Please cite this article in press as: Yannakoulia, M., et al., Cognitive health and Mediterranean: Just diet or lifestyle pattern? Ageing Res. Rev. (2014), http://dx.doi.org/10.1016/j.arr.2014.10.003 ARTICLE IN PRESS G Model ARR 540 1–5 Ageing Research Reviews xxx (2014) xxx–xxx Contents lists available at ScienceDirect Ageing Research Reviews jou rn al hom epage: www.elsevier.com/locate/arr Review Cognitive health and Mediterranean: Just diet or lifestyle pattern? Mary Yannakoulia a , Meropi Kontogianni a , Nikolaos Scarmeas b,c,*,1 Q1 a Department of Nutrition and Dietetics, Harokopio University, Athens, Greece b Taub Institute for Research in Alzheimer’s Disease and the Aging Brain, Gertrude H. Sergievsky Center, Department of Neurology, Columbia University, New York, NY, USA c Department of Social Medicine, Psychiatry and Neurology, National and Kapodistrian University of Athens, Greece a r t i c l e i n f o Article history: Received 1 April 2014 Received in revised form 13 July 2014 Accepted 8 October 2014 Available online xxx Keywords: Alzheimer’s disease Mediterranean diet Cognitive decline Nutrition Lifestyle Behaviors a b s t r a c t Mediterranean diet is a term used to describe the traditional eating habits of people in Crete, South Italy and other Mediterranean countries. It is a predominantly plant-based diet, with olive oil being the main type of added fat. There are many observational studies exploring the potential association between adherence to the Mediterranean diet and cognitive decline. The present review focuses on lon- gitudinal studies with repeated cognitive assessments. It also evaluates evidence on behaviors related to the Mediterranean way of living, that have been shown to be associated with cognition, namely social interaction, participation in leisure activities, including physical activities, and sleep quality. The syner- gistic association-effect of these lifestyle behaviors, including diet, is unknown. Lifestyle patterns may constitute a new research and public health perspective. © 2014 Elsevier B.V. All rights reserved. Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 1.1. What lies behind the Mediterranean diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 1.2. Effects on health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 2. Evidence for the effect of the Mediterranean diet on cognition and dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 3. Moving from the Mediterranean diet to a Mediterranean lifestyle: should we look beyond foods when evaluating associations with cognition? 00 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 1. Introduction 1.1. What lies behind the Mediterranean diet The concept of the Mediterranean diet was originally conceived by Ancel Keys, in the Seven Countries Study (Keys, 1970; Nestle, 1995). However, the core foods of the diet of people living around the Mediterranean basin can be recognized in the BC era: bread, olive oil, and wine were the basis of the Greek and Roman diets and, * Corresponding author at: Department of Neurology, Columbia University Med- ical Center, Sergievsky Center, 622 West 168th street, PH 19th floor, New York, NY 10032, USA. Tel.: +1 2123421350. E-mail address: ns257@columbia.edu (N. Scarmeas). 1 Address: National and Kapodistrian University of Athens, Department of Social Medicine, Psychiatry, and Neurology, 72 Vasilisis Sofias Avenue, Athens 11528, Greece. thereafter, important within Christian religions. Bread was sym- bolic of agriculture and human civilization and olive trees were the identity of Mediterranean lands (Ferrari and Rapezzi, 2011). Fol- lowing Key’s observations that all-cause and coronary heart disease death rates were lower in cohorts with olive oil as the main dietary fat compared to northern European ones (Keys et al., 1986), the notion that the high consumption of olive oil, bread, fruits, vegeta- bles, and cereals may be responsible for profound health benefits was spread in the scientific community (Sofi et al., 2013). Nowa- days, the term Mediterranean diet is widely used to describe the traditional dietary habits of people in Crete, South Italy and other Mediterranean countries, and is schematically depicted as a food pyramid (Simopoulos, 2001; Willett et al., 1995). This dietary pat- tern is characterized by abundance of plant foods: fruits, mainly as the typical after-dinner dessert, vegetables, either as main or side dish, a lot of bread, other forms of cereals, legumes, nuts, and seeds. Olive oil is the principal source of fat. Mediterranean http://dx.doi.org/10.1016/j.arr.2014.10.003 1568-1637/© 2014 Elsevier B.V. All rights reserved. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56