Women & Heart Disease Part 2: Mediterranean or Low-Fat Eating?

What is the eating pattern that was among the four factors discussed in my last Smart Bytes™ post that seemed able to prevent 80 percent of sudden cardiac deaths in the Nurses’ Health Study?  Many people automatically assume heart-healthy eating means low-fat eating.  But it’s the Mediterranean eating pattern, which focuses on nutrient-rich plant foods and healthy fats, that studies say may be the best bet for many. 

That’s especially true for women, because it’s an eating pattern linked with higher HDL (“good”) cholesterol levels, which are key to reducing women’s heart disease risk.  Mediterranean-style eating patterns also remind us that heart-healthy eating is not just about avoiding the “bad”. It’s also about an abundance of foods that supply health-protective antioxidants and other substances, and about preparing those foods deliciously so we will make the eating pattern a long-term part of our lifestyle.

So what are the essentials for a health-promoting Mediterranean eating pattern?

In the Nurses’ Health Study, researchers graded women’s diets along nine factors to create an overall score for how closely eating habits matched what seem the essential health-promoting parts of a Mediterranean-style eating pattern:

• Above average intake of vegetables, fruits, whole grains, nuts, beans and fish
• Fat consumption that emphasizes monounsaturated fat (found especially in olive oil) rather than saturated fat (from fatty meat, full-fat dairy and butter)
• Moderate intake of alcohol (women earned one point for a half to one standard-size drink per day)
•  Below average intake of red and processed meat

In this study, compared to women who scored the lowest, those women who scored highest along these nine hallmarks of a Mediterranean eating pattern were 40 percent less likely to face sudden cardiac death.

In an analysis of 18 large population studies that followed people from four to 20 years, other researchers linked each 2-point increase in Mediterranean diet score with 10 percent lower incidence or death from heart disease among men and women.  The bonus: a more Mediterranean-style eating pattern reduced overall deaths, too, as each 2-point increase was also linked with a six percent drop in cancer incidence or mortality.

These studies included populations in the U.S., as well as many in Europe.  A study that included only American men and women aged 50 to 71 followed for ten years also links the basic characteristics of a Mediterranean eating pattern with fewer deaths.  After adjusting for factors such as age, weight, physical activity and smoking, higher scores in this NIH-AARP study were linked with about 20 percent fewer deaths due to heart disease, as well as 12 to 17 percent fewer deaths due to cancer.

So what does a Mediterranean diet look like in an American woman? 

It’s not about the style of cuisine or the herbs and spices that flavor the food. This eating pattern is about the balance of foods that create a predominantly plant-based diet.

In the NIH-AARP study, women scoring highest on Mediterranean score ate, based on a total of 2000 calories a day, about 5 standard-size (half-cup) servings of vegetables (not including potatoes) and about 5 servings of fruit daily.  Although these American women did not eat dried beans and peas as often as today’s recommendations consider optimal, they ate them regularly and about four times more often as women scoring low on the Mediterranean diet.  They ate fish frequently, limited red meat, and monounsaturated fat like olive oil dominated over saturated fat.  Don’t misinterpret their more Mediterranean diet as abounding in alcohol; high scorers averaged about four drinks a week.

Not the Only Option

Is the Mediterranean pattern the only choice for women to promote health and a healthy weight? Not at all. Depending on genetics, other health conditions and food preferences, some women may do well with plant-focused eating patterns that are low in fat.  Some prefer ultra-low-fat vegan diets, which can bring beneficial changes in many heart disease risk factors.  Some prefer an omnivore eating pattern that simply limits meat and includes an abundance of vegetables, fruits and whole grains, like the DASH diet.

The DASH diet was originally developed to manage blood pressure, but has since been found effective for reducing LDL cholesterol and in some studies improves insulin function.  In a study comparing the DASH diet to a “standard” low-fat diet for type 2 diabetes, the DASH approach brought greater decreases in waist, fasting blood sugar and A1C (a marker of longer-term blood sugar control).  With its 7 to 12 servings of vegetables and fruits daily, the DASH diet was higher in fiber as well as potassium.

A primary difference between the DASH and Mediterranean eating patterns lies in use of fat. The DASH diet is low-fat, with added fat limited to two to three teaspoons of oil daily.  A Mediterranean diet is classified as moderate in total amount of fat.  Saturated fat is low, as fat comes primarily from olive oil and nuts. Beans and fish are included even more often than in the DASH eating pattern, and red meat less often.

One analysis compared low-fat and Mediterranean diets for their effect on heart health, pulling together results from six studies that included thousands of people followed for two to four years.  Overall, among the generally overweight people in these studies, the Mediterranean eating patterns brought greater decreases in weight, waist, blood pressure, a marker of inflammation known as CRP, and fasting blood sugar.  The two diets showed no differences in impact on LDL, HDL or insulin levels.

I’d like to move beyond looking for “the best” eating pattern.  Multiple studies now show advantages for each of these plant-based eating styles.  The important question is what eating pattern will best promote your overall health.  If you’ve not been able to stick with low-fat diets in the past, or if they have not brought the health improvements you seek, you may want to get past the old focus on restricting fat, and switch to a pattern that focuses on lots of plant foods and makes room for more use of healthy fats.

 Beyond  LDL or HDL level

The Mediterranean eating pattern wraps up multiple nutritional goals in one fell swoop.

It reduces saturated fat, which reduces LDL (“bad”) cholesterol, but it does not lower the all-important HDL (“good”) cholesterol.  Even more importantly, as we are learning that neither LDL nor HDL cholesterol is all the same, choices that create this eating pattern tend to improve the sub-categories of LDL and HDL most strongly linked with health.

Heart disease is now recognized as a disease of much more than just lipids like cholesterol – it is a disease of chronic inflammation.  The many vitamins and natural antioxidant compounds from the abundant plant foods in this eating pattern help counter damage to blood vessels from highly reactive free radicals.

♥ Flavonoids: Women in one study who had the highest consumption of flavonoids from food suffered nearly 20 percent fewer heart disease deaths over a seven-year period compared to those who consumed the least.  High flavonoid consumption came from an average total of six servings of vegetables and fruits daily.  Other important sources of flavonoids include whole grains, beans and nuts. In fact, even extra virgin olive oil itself provides antioxidant phytochemicals.

♥ Dietary Fiber: Among men and women in EPIC, a massive study in ten European countries, each 10 grams of dietary fiber per day was linked with 15 percent fewer atherosclerosis-related heart disease deaths. Fiber, which we get from less-processed forms of all the plant foods mentioned here, helps lower LDL cholesterol, but does much more. Some types of fiber are fermented by our gut bacteria to form anti-inflammatory compounds that can be absorbed and travel throughout the body. Fiber also tends to slow absorption of carbohydrate from our gut, which can lead to lower levels of insulin.

What about weight?

Some people fear the weight impact of a diet that includes regular use of olive oil and nuts, yet studies do not support that fear.  Population studies show that adults with a more Mediterranean-type eating pattern tend to gain less weight and are less likely to become overweight or obese.  It becomes even more supportive of weight loss when you make choices that deliberately decrease calories and when you include regular physical activity.

A diet to lower risk of heart disease (and cancer) needs to help women reach and maintain a healthy weight.  The good news is that a Mediterranean-style eating pattern offers direct health benefits and potential weight management help because of its abundance of hunger-satisfying, low-calorie plant foods.  Moderate use of olive oil and nuts does not “undo” weight control, because other calorie-dense choices (such as fatty meat, cookies and soft drinks) are scarce.  More good news is that Mediterranean-style eating habits make vegetables, whole grains and beans taste so good, continuing the habits long-term is a joy, not a burden.

Regardless of the approach, don’t lose sight of the fact that none of the eating patterns linked with health promote all-you-can-eat munching.  Portions still matter.  And although I’ve used the word “diet” in this discussion, let’s be clear that I’m not encouraging anything that you “go on” and later “go off”.  I’m using the word diet to refer to a customary eating pattern.  Find one that really works for you and embrace it.

Let’s Talk:  What’s been your experience with low-fat and Mediterranean-type eating patterns?  Have you tried creating a unique synthesis of healthy patterns that fits you? Please comment below and share tips that have worked for you.

Resources

If you’d like to learn more about a Mediterranean-style eating pattern, check the abundant materials from Oldways.

You can get some basic information about the DASH diet, which is low in fat and abundant in vegetables and other plant foods, from the National Institutes of Health.  For more detailed information, Marla Heller, MS, RD, is an expert on the DASH diet and has lots to share.

For another great resource, check this fact sheet, Heart Health for Women, from the registered dietitians at SCAN (Sports, Cardiovascular and Wellness Nutrition dietetic practice group of the Academy of Nutrition and Dietetics).

References

Chiuve SE, et al. Adherence to a low-risk, healthy lifestyle and risk of sudden cardiac death among women. JAMA. 2011..306(1):62-9.

Sofi, F et al.  Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis.  Am J Clin Nutr. 2010. 92(5):1189-96.

Mitrou, PN et al. Mediterranean Dietary Pattern and Prediction of All-Cause Mortality in a US Population: Results From the NIH-AARP Diet and Health Study. Arch Intern Med. 2007;167(22):2461-2468.

Chainani-Wu, N et al.  Changes in emerging cardiac biomarkers after an intensive lifestyle intervention. Am J Cardiology, 2011.  108(4):498-507.

Azadbakht, L et al.  Effects of the Dietary Approaches to Stop Hypertension (DASH) eating plan on cardiovascular risks among type 2 diabetic patients: a randomized crossover clinical trial. Diabetes Care, 2011.

Nordmann, AJ et al. Meta-Analysis Comparing Mediterranean to Low-Fat Diets for Modification of Cardiovascular Risk Factors. The American Journal of Medicine, 2011. 124: 841-851.

McCullough, ML et al. Flavonoid intake and cardiovascular disease mortality in a prospective cohort of US adults. Am J Clin Nutr. 2012. 95(2):454-64.

Crowe FL, et al.  Dietary fibre intake and ischaemic heart disease mortality: the European Prospective Investigation into Cancer and Nutrition-Heart study. Eur J Clin Nutr. 2012 May 23. doi: 10.1038/ejcn.2012.51.

Esposito, K et al. Mediterranean Diet and Weight Loss: meta-analysis of randomized controlled trials. MetabSyndrRelatDisord, 2011. 9(1):1-12.