increased after the
LFD intervention (P < 0.05; all). The long-term effect (one year)
of these interventions, as well as the effect of different Med-Diet
components in the reduction of inflammatory biomarkers, has
also been additionally evaluated in 516 high-risk subjects. After
the follow-up, the Med-Diet groups had significant decreases in
the plasma concentrations of IL6, tumor necrosis factor receptor
(TNFR) 60 and TNFR80 (P < 0.05), while intercellular adhesion
molecule 1 (ICAM-1), TNFR60 and TNFR80 concentrations increased in the LFD group (P < 0.002). In addition, those subjects
allocated in the highest tertile of VOO and vegetable consumption had a significant diminution of plasma TNFR60 concentration compared with those in tertile 1 (P < 0.02).
In conclusion, the Med-Diet provides an anti-inflammatory effect to the cardiovascular
system since it down-regulates cellular and
circulating inflammatory biomarkers related to atherogenesis in subjects at high cardiovascular risk.
Salas-Salvadó J, Garcia-Arellano A, Estruch R, Marquez-Sandoval F, Corella D, Fiol M, Gómez-Gracia E, Viñoles E, Arós F, Herrera C, Lahoz C, Lapetra J, Perona
JS, Muñoz-Aguado D, Martínez-González MA, Ros E; PREDIMED Investigators. Components of the Mediterranean-type food pattern and serum inflammatory markers
among patients at high risk for cardiovascular disease. Eur J Clin Nutr. 2008 May;62(5):651-9. Epub 2007 Apr 18. PubMed PMID: 17440519.
45
Urpi-Sarda M, Casas R, Chiva-Blanch G, Romero-Mamani ES, Valderas-Martínez P, Salas-Salvadó J, Covas MI, Toledo E, Andres-Lacueva C, Llorach R, García-Arellano
A, Bulló M, Ruiz-Gutierrez V, Lamuela-Raventos RM, Estruch R. The Mediterranean diet pattern and its main components are associated with lower plasma concentrations
of tumor necrosis factor receptor 60 in patients at high risk for cardiovascular disease. J Nutr. 2012 Jun;142(6):1019-25. doi: 10.3945/jn.111.148726. Epub 2012 Apr 25.
46
Estruch R, Martínez-González MA, Corella D, Salas-Salvadó J, Ruiz-Gutiérrez V, Covas MI, Fiol M, Gómez-Gracia E, López-Sabater MC, Vinyoles E, Arós F, Conde M,
Lahoz C, Lapetra J, Sáez G, Ros E; PREDIMED Study Investigators. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern
Med. 2006 Jul 4;145(1):1-11.
44
24
PREDIMED RESEARCH CORE
PUBLICATIONS
2006
2009
Estruch R; Martínez-González MA; Corella D; et al.
Effects of a Mediterranean-Style Diet on Cardiovascular Risk Factors. A Randomized Trial.
Ann Intern Med. 2006;145:1-11.
Zamora-Ros R, Urpí-Sardà M, Lamuela-Raventós
RM, et al.
Resveratrol metabolites in urine as biomarker of
wine intake in free-living subjects: The PREDIMED Study.
Free Radic Biol Med. 2009;46:1562-6.
Zamora-Ros R; Urpí-Sardà M; Lamuela-Raventós RM; et al.
Diagnostic Performance of Urinary Resveratrol
Metabolites as a Biomarker of Moderate Wine
Consumption.
Clin Chem. 2006;52:1373-80.
Trichopoulou A; Corella D; Martínez-González MA; et al.
The Mediterranean Diet and Cardiovascular Epidemiology.
Nutr Rev. 2006;64:13-19.
2007
Samaha F; Martínez-González MA; Ros E; et al.
Effects of a Mediterranean-Style Diet on Cardiovascular Risk Factors (Letter).
Ann Intern Med. 2007;146:73; author reply 73-4.
Fitó M; Guxens M; Corella D; et al.
Effect of a Traditional Mediterranean Diet on Lipoprotein Oxidation. A Randomized Controlled Trial.
Arch Intern Med. 2007;167:1195-203.
2008
Buil-Cosiales P; Irimia P; Berrade N; et al.
Carotid intima-media thickness is inversely associated with olive oil consumption.
Atherosclerosis. 2008;196:742-8.
Salas-Salvadó J; Garcia-Arellano A; Estruch R; et al.
Components of the mediterranean-type food pattern and serum Inflammatory markers among patients at high risk for cardiovascular disease.
Eur J Clin Nutr. 2008;62:651-9.
Sánchez-Tainta A; Estruch R ; Bulló M; Corella D;
Gómez-Gracia E; Fiol M; Algorta J; I. Covas M; Lapetra J; Zazpe I; Ruiz-Gutiérrez V; Ros E; MartínezGonzález MA for the PREDIMED group
Adherence to a Mediterranean-type diet and reduced prevalence of clustered cardiovascular risk
factors in a cohort of 3204 high-risk subjects
Eur J Cardiov Prev Rehab. 2008;15:589-93.
Zazpe I; Sánchez-Tainta A; et al, for the PREDIMED group.
A Large Randomized Individual and Group Intervention Conducted by Registered Dietitians Increased Adherence to Mediterranean - TypeDiets:
The PREDIMED Study
J Am Diet Assoc. 2008;108:1134-1144.
Salas-Salvadó J, Fernández-Ballart J, Ros E, et al for
the PREDIMED Study Investigators.
Effect of a Mediterranean diet supplemented with
nuts on metabolic syndrome status: one-year results of the PREDIMED randomized trial.
Arch Intern Med. 2008;168:2449-58.
Medina-Remón A, Barrionuevo-González A, Zamora-Ros R, et al.
Rapid Folin-Ciocalteu method using microtiter
96-well plate cartridges for solid phase extraction
to assess urinary total phenolic compounds, as a
biomarker of total polyphenols intake.
Anal Chim Acta. 2009;634:54-60.
Razquin C, Martínez JA, Martinez-Gonzalez MA, et al.
A 3 years follow-up of a Mediterranean diet rich in
virgin olive oil is associated with high plasma antioxidant capacity and reduced body weight gain.
Eur J Clin Nutr. 2009 ;63:1387-93.
Schröder H, de la Torre R, Estruch R, et al.
Alcohol consumption is associated with high concentrations of urinary hydroxytyrosol
Am J Clin Nutr. 2009;90:1329-35.
Martinez-Gonzalez MA, Bes-Rastrollo M, Serra-Majem L, et al.
Mediterranean food pattern and the primary prevention of chronic disease: recent developments.
Nutr Rev. 2009;67:S111-6.
Buil-Cosiales P, Irimia P, Ros E, et al.
Dietary fibre intake is inversely associated with
carotid intima-media thickness: a cross-sectional
assessment in the PREDIMED study.
Eur J Clin Nutr. 2009;63:1213-9.
Bulló M, Amigó-Correig P, Márquez-Sandoval F,et al.
Mediterranean diet and high dietary acid load associated with mixed nuts: effect on bone metabolism in elderly subjects.
J Am Geriatr Soc. 2009;57:1789-98.
Estruch R, Martínez-González MA, Corella D, Basora-Gallisá J, Ruiz-Gutiérrez V, Covas MI, Fiol M, Gómez-Gracia E, López-Sabater MC, Escoda R, Pena
MA, Diez-Espino J, Lahoz C, Lapetra J, Sáez G, Ros
E; PREDIMED Study Investigators.
Effects of dietary fibre intake on risk factors for
cardiovascular disease in subjects at high risk.
J Epidemiol Community Health. 2009;63:582-8.
Barceló F, Perona JS, Prades J, et al.
Mediterranean-style diet effect on the structural
properties of the erythrocyte cell membrane of
hypertensive patients: the Prevencion con Dieta
Mediterranea Study.
Hypertension. 2009;54:1143-50.
Razquin C, Martinez JA, Martinez-Gonzalez MA, et al.
The Mediterranean diet protects against waist
circumference enlargement in 12Ala carriers for
the PPARgamma gene: 2 years’ follow-up of 774
subjects at high cardiovascular risk.
Br J Nutr. 2009;102:672-9.
Babio N, Bulló M, Basora J, Martínez-González MA,
Fernández-Ballart J, Márquez-Sandoval F, Molina C,
Salas-Salvadó J; on behalf of the Nureta-PREDIMED
investigators.
Adherence to the Mediterranean diet and risk of
metabolic syndrome and its components.
Nutr Metab Cardiovasc Dis. 2009;19:563-70.
Guxens M, Fitó M, Martínez-González MA, et al.
Hypertensive status and lipoprotein oxidation in
an elderly population at high cardiovascular risk.
Am J Hypertens. 2009;22:68-73.
Corella D, González JI, Bulló M, et al for the PREDIMED group
Polymorphisms cyclooxygenase-2 -765G>C and
interleukin-6 -174G>C are associated with serum
inflammation markers in a high cardiovascular
risk population and do not modify the response
to a Mediterranean diet supplemented with virgin
olive oil or nuts.
J Nutr. 2009;139:128-34.
Mena MP, Sacanella E, Vazquez-Agell M, et al for the
PREDIMED group.
Inhibition of circulating immune cell activation: a
molecular antiinflammatory effect of the Mediterranean diet.
Am J Clin Nutr. 2009;89:248-56.
Fandos M, Corella D, Guillén M, et al.
Impact of cardiovascular risk factors on oxidative
stress and DNA damage in a high risk Mediterranean population.
Free Radic Res. 2009;43:1179-86.
Escurriol V, Cofán M, Serra M, et al.
Serum sterol responses to increasing plant sterol
intake from natural foods in the Mediterranean diet.
Eur J Nutr. 2009;48:373-82.
Toledo E, Delgado-Rodríguez M, Estruch R, et al.
Low-fat dairy products and blood pressure: follow-up of 2290 older persons at high cardiovascular risk participating in the PREDIMED study.
Br J Nutr. 2009;101:59-67.
2010
Llorente-Cortés V, Estruch R, Mena MP, et al.
Effect of Mediterranean diet on the expression of
pro-atherogenic genes in a population at high cardiovascular risk.
Atherosclerosis. 2010;208:442-50.
Razquin C, Martínez JA, Martínez-González MA, et al.
A 3-year intervention with a Mediterranean diet
modified the association between the rs9939609
gene variant in FTO and body weight changes.
Int J Obes. 2010;34:266-72.
Fernández-Ballart JD, Piñol JL, Zazpe I, et al.
Relative validity of a semi-quantitative food-frequency questionnaire in an elderly Mediterranean
population of Spain.
Br J Nutr. 2010;1-9.
25
Zazpe I, Estruch R, Toledo E, et al.
Predictors of adherence to a Mediterranean-type
diet in the PREDIMED trial.
Eur J Nutr. 2010;49:91-9.
Konstantinidou V, Covas MI, Muñoz-Aguayo D,et al.
In vivo nutrigenomic effects of virgin olive oil polyphenols within the frame of the Mediterranean
diet: a randomized controlled trial.
FASEB J. 2010;24:2546-57.
Prieto RM, Fiol M, Perello J, et al.
Effects of Mediterranean diets with low and high
proportions of phytate-rich foods on the urinary
phytate excretion.
Eur J Nutr. 2010;49:321-6.
de la Fuente-Arrillaga C, Vázquez Ruiz Z, Bes-Rastrollo M, et al
Reproducibility of an FFQ validated in Spain.
Public Health Nutr. 2010;28:1-9.
Lohse B, Psota T, Estruch R, et al. on behalf of the
PREDIMED study investigators
Eating Competence of Elderly Spanish Adults is
Associated with a Healthy Diet and a Favorable
Cardiovascular Disease Risk Profile.
J Nutr. 2010;140:1322-7.
Perona JS, Covas MI, Fito M, et al.
Reduction in systemic and VLDL triacylglycerol concentration after a 3-month mediterranean-style diet
in high-cardiovascular-risk subjects
J Nutr Biochem. 2010;21:892-8.
Razquin C, Martínez JA, Martínez-González MA, et al.
A 3-year Mediterranean-style dietary intervention
may modulate the association between adiponectin gene variants and body weight change.
Eur J Nutr. 2010;49:311-9.
Corella D, Carrasco P, Fitó M, et al.
Gene-environment interactions of CETP gene
variation in a high cardiovascular risk Mediterranean population.
J Lipid Res. 2010;51:2798-807.
Razquin C, Martínez JA, Martínez-Gonzalez MA, et al.
A Mediterranean diet rich in virgin olive oil may reverse the effects of the - 174G/C IL6 gene variant
on 3-year body weight change.
Mol Nutr Food Res. 2010;54, 1-8.
Estruch R.
Anti-inflammatory effects of the Mediterranean
diet: the experience of the PREDIMED study.
Proc Nutr Soc. 2010;69:333-40.
Sotos-Prieto M, Guillén M, Guillem-Sáiz P, et al.
The rs1466113 polymorphism in the somatostatin
receptor 2 gene is associated with obesity and
food intake in a Mediterranean population.
Ann Nutr Metab. 2010 ;57:124-31.
2011
Medina-Remón A, Zamora-Ros R, Rotchés-Ribalta
M, et al et al on behalf of the PREDIMED group
Total polyphenol excretion and blood pressure in
subjects at high cardiovascular risk.
Nutr Metab Cardiovasc Dis. 2011;21:323-31
26
Casas-Agustench P, Bulló M, Ros E, Basora J, et al
on behalf of the Nureta-PREDIMED investigators
Cross-sectional association of nut intake with adiposity in a Mediterranean population.
Nutr Metab Cardiovasc Dis. 2011;21:518-25
Salas-Salvadó J, Bulló M, Babio N, et al. on behalf of
the PREDIMED study investigators
Reduction in the Incidence of Type 2-Diabetes
with the Mediterranean Diet: Results of the PREDIMED-Reus Nutrition Intervention Randomized Trial.
Diabetes Care 2011;34:14-9.
Sala-Vila A, Harris WS, Cofán M, et al.
Determinants of the omega-3 index in a Mediterranean population at increased risk for CHD.
Br J Nutr. 2011;106:425-31
Murie-Fernandez M, Irimia P, Toledo E, et al on behalf
of the PREDIMED Investigators.
Carotid intima-media thickness changes with
Mediterranean diet: A randomized trial (PREDIMED-Navarra).
Atherosclerosis. 2011;219:158-62.
Bulló M, Garcia-Aloy M, Martínez-González MA, et al.
Association between a healthy lifestyle and general obesity and abdominal obesity in an elderly
population at high cardiovascular risk.
Prev Med. 2011;53:155-61.
Solá R, Fitó M, Estruch R, et al.
Effect of a traditional Mediterranean diet on apolipoproteins B, A-I, and their ratio: A randomized,
controlled trial.
Atherosclerosis. 2011;218:174-80.
Schröder H, Fitó M, Estruch R, et al., on behalf of the
PREDIMED Study Investigators.
Validation of a short screener for assessing Mediterranean Diet adherence among older Spanish
men and women.
J Nutr 2011;141:1140-5.
Sánchez-Villegas A, Galbete C, Martínez-González MA, et al.
The effect of the Mediterranean Diet on plasma
Brain Derived Neurotrophic Factor (BDNF) levels:
the PREDIMED-NAVARRA randomized trial.
Nutr Neurosci 2011;14:195-201.
Martínez N, Urpi-Sarda M, Martínez-González MA, et al.
Dealcoholised beers reduce atherosclerosis and
expression of adhesion molecules in apoE-de
cient mice.
Br J Nutr. 2011 ;105:721-30.
Diez-Espino J, Buil-Cosiales P, Serrano-Martínez M, et al.
Adherence to the Mediterranean diet in patients
with type 2 diabetes mellitus and HBA1c Level.
Ann Nutr Metab. 2011 ;58:74-8.
Bach-Faig A, Berry EM, Lairon D, et al.
Mediterranean Diet Foundation Expert Group.
Mediterranean diet pyramid today. Science and
cultural updates.
Public Health Nutrition 2011 ;14:2274-84.
Bulló M, Garcia-Aloy M, Basora J, et al.
Bone quantitative ultrasound measurements in
relation to the metabolic syndrome and type 2
diabetes mellitus in a cohort of elderly subjects
at high risk of cardiovascular disease from the
PREDIMED study.
J Nutr Health Aging. 2011 ;15:939-44.
2012
Martínez-González MA, Corella D, Salas-Salvado J, et al.
Cohort Profile: design and methods of the PREDIMED study.
Int J Epidemiol. 2012;41:377-85.
Babio N, Sorlí M, Bulló M, et al.
Association between red meat consumption and
metabolic syndrome in a Mediterranean population at high cardiovascular risk: cross-sectional
and 1-year follow-up assessment.
Nutr Metab Cardiovasc Dis. 2012;22:200-7.
Valls-Pedret C, Lamuela-Raventós RM, Medina-Remón A, et al.
Polyphenol-rich foods in the Mediterranean diet
are associated with better cognitive function in
elderly subjects at high cardiovascular risk.
J Alzheimers Dis. 2012 ;29:773-82.
Guasch-Ferré M, Bulló M, Costa B, et al. on behalf of
the PREDI-PLAN Investigators.
A risk score to predict type 2 diabetes mellitus in
an elderly Spanish Mediterranean population at
high cardiovascular risk.
PLoS One. 2012 ;7:e33437.
Díaz-López A, Bulló M, Martínez-González MA, et al.
Effects of Mediterranean Diets on Kidney Function: A Report From the PREDIMED Trial.
Am J Kidney Dis. 2012 ;60:380-9.
Guasch-Ferré M, Bulló M, Martínez-González MA, et al.
Waist-to-Height Ratio and Cardiovascular Risk
Factors in Elderly Individuals at High Cardiovascular Risk.
PLoS One. 2012 ;7:e43275.
Martínez-González MA, García-Arellano A, Toledo E,
et al. on behalf of the PREDIMED Study Investigators.
A 14-Item Mediterranean Diet Assessment Tool
and Obesity Indexes among High-Risk Subjects:
The PREDIMED Trial.
PLoS One. 2012 ;7:e43134.
Zamora-Ros R, Urpi-Sarda M, Lamuela-Raventós RM, et
al. on behalf of the PREDIMED Study Investigators.
High urinary levels of resveratrol metabolites are
associated with a reduction in the prevalence of
cardiovascular risk factors in high-risk patients.
Pharmacol Res. 2012 ;65:615-620.
Urpi-Sarda M, Casas R, Chiva-Blanch G, et al.
The Mediterranean diet pattern and its main components are associated with lower plasma concentrations of tumor necrosis factor receptor 60
in patients at high risk for cardiovascular disease.
J Nutr 2012 ;142:1019-25.
Cabré A, Babio N, Lázaro I, et al.
FABP4 predicts atherogenic dyslipidemia development. The PREDIMED study.
Atherosclerosis 2012 ;222:229-34.
Medina-Remón A, Vallverdú-Queralt A, Arranz-Martínez
S, et al. on behalf of the PREDIMED Study Investigators.
Gazpacho consumption is associated with lower blood pressure and reduced hypertension in a
high cardiovascular risk cohort. Cross-sectional
study within the PREDIMED trial.
Nutr Metab Cardiovasc Dis. 2012 [Epub ahead of print].
Ibarrola-Jurado N, Salas-Salvadó J, MartínezGonzález MA, Bulló M.
Dietary phylloquinone intake and risk of type 2
diabetes in elderly subjects at high risk of cardiovascular disease.
Am J Clin Nutr. 2012 ;96;1113-8.
Bulló M, Casas R, Portillo MP, et al., on belhalf of the
PREDIMED investigators.
Dietary glycemic index/load and peripheral adipokines and inflammatory markers in elderly subjects at high cardiovascular risk.
Nutr Metab Cardiovas 2013;23:443-50.
Hu EA, Toledo E, Diez-Espino J, et al. on behalf of the
PREDIMED Study Investigators.
Lifestyles and risk factors associated with adherence to the Mediterranean diet: a baseline assessment of the PREDIMED trial.
Plos One. 2013 ;29;8:e60166..
Zamora-Ros R, Urpi-Sarda M, Lamuela-Raventós RM,
et al. on behalf of the PREDIMED Study Investigators.
High urinary levels of resveratrol metabolites
are associated with a reduction in the prevalence of cardiovascular risk factors in highrisk patients.
Pharmacol Res. 2012 ;65:615-20.
Mitjavila MT, Fandos M, Salas-Salvadó J, et al.
The Mediterranean diet improves the systemic
lipid and DNA oxidative damage in metabolic
syndrome individuals. A randomized, controlled, trial.
Clin Nutr. 2013 ;32:172-8.
Martínez-Lapiscina EH, Clavero P, Toledo E, et al.
Mediterranean diet improves cognition: the
PREDIMED-NAVARRA randomised trial.
J Neurol Neurosurg Psychiatry. 2013 ;[Epub ahead of print].
Urpi-Sarda M, Casas R, Chiva-Blanch G, et al.
Virgin olive oil and nuts as key foods of the Mediterranean diet effects on inflammatory biomakers
related to atherosclerosis.
Pharmacol Res. 2012 ;65:577-83.
Bulló M, Moreno-Navarrete JM, Fernández-Real JM,
Salas-Salvadó J.
Total and undercarboxylated osteocalcin predict
changes in insulin sensitivity and β cell function in
elderly men at high cardiovascular risk.
Am J Clin Nutr. 2012 ;95:249-55.
Estruch R, Ros E, Salas-Salvadó J, et al. on behalf of
the PREDIMED Study Investigators.
Primary Prevention of Cardiovascular Disease
with a Mediterranean Diet.
N Engl J Med. 2013 ;368:1279-90.
Fernández-Real JM, Corella D, Goumidi L, et al.
Thyroid hormone receptor alpha gene variants
increase the risk of developing obesity and show
gene-diet interactions.
Int J Obes (Lond). 2013 ;[Epub ahead of print].
Corella D, Ortega-Azorín C, Sorlí JV, et al.
Statistical and biological gene-lifestyle interactions
of MC4R and FTO with diet and physical activity on
obesity: new effects on alcohol consumption.
PLoS One. 2012 ;7:e52344.
Ibarrola-Jurado N, Bulló M, Guasch-Ferré M, et al. on
behalf of the PREDIMED Study Investigators.
Cross-Sectional Assessment of Nut Consumption and Obesity, Metabolic Syndrome
and Other Cardiometabolic Risk Factors: The
PREDIMED Study.
PLoS One. 2013 ;8:e57367.
Ortega-Azorín C, Sorlí JV, Asensio EM, et al.
Associations of the FTO rs9939609 and the MC4R
rs17782313 polymorphisms with type 2 diabetes
are modulated by diet, being higher when adherence to the Mediterranean diet pattern is low.
Cardiovasc Diabetol 2012 ;11:137.
Juanola-Falgarona M, Salas-Salvadó J, Estruch R, et al.
Association between dietary phylloquinone intake
and peripheral metabolic risk markers related to
insulin resistance and diabetes in elderly subjects
at high cardiovascular risk.
Cardiovasc Diabetol. 2013 ;12:7.
Fernández-Real JM, Bulló M, Moreno-Navarrete JM, et al.
A Mediterranean diet enriched with olive oil is
associated with higher serum total osteocalcin
levels in elderly men at high cardiovascular risk.
J Clin Endocrinol Metab 2012 ;97:3792-8.
Tresserra-Rimbau A, Medina-Remón A, PérezJiménez J, et al.
Dietary intake and major food sources of polyphenols in a Spanish population at high cardiovascular risk: The PREDIMED study.
Nutr Metab Cardiovasc Dis. 2013 ;[Epub ahead of print].
Corella D, Carrasco P, Sorlí JV, et al.
Education modulates the association of the FTO
rs9939609 polymorphism with body mass index
and obesity risk in the Mediterranean population.
Nutr Metab Cardiovasc Dis 2012 ;22:651-8.
2013
Mayneris-Perxachsa J, Guerendiain M, Castellotea AI,
et al. on behalf of the PREDIMED Study Investigators.
Plasma fatty acid composition, estimated desaturase activities, and their relation with the metabolic syndrome in a population at high risk of
cardiovascular disease.
Clin Nutr. 2013 ;[Epub ahead of print].
Guasch-Ferré M, Bulló M, Babio N, et al.
Mediterranean Diet and Risk of Hyperuricemia in
Elderly Participants at High Cardiovascular Risk.
J Gerontol A Biol Sci Med Sci. 2013; [Epub ahead of print].
Martínez-Lapiscina EH, Clavero P, Toledo E, et al.
Virgin olive oil supplementation and long-term cognition: the PREDIMED-navarra randomized trial.
J Nutr Health Aging. 2013;17:544-52.
García-Calzón S, Gea A, Razquin C, et al.
Longitudinal association of telomere length and
obesity indices in an intervention study with a Mediterranean diet: the PREDIMED-NAVARRA trial.
Int J Obes (Lond) 2013 ;[Epub ahead of print].
Zamora-Ros R, Serafini M, Estruch R, et al.
Mediterranean diet and non enzymatic antioxidant capacity in the PREDIMED study: Evidence
for a mechanism of antioxidant tuning.
Nutr Metab Cardiovasc Dis 2013 ;[Epub ahead of print].
Babio N, Ibarrola-Jurado N, Bulló M, et al.
White blood cell counts as risk markers of developing metabolic syndrome and its components in
the Predimed study.
PLoS One. 2013 ;8:e58354.
Castañer O, Corella D, Covas MI, et al.
In vivo transcriptomic profile after a Mediterranean diet in high-cardiovascular risk patients: a
randomized controlled trial.
Am J Clin Nutr. 2013 ;98:845-53.
Guasch-Ferré M, Bulló M, Martínez-González MÁ, et al.
Frequency of nut consumption and mortality risk
in the PREDIMED nutrition intervention trial.
BMC Med. 2013 ;11:164.
Díaz-López A, Bulló M, Basora J, et al.
Cross-sectional associations between macronutrient intake and chronic kidney disease in a population at high cardiovascular risk.
Clin Nutr. 2013 ;32;606-12
Díaz-López A, Chacón MR, Bulló M, et al.
Serum sTWEAK Concentrations and Risk of
Developing Type 2 Diabetes in a High Cardiovascular Risk Population: A Nested Case-Control Study.
J Clin Endocrinol Metab. 2013 ;98:3482-90.
Bautista-Castaño I, Sánchez-Villegas A, Estruch R, et
al. on behalf of the PREDIMED Study Investigators.
Changes in bread consumption and 4-year
changes in adiposity in 2 Spanish subjects at high
cardiovascular risk.
Br J Nutr. 2013 ;110;337-46
PREDIMED RESEARCH CORE
PUBLICATIONS
27
NUTRITION
IN EVERY
HANDFUL
Nuts, such as almonds, Brazils, cashews,
hazelnuts, macadamias, peanuts, pecans,
pine nuts, pistachios and walnuts, may help
reduce the risk for chronic diseases such as
heart disease, diabetes and some forms of
cancer. And, in addition to their great taste,
all nuts are cholesterol-free and full of important nutrients, including protein, fiber
and phytochemicals. They’re also a great
source of vitamins such as folic acid, niacin,
and vitamins E and B-6, and minerals like
magnesium, copper, zinc, selenium, phosphorus and potassium.
The majority of the fat in nuts is unsaturated,
or “good” fat (i.e., mono- and polyunsaturated fats). The key to including nuts in the
diet without adding extra fat and calories is
portion control. As little as one handful —or
one ounce— of nuts per day can provide
nutritional benefits.
Either add an ounce all at once, or enjoy
them throughout the day. Mix and match
your favorite nuts with any food... experiment and Go Nuts!
28
HAVE YOU HAD YOUR DAILY
HANDFUL OF NUTS TODAY?
29
NUTRITION IN EVERY HANDFUL
Not to forget dried fruits,
another healthy addition to your diet.
30
PRESS
CLIPPING
Mediterranean Diet Fights Heart Disease,
Study Finds
ABC News - ‎Feb 27, 2013‎
Eating a Mediterranean diet rich in olive oil and nuts lowers the
rate of major cardiovascular events, at least among people at
increased risk for heart disease, a new study found. In a randomized trial in Spain in high-risk people, those who ate the ...
Mediterranean-style diets found to cut
heart risks
gulfnews.com - ‎Feb 27, 2013‎
New York: Pour on the olive oil, preferably over fish and
vegetables: One of the longest and most scientific tests of
a Mediterranean diet suggests this style of eating can cut
the chance of suffering heart-related problems, especially
strokes, in older people at ...
Can Olive Oil and Nuts Prevent Heart
Attacks?
Huffington Post - ‎Feb 27, 2013‎
A new study, just published online in the prestigious New
England Journal of Medicine, was able to prove that diet
-- a tasty and rather easy one to keep, at that -- was able to
reduce stroke and heart disease by 30 percent. The study,
led by Dr. Ramón Estruch ...
If You Eat the Mediterranean Way, Can
You Drop Your Heart Meds?
Forbes - ‎Feb 26, 2013‎
Earlier this week, results from a massive study on the benefits of the Mediterranean diet were published in the New
England Journal of Medicine. The study–which lasted five
years and included 7,500 participants ages 55-80–was a
triumph for the Med diet, ...
Mediterranean-style diet may reduce
heart risk
Xinhua - ‎Feb 26, 2013‎
BEIJING, Feb. 26 (Xinhuanet) -- Mediterranean-style diet rich
in fatty fish, beans, fruits and vegetables beats low-fat diet in
preventing cardiovascular disease, especially strokes, in older
people at high risk of them, says a new study released Monday
by the ...
Mediterranean diet shows key benefits,
study finds
Boston Globe - ‎Feb 25, 2013‎
A study in Spain found a reduction in heart attacks and
strokes when patients followed Mediterranean diet, which
includes olive oil.
Mediterranean diet ‘as good as statins’
Telegraph.co.uk - ‎Feb 25, 2013‎
They believe a diet of fish, chicken, fruit and vegetables is
“better than a drug” because it does not have side effects,
while cholesterol-lowering statins can cause problems like
muscle cramps. The academics made their conclusions after
conducting a five-year ...
Continues on Page 32
31
PRESS
CLIPPING
Mediterranean diet lowers risk of heart
attack, stroke
CNN - ‎Feb 25, 2013‎
(TIME.com) -- The Mediterranean diet is a well-known weapon in the fight against heart disease, but exactly how effective is it? To find out, researchers led by Dr. Ramón Estruch,
from the Department of Internal Medicine at the Hospital
Clinic of Barcelona, put ...
Mediterranean diet cuts heart attack risk
Times of India - ‎Feb 26, 2013‎
A diet rich in olive oil, nuts and other Mediterranean foods
reduces the risk of heart attack, stroke or death from heart disease by up to 30 per cent, according to a study published in
the New England Journal of Medicine. “We observed that an ...
A Healthy Diet That Includes, Yes,
Chocolate
New York Times - ‎Feb 25, 2013‎
The Mediterranean diet that participants in the new study
were told to follow differs in some respects from the advice
people generally get about healthy eating. It allows people to
eat as many nuts and eggs and even as much chocolate as
they want, as long ...
Eating a Mediterranean diet ‘cuts your
heart and stroke risk by a third’
Daily Mail - ‎Feb 25, 2013‎
Eating a Mediterranean-style diet can cut heart attacks,
strokes and death rates in people at high risk of heart disease by as much as a third, research shows. Changing the
balance of foods in a diet can lessen the risk even before
heart-related illness strikes, ...
Mediterranean diet reduces
cardiovascular risk
Washington Post - ‎Feb 25, 2013‎
The “Mediterranean diet,” featuring vegetables, fruits, fish,
nuts and olive oil but almost no red meat or sweets, slightly
reduces the risk of cardiovascular disease ...
Mediterranean diet, with olive oil and
nuts, beats low-fat diet
Los Angeles Times - ‎Feb 25, 2013‎
In a head-to-head contest, a Mediterranean diet, even
drenched in olive oil and studded with nuts, beat a low-fat
diet, hands-down, in preventing stroke and heart attack in
healthy older subjects at high risk of developing cardiovascular disease. The latest ...
32
The Mediterranean Diet: The New Gold
Standard?
Forbes - ‎Feb 25, 2013‎
Earlier today I summarized the important new PREDIMED
study published in the New England Journal of Medicine
showing the cardiovascular benefits of the Mediterranean
diet. This study– a rare and much welcome instance of a large
randomized ...
Mediterranean diet ‘cuts strokes and
heart attacks in at-risk groups’
The Guardian - ‎Feb 25, 2013‎
Eating a Mediterranean diet rich in either extra-virgin olive
oil or nuts cuts by 30% the chances of those at risk of heart
attacks or strokes suffering either event or dying of a heart
condition, research reveals. The findings, published online
by the New England ...
Mediterranean diet may be better for your
heart than cutting down on fat
CBS News - ‎Feb 25, 2013‎
If you want to reap heart-healthy benefits, you may want to
go on the Mediterranean diet. A Spanish study, published in
the New England Journal of Medicine on Feb. 25, showed
the Mediterranean diet was able to help people who were at
high risk for ...
Mediterranean diet cuts risk of stroke
USA TODAY - ‎Feb 25, 2013‎
The diet features lots of fruit, vegetables, nuts and olive oil;
moderate amounts of fish and poultry; but little dairy, red or
processed meat or sweets; as well as moderate amounts of
wine with meals.
Olé! How the New Spanish Study Should
Change Your Diet
Forbes - ‎Feb 25, 2013‎
Today the New England Journal of Medicine has published
a Spanish study comparing two versions of the Mediterranean diet with a low fat diet and the result is important
news if you are interested in reducing your risk of heart
disease and stroke.
Large Trial Shows Cardiovascular Benefits Of Mediterranean Diet
Forbes - ‎Feb 25, 2013‎
A large new trial offers powerful evidence that a Mediterranean diet can reduce the risk for cardiovascular disease.
Results of the PREDIMED (Prevención con Dieta Mediterránea) study were published online in the New England
Journal of Medicine.
RECIPES > Starters
Ajoblanco with grapes
Ingredients:
To prepare the
soup:
200 g of sprinkled
almonds
300 g of water
2 spoonfuls of
vinegar
(vinegar from
Jerez)
Salt
SUPPLEMENT
MED DIET
WITH A
HANDFUL
OF NUTS:
RECIPES
To prepare the
garmish:
6 grape grains
8 fried bread
cubes
Olive oil mixed
with fried garlic
12 tender almonds
12 prawns
Leave the sprinkled almonds soaking in water during 12 hours. Grind them finely and
strain them. Put a pinch of salt and vinegar. Peel the grapes and cut them in halves.
Peel the prawns and sauté them with a bit of olive oil. Set up the dishes with the
grapes, the prawns and the almonds and spill a bit of the olive oil and fried garlic
mixture on the top.
Add some mint leaves. Finally serve the dish along with the soup in a cold jar.
Nuts and dried fruits are the perfect ingredients
to discover new flavours
and textures. Including
the m i n ou r m e a ls
guarantees an amazing
and unique taste.
RECIPES > Starters
Dried fruit crepes
Ingredients:
8 crepes
16 spoonfuls of whipped cream
4 dates
4 figs
4 dried apricots
16 pistachios
16 golden raisins
16 raisins
4 prunes
2 spoonfuls of icing sugar
Set up the crepes with the whipped cream and the nuts and dried fruits.
Sprinkle with the icing sugar.
RECIPES > Starters
Spinach, raisin and pine nut muffins
Ingredients:
8 slices of bread
500 g fresh cooked spinach
50 g smoked bacon
diced
2 tablespoons of pine nuts
2 tablespoons of raisins
2 eggs
200 g goat cheese
200 cc single cream
salt
olive oil
Sauté the spinach, bacon, raisins and pine nuts with the olive oil and salt. Cut the
bread into identical circles with a pastry-cutter in the same size as the moulds you
will be using. Beat the eggs with the cream, salt and pepper and moisten the bread
in this mixture. Line each mould or flan case with a circle of bread. Fill with 2 tablespoons of the spinach mixture, a piece of cheese, more spinach and finally another
circle of bread. Bake in a bain-marie at 160ºC for 20 minutes and then turn out. They
can be served on their own or with a salad.
33
SUPPLEMENT MED DIET WITH A HANDFUL OF NUTS: RECIPES
RECIPES > Starters
Peanut-coated prawns with Brazil nut sauce
Ingredients:
Prawns:
12 raw king prawn tails
200 g fried or roasted peanuts
1 egg
olive oil
Sauce:
the prawn heads
100 cc olive oil
25 g Brazil nuts
Prawns: chop the peanuts fairly finely. Beat the egg and dip the prawn tails in it, roll them in the chopped peanuts, then repeat
once again. Fry in plenty of hot oil for a few minutes. When they have turned golden, serve with the sauce. Sauce: cover the prawn
heads with oil and cook over a low heat for 15 minutes, then strain. Brown the nuts in a frying pan with a splash of oil, stirring
constantly, then chop them roughly and mix into the prawn oil.
RECIPES > Starters
Chilled macadamia soup with a sultana and dried apricot brochette
Ingredients:
Soup:
1 small garlic clove
300 g raw macadamia nuts
200 g breadcrumbs
1.5 litre water
salt
100 cc olive oil
30 cc vinegar
Brochette:
8 dried apricots
16 large sultanas
4 tablespoons tempura flour
8 tablespoons iced water
olive oil
Put the garlic, macadamia nuts, breadcrumbs, oil, vinegar, salt and water in a blender. Blend until you get a smooth liquid with
a bit of body. Brochette: dissolve the tempura flour in the iced water. Dip the dried fruits in it and then fry them in plenty of hot
oil. Allow to cool a little then make up the brochettes by alternating the two fruits on wooden skewers. Serve the soup in glasses
topped with the brochette.
RECIPES > Meat Dishes
Chicken with dates, almonds, pine nuts and honey
Ingredients:
1 chicken cut into small pieces
olive oil
salt
2 onions
2 garlic cloves
2 tablespoons raw almonds
12 dates
1 bay leaf
pine nuts
1 tablespoon mixed spice (cinnamon, pepper, nutmeg, cumin, turmeric, ginger)
2 tablespoons honey
Season the chicken and fry until golden. Add the finely-sliced onion. When golden, add the garlic, followed by the spices, and cover with water. Cook over a low heat for 25 minutes. Add the almonds, dates, pine nuts and honey and cook for 10 more minutes
before serving.
34
RECIPES > Meat Dishes
Lamb with mint, sultanas, dried apricots and a crust of pistachios and cashews
Ingredients:
2 shoulders of lamb
2 cloves garlic
olive oil
salt
pepper
150 cc dry white wine
250 g dried apricots
3 tablespoons sultanas
a large bunch of fresh mint
Crust:
100 g raw cashews
50 g raw pistachios
Rub the shoulders with the garlic, season them and drizzle with oil. Roast for 30 minutes at 200ºC. Then lower the temperature
to 170ºC and add the wine. Roast for another 50 minutes, adding water from time to time. Remove from the oven, separate the
juice, and while still hot cover with the finely-chopped pistachios and cashews. Return to the oven with the grill set on high until
golden. Put the cooking juices in a pan and add the sultanas and dried apricots. Finely chop the mint and add to the sauce. Serve
the shoulders with the sauce on the side.
RECIPES > Fish Dishes
Fish stew with almonds, hazelnuts, walnuts and pine nuts
Ingredients:
1.5 kilos white fish fillets
2 onions
2 carrots
1 tomato
1 small garlic clove
100 g nuts (roasted almonds, roasted
hazelnuts, walnuts and pine nuts)
1 sachet saffron
20 g flour
250 g clams
1 bay leaf
salt
olive oil
Open the clams in a little boiling water, drain and reserve the liquid. Gently sauté the onion and carrot until soft and golden. Add
the grated tomato and allow to reduce. Add the flour, stir in well, and then the wine. Add some of the clam liquid and leave to cook
for 30 minutes. Strain, pressing firmly through a sieve, and reserve the liquid. Finely chop the nuts, garlic and saffron in a blender
with a little water. Put in a pan with the reserved cooking juices. Add the fish and cook for 10 minutes over a low heat before finally
adding the clams.
RECIPES > Fish Dishes
Fish with cashews, pistachios and white sauce
Ingredients:
4 fish fillets
25 g butter
50 cc white wine
50 g raw cashews
50 g raw pistachios
200 cc single cream
olive oil
salt
Melt the butter and a splash of oil in a frying pan. Add the cashews and pistachios, roughly chopped. Fry until golden. Place the fish
fillets in an oven dish with the salt, oil, wine and nuts. Bake for 8 minutes at 180ºC. Add the cream and bake for another 3 minutes.
35
SUPPLEMENT MED DIET WITH A HANDFUL OF NUTS: RECIPES
RECIPES > Desserts
Pecan cake with almond cream
Ingredients:
Cake:
4 eggs
200 g sugar
50 g butter
50 g flour
250 g ground pecan nuts
50 cc dessert wine
150 g raw sliced almonds
icing sugar
a few drops of water
Almond cream:
125 g raw almonds
500 ml water
100 g sugar
30 g cornflour
1 cinnamon stick
zest of half a lemon
pinch of salt
Put the eggs and sugar in a large bowl. Beat with an electric whisk until you have a pale, foamy mixture. Add the melted butter,
wine, flour and ground pecans. Pour the mixture into a silicone cake mould of 28 cm. Bake for 20 minutes at 180ºC. Remove the
cake from the oven and cover with the almond slices, then return for another 10 minutes. Finally, sprinkle with icing sugar. Almond
cream: blend the almonds with the water until you have a fine mass, then press through a fine-meshed sieve. In a pan, mix the
sugar, cornflour and almond milk. Add the lemon zest, cinnamon and salt. Put over a medium heat and cook, stirring constantly,
until it thickens. Allow to cool and serve with the cake.
RECIPES > Desserts
Ice-cream with sugared walnuts, hazelnuts and almonds
Ingredients:
Sugared nuts:
200 g of mixed nuts (almonds, hazelnuts
and walnuts)
200 g sugar
pinch of cinnamon
50 cc water.
Ice-cream:
1 litre milk
zest of 1 lemon
10 egg yolks
250 g sugar
Ice-cream: put the sugar, water and nuts in a pan. Cook over a medium heat, stirring constantly, until the sugar has caramelized
and coated the nuts. Meanwhile, put the milk and the cinnamon in a pan and bring to the boil. Remove from the heat. Mix the
egg yolks and sugar and stir into the milk. Put the pan back on the heat and stir constantly until the mixture starts thickening; the
temperature should not exceed 65ºC. Add the nuts and leave to cool. Put the mixture in an ice-cream maker and churn for 20 minutes: Sugared Nuts: we add all the ingredients in a saucepan. We cook them and stir constantly until all the syrup thick and wrap
the fruit in a crust form.
RECIPES > Desserts
Hazelnut mousse with chocolate and pecan sauce
Ingredients:
Mousse:
500 ml milk
75 g ground toasted hazelnuts
4 egg yolks
150 g sugar
40 g cornflour
3 pasteurized egg whites
Sauce:
100 cc single cream
100 g chocolate fondant
50 g chopped pecans
Sauce: heat the cream. When it comes to the boil, add the chocolate and pecans and stir until you get a thick, smooth sauce.
Mousse: in a pan, mix the egg yolks with the sugar, cornflour and milk in that order. Add the hazelnuts and put on the heat. Bring
just to the boil, stirring constantly, then remove from the heat and leave to cool. Beat the egg whites to soft peaks and fold into
the hazelnut mix. Place the mousse in the fridge for 2 hours. When ready to serve, fill individual glasses with the mousse and pour
the chocolate and pecan sauce over.
36
ABOUT INC
With more than 600 members from over 60 countries, the INC is working to spread
facts about nuts, dried fruits, health and nutrition. Our purpose is to assist health professionals and researchers in getting information about the latest findings regarding
nuts and dried fruit and health.
Mission
The International Nut and Dried Fruit Council Foundation (INC) represents and endorses activities that provide its membership with new opportunities for increasing
global consumption of almonds, apricot kernels, Brazil nuts, cashews, hazelnuts,
macadamias, pecans, pine nuts, pistachios, walnuts, peanuts, dates, dried apricots,
dried cranberries, dried figs, prunes and raisins.
The INC’s mission is to be the international source for information on nuts and dried
fruits for:
•
•
•
•
•
•
Health
Nutrition
Statistics on production, trade and consumption
Food safety
Government standards
Government regulations regarding trade barriers and trade quality standards
Objectives
• Increasing understanding about production, processing, marketing, distribution
and consumption trends in the nut and dried fruit industry.
• Increasing market access by monitoring customs duties and trade barriers and
advising governments on behalf of INC membership.
• Assuring global quality standards and trading terms are within the framework of existing national and international bodies and do not inhibit trade within the industry.
• Promoting research, especially nutrition, education and new product development.
• Promoting international cooperation by interacting with various public, private, national and international organizations, which share our common goals.
• Increasing goodwill and mutual understanding of the nut and dried fruit industry by
promoting international meetings in producing and consuming countries.
• Providing a single source of annual statistical information from producing and consuming countries.
37
ABOUT INC
WORLD FORUM
FOR NUTRITION
RESEARCH AND
DISSEMINATION
The INC World Forum for Nutrition Research and Dissemination is aimed at becoming
the international umbrella for scientific research related to health and nutrition for nuts
and dried fruits. The Forum promotes calls for scientific projects, defines research
priorities, and disseminates the results of the different research studies worldwide in
several languages.
Objectives
• To promote and coordinate research from around the world.
• To promote calls for specific research projects.
• To disseminate the results of the studies worldwide in several languages.
Activities
• Defining research priorities in relation to nuts and dried fruits.
• Submitting and monitoring health claims.
• Launching a call for research projects.
• Proposing candidates for the INC Award for Excellence in Research.
Chairman:
Prof. Jordi Salas Salvadó, Chair of Human Nutrition, School of Medicine, Rovira i
Virgili University, Reus, Spain.
President Delegate INC Executive Committe:
Mr. Antonio Pont, INC Honorary President, Co-Founder and Former President, Reus,
Spain.
Academic Honorary Committee
Task: Defining the priorities and research topics of interest every 2 years.
Members:
Dr. David Jenkins,
Director of the Clinical Nutrition Risk Factor at St. Michael’s Hospital in Toronto, Canada.
Prof. Gerhard Rechkemmer,
President and Professor at Max Rubner-Institut, Germany.
Dr. Joan Sabaté,
Chair and Professor, Department of Nutrition, Loma Linda University, California, USA.
38
Evaluating Nutrition Committee
Tasks:
• Evaluating the Expressions of Interest and Scientific Award Nominees according
to the objectives of the Forum and research topics of interest set by the Academic
Honorary Committee and the INC Executive Committee.
• Implementing the activities of the Forum according to the guidelines of the INC
Executive Committee.
• Prioritizing candidates for the INC Award for Excellence in Research in relation to
research on nuts and dried fruits.
Members:
•
•
•
•
Dr. Cesarettin Alasalvar, TUBITAK, Turkey.
Dr. Josefina Bressan, Federal University of Viçosa, Brazil.
Dr. Constance Geiger, University of Utah, Division of Nutrition, USA.
Dr. Denis Lairon, Joint Research Unit Nutrition, Obesity and Thrombotic Risk, Faculté de Médecine, Marseille, France.
• Dr. Girish B. Maru, Advanced Center for Treatment Research and Education in Cancer, Tata Memorial Cancer Centre, India.
• Ms. Maureen Ternus, INC Nutrition Research and Education Foundation, USA.
Consumption of nuts and dried fruits keeps increasing, and credit should be given
to the efforts of the industry and the health properties of these products. Nowadays,
information on the health benefits of the daily intake of nuts and dried fruits for the
treatment and prevention of many diseases can be found in hundreds of scientific and
medical journals. Even so, the health-cost burden from the lack of nuts and dried fruit
in our diets is immense. When one considers the trend data for heart diseases, cancer
and obesity prevalence, one realizes there is still much to do.
With this in mind, the INC created the World Forum for Nutrition and Research Dissemination in 2012, and launched a call for research projects on 23rd January 2013.
Call for Research Projects
The Call for Expressions of Interest was addressed to public and private institutions,
as well as not-for-profit organizations, and encouraged cooperative research implying INC associate members. It was sent out to more than 120 researchers who have
published studies related to nuts and/or dried fruits over the last few years, and more
than 50 associations around the world.
The guidelines outlined the specific wish for cooperative projects which would bridge
different research areas, as the interaction of disciplines and research groups often
lead to new knowledge and understanding of correlations.
This action was aimed at promoting epidemiological, basic, clinic and strategic research that might contribute to enhance the understanding of the health effects of
nuts and dried fruits; to promote the production of healthy and safe products; and to
produce and disseminate knowledge in accordance with the mission of the Forum.
2013 Research Priorities
1. Nuts and/or dried fruits and cancer
2. Nut and/or dried fruits and cognitive function
3. Nut and/or dried fruit consumption and insulin resistance and/or secretion
4. Nut consumption and depression
5. Meta-analysis of clinical trials
6. Nuts and/or dried fruits as part of a healthy diet
39
GO NUTS
GO HEALTHY!
Carrer de la Fruita Seca, 4
Polígon Tecnoparc
43204 REUS, Spain
tel: +34 977 331 416
[email protected]
www.nutfruit.org