1

Adherence to the Mediterranean Diet Reduces Risk Factors for CVD

Caitlin Alfano

Long Island University Post

NTR 609: Advanced Nutrition I

Dr. Tavora Buchman

November 11, 2020

2

Adherence to the Mediterranean Diet Reduces Risk Factors for CVD

Cardiovascular disease (CVD) is the number one leading cause of death in the United

States. The Mediterranean diet has been potentially beneficial towards lowering the risk of CVD.

The Mediterranean diet consists of minimally processed foods, is predominantly plant based,

contains monounsaturated fat from olive oil, as well as low saturated fats, red meats, and dairy.

Adults who adhere to the Mediterranean diet will reduce their risk of CVD by positively

influencing their lipid profile, blood pressure, body weight, atherosclerosis, and glycemic

control. 

A well-known risk factor for CVD is dyslipidemia; an elevated lipid concentration in the

blood. According to the World Health Organization (WHO), dyslipidemia is directly linked to

more than half of the global cases of coronary heart disease. A major factor accountable for

increasing the risk of CVD is blood cholesterol concentration specifically low-density

lipoprotein (LDL). This leads to the buildup of cholesterol in the arteries, forming

atherosclerosis. On the other hand, having an increase in high density lipoproteins (HDL) is

beneficial. This is beneficial because HDL absorbs cholesterol in the body and carries it back to

the liver where it can be excreted in bile. Therefore, high levels of HDL can lower the risk of

CVD (Assmann et al., 2004). 

HDL is synthesized in the liver and intestines where the production of its main structural

component apolipoprotein, Apo-AI takes place; Apo-AI receives cholesterol and phospholipids.

As HDL circulates it receives free cholesterol and phospholipids from peripheral tissues, very

low-density lipoprotein (VLDL), and chylomicrons. HDL is then delivered to the liver for

removal. The cholesterol then is able to bind with bile where it can be eliminated from the body

(Bailey & Mohiuddin, 2020). 

3

Figure 1

Pathway of the conversion of HDL cholesterol

Note: From “Metabolic and vascular effect of the Mediterranean diet,” by Tuttolomondo, A.,

Simonetta, I., Daidone, M., Mogavero, A., Ortello, A., & Pinto, A. (2019). Metabolic and

Vascular Effect of the Mediterranean Diet. International journal of molecular sciences, 20(19),

4716. https://doi.org/10.3390/ijms20194716

Comprehensive research has shown evidence that a Mediterranean diet can reduce CVD

risk factors such as diabetes, hypertension, lipid profile, and atherosclerosis (Tuttolomondo et al.,

2019). The beneficial components of the Mediterranean diet include a variety of different

vegetables and low glycemic index foods that can reduce the development of diabetes. A low

glycemic index food digests and absorbs at a slower rate causing a smaller rise in blood glucose.
4

Hypertension is a condition defined as persistent elevated systolic and/or diastolic blood

pressure. Polyphenols are a major component in olive oil which has been found to have a

vasoprotective effect. The Mediterranean diet is associated with foods that are low in sodium

which is correlated with lowering blood pressure (Tuttolomondo et al., 2019).  

Atherosclerosis is the primary cause of CVD due to cholesterol rich lipoproteins and

apolipoprotein B that are oxidized and produce proinflammatory molecules. As a result, this

activates the endothelium where LDL is oxidized and increases the amount of plaque in the

arteries along with inflammation. All these risk factors can contribute to CVD but adhering to the

Mediterranean diet may mitigate the risk. Within the Mediterranean diet, the main source of fatty

acids is derived from extra virgin olive oil. This oil is rich in omega-6 and omega 3 fatty acids.

The omega-3 fatty acids have an anti-inflammatory response on the body, resulting in reduced

oxidative stress, advanced glycation end products, and free radicals; ultimately reducing the

plaque buildup in the arteries (Tuttolomondo et al., 2019). 

Additional research has shown how the Mediterranean diet is beneficial for reducing

CVD risk factors. A 2020 study conducted by Michaëlsson et al. aimed to evaluate the

association of BMI with adherence to a Mediterranean diet on all cause and CVD mortality. In a

longitudinal cohort study 79,003 individuals with a mean age of 61 participated in a 21 year

follow up. BMI was classified as normal weight (20-24.9 kg/m2), overweight (25-29.9 kg/m2,

and obese (30+ kg/m2). Adherence to the Mediterranean diet was classified into three categories:

0 to < 4, 4 to < 6, and 6–8 score points. During the follow up 30,389 participants died. The

results proved that overweight individuals who had a high Mediterranean diet had the lowest

hazard ratio. Obese individuals did not experience a higher mortality on the high Mediterranean

diet. In contrast, the individuals who were classified as a normal weight and on the low
5

Mediterranean diet had a high mortality rate. CVD mortality for obese individuals remained

moderately increased even while on the high Mediterranean diet compared to those who were

normal weight (Michaëlsson et al., 2020). 

In 2019 Alverez-Alverez et al. conducted a similar study on Mediterranean diet

adherence and CVD risk factors A cross-sectional study with 6,874 adults considered

overweight, obese, and/or with metabolic syndrome participated. Both genders aged 55-75 years

old were randomly assigned to 4 groups: Mediterranean diet, physical activity promotion,

behavioral support, or a control group.  A registered dietitian administered a 17-item

questionnaire to assess the participants adherence to the diet. The researchers found a significant

decrease in diabetes risk in the Mediterranean diet that had a high consumption of extra-virgin

olive oil compared to the control group. There was a significant reduction in the prevalence of

obesity for those who adhered to the Mediterranean diet along with lower BMI and waist

circumference. There was also a positive association in adherence to the diet and lower

prevalence of hypertension. Lastly there was a decrease in triglycerides levels and higher HDL

cholesterol (Alverez-Alverez et al., 2019). 

While the previous researchers examined adherence and reduction in CVD risk with a

Mediterranean diet, Foscolou et al. (2018) examined the association of lipoprotein-alpha on CVD

risk factors. An epidemiological study was carried out with 3,042 people from Athens. The

principal goal of the study was to investigate the prevalence of CVD risk factors, the CVD

incidence in healthy Greek adults, and their associations with various socioeconomic, lifestyle,

and psychological characteristics. An interview, medical examination, and questionnaire was

provided to the participants. There was a 10 year follow up for the study, and out of all the

participants, 317 experienced CVD. Overall the study found that there was a strong inverse
6

relationship between lipoprotein-alpha levels and Mediterranean diet adherence. This may be

potentially related to the high monounsaturated fatty acid content contained in the Mediterranean

diet. The diet is rich in olives and nuts, and therefore is less susceptible to oxidation which forms

atherosclerosis (Foscolou et al., 2019). 

Figure 2

The Mediterranean Diet and Lipoprotein-Alpha and CVD Risk

Note: An explanation of the data in the figure. From “The mediating role of Mediterranean diet

on the association between Lp(a) levels and cardiovascular disease risk: A 10-year follow-up of

the ATTICA study” by Foscolou, A., Georgousopoulou, E., Magriplis, E., Naumovski, N.,

Rallidis, L., Matalas, A.-L., Chrysohoou, C., Tousoulis, D., Pitsavos, C., & Panagiotakos, D.

(2018), Clinical Biochemistry, 60, 33–37. https://doi.org/10.1016/j.clinbiochem.2018.07.011

Estruch et al. (2013) conducted an observational cohort study to examine the primary

prevention of CVD risk with adherence to the Mediterranean diet in Spain. A total of 7,447
7

participants, ages 55-80 years old, who were considered high cardiovascular risk, were randomly

assigned to three diets. A Mediterranean diet with supplemented extra-virgin olive oil, a

Mediterranean diet with supplemented mixed nuts, or a control diet with reduced dietary fat. A

4.8 year follow up was then conducted. Both groups had a reduced incidence of cardiovascular

problems in high risk individuals. There was also a reduced risk of stroke throughout both

groups. The researchers proposed that since the Mediterranean diet is consistent with nutrient-

rich foods it induces favorable changes in intermediate pathways of cardiometabolic risk. This is

inclusive of blood lipids, insulin sensitivity, reduction in oxidation, and inflammation (Estruch et

al., 2013). 

According to Alverez-Alverez at al. (2019) and Michaëlsson et al. (2020) both

researchers found similar results in regard to obesity risk factor. Adults who adhered to the

Mediterranean diet resulted in lower CVD mortality (Michaëlsson et al., 2020). Similarly,

Alverez-Alverez et al. (2019) found that adults who adhered to the Mediterranean diet decreased

prevalence of obesity, which is a risk factor for CVD. Therefore a Mediterranean diet is

beneficial to control body weight therefore reducing obesity prevalence.

On the other hand, Estruch et al. (2013) and Foscolou et al. (2018) examined lipid profile

and how the Mediterranean diet can help reduce the development of CVD. Estruch et al. (2013)

found a decreased prevalence in cardiovascular problems in those considered high risk for CVD.

While the other researchers, Foscolou et al. (2018) examined specifically lipoprotein-Alpha. The

results concluded that the high mono-unsaturated fat in the Mediterranean diet can help reduce

oxidation. As a result, this reduces the formation of arthrosclerosis.

8

CVD is a major health burden that negatively impacts an individual’s well-being and may

even lead to death. Today's diet is high in saturated fat, meat, dairy and processed foods

increasing an individual's risk for CVD. The studies above examine the risk factors associated

with CVD and how adherence to a Mediterranean diet can positively impact adverse

cardiovascular effects. The overall consensus is that following a Mediterranean diet can benefit

the risk factors of CVD including lipid profile, blood pressure, body weight, atherosclerosis, and

glycemic control in adults. 

9

References

Álvarez-Álvarez, I., Martínez-González, M. Á., Sánchez-Tainta, A., Corella, D., Díaz-López, A.,

Fitó, M., Vioque, J., Romaguera, D., Martínez, J. A., Wärnberg, J., López-Miranda, J.,

Estruch, R., Bueno-Cavanillas, A., Arós, F., Tur, J. A., Tinahones, F. J., Serra-Majem, L.,

Martín, V., Lapetra, J., & Toledo, E. (2019). Adherence to an energy-restricted

Mediterranean diet Score and prevalence of cardiovascular risk factors in the

PREDIMED-Plus: a cross-sectional study. Revista Espanola de Cardiologia (English

Ed.), 72(11), 925–934. https://doi.org/10.1016/j.rec.2018.08.010

American Heart Association. What is the Mediterranean diet? Retrieved from

https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-

basics/mediterranean-diet

Assmann, G., & Gotto, A. M., Jr. (2004). HDL cholesterol and protective factors in

atherosclerosis. Circulation, 109(23 Suppl 1), III8-III14.

Bailey, A., & Mohiuddin, S. S. (2020). Biochemistry, High Density Lipoprotein (HDL).

Estruch, R., Ros, E., Salas-Salvadó, J., Covas, M.-I., Corella, D., Arós, F., Gómez-Gracia, E.,

Ruiz-Gutiérrez, V., Fiol, M., Lapetra, J., Lamuela-Raventos, R. M., Serra-Majem, L.,

Pintó, X., Basora, J., Muñoz, M. A., Sorlí, J. V., Martínez, J. A., & Martínez-González,

M. A. (2013). Primary prevention of cardiovascular disease with a Mediterranean diet.

The New England Journal of Medicine, 368(14), 1279–1290.

https://doi.org/10.1056/NEJMoa1200303

Foscolou, A., Georgousopoulou, E., Magriplis, E., Naumovski, N., Rallidis, L., Matalas, A.-L.,

Chrysohoou, C., Tousoulis, D., Pitsavos, C., & Panagiotakos, D. (2018). The mediating

role of Mediterranean diet on the association between Lp(a) levels and cardiovascular
10

disease risk: A 10-year follow-up of the ATTICA study. Clinical Biochemistry, 60, 33–

37. https://doi.org/10.1016/j.clinbiochem.2018.07.011

Karageorgou, D., Magriplis, E., Bakogianni, I., Mitsopoulou, A. V., Dimakopoulos, I., Micha,

R., Michas, G., Ntouroupi, T., Tsaniklidou, S. M., Argyri, K., Chourdakis, M.,

Panagiotakos, D. B., & Zampelas, A. (2020). Dietary patterns and cardiovascular disease

in Greek adults: The Hellenic National Nutrition and Health Survey (HNNHS).

Nutrition, Metabolism, and Cardiovascular Diseases: NMCD, 30(2), 201–213.

https://doi.org/10.1016/j.numecd.2019.09.024

Michaëlsson, K., Baron, J. A., Byberg, L., Höijer, J., Larsson, S. C., Svennblad, B., Melhus, H.,

Wolk, A., & Warensjö Lemming, E. (2020). Combined associations of body mass index

and adherence to a Mediterranean-like diet with all-cause and cardiovascular mortality: A

cohort study. PLoS Medicine, 17(9), e1003331.

https://doi.org/10.1371/journal.pmed.1003331

Tuttolomondo, A., Simonetta, I., Daidone, M., Mogavero, A., Ortello, A., & Pinto, A. (2019).

Metabolic and Vascular Effect of the Mediterranean Diet. International journal of

molecular sciences, 20(19), 4716. https://doi.org/10.3390/ijms20194716