VIEWPOINT Back to the future: The Mediterranean diet paradigm A. Naska a, *, A. Trichopoulou b a Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias Str., Athens 11527, Greece b Hellenic Health Foundation, Athens, Greece Received 6 November 2013; received in revised form 26 November 2013; accepted 27 November 2013 Available online --- KEYWORDS Mediterranean diet; Coronary heart disease; Life style Abstract The Mediterranean diet was introduced to the scientific community by the classic Seven Countries study. Since then data on the association between this diet and cardiovascular disease, cancer and other chronic diseases have been accumulating. The Mediterranean diet is characterized by a high intake of olive oil, plant products, fish and seafood; a low intake of dairies, meat and meat products; and a moderate ethanol intake. The Mediterranean diet has been operationalized through various computational scores (e.g. the Mediterranean diet score for adults and the KIDMED index for children) which are all based on the dietary components that capture its essence. Next to evidence generated through both observational studies and intervention trials on the inverse association between Mediterranean diet and several risk fac- tors, inflammatory markers and mortality or incidence of disease, there is increasing evidence that Mediterranean populations are abandoning their traditional eating habits. Publications pre- senting changes over time in the diet of populations participating in the Seven Countries Study point towards an increase in the intake of processed foods and saturated fat and a decrease in the intake of plant foods and monounsaturated fatty acids. Findings are alarming, particularly in relation to younger generations. Studies among children and adolescents in the Mediterranean region clearly indicate that the largest proportions of these populations poorly adhere to their traditional diet. Mediterraneans have clearly not been the major benefactors in the research on the effects of the Mediterranean lifestyle and younger populations in the regions are already following the wrong path. ª 2013 Elsevier B.V. All rights reserved. The Mediterranean diet was first considered by Ancel Keys and his colleagues as a low saturated lipid diet that was conveying protection against coronary heart disease by lowering plasma cholesterol levels [14]. Over the years, however, the emphasis has shifted away from the low saturated lipid content of this diet towards its high content of olive oil and its overall composition. Moreover, the study of the Mediterranean diet expanded beyond its ef- fects on coronary heart disease, to include possible effects on total mortality, cardiovascular disease, several types of cancer and other chronic degenerative diseases or condi- tions [11,12,17,26]. The Mediterranean diet has not been developed on the basis of current evidence for health-conducive dietary choices. It is rather a natural experiment, a combination of eating habits traditionally followed by individuals in the olive-growing areas bordering the Mediterranean Sea and it is characterized by a high intake of fruit and nuts, veg- etables, legumes, cereals, fish and seafood; a low intake of dairy products, meat and meat products; and a moderate ethanol intake mainly in the form of wine and during meals. Olive oil is the main added lipid and its increased * Corresponding author. Tel.: þ30 210 7462106; fax: þ30 210 7462079. E-mail address: anaska@nut.uoa.gr (A. Naska). Please cite this article in press as: Naska A, Trichopoulou ABack to the future: The Mediterranean diet paradigm, Nutrition, Metabolism & Cardiovascular Diseases (2013), http://dx.doi.org/10.1016/j.numecd.2013.11.007 0939-4753/$ - see front matter ª 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.numecd.2013.11.007 Nutrition, Metabolism & Cardiovascular Diseases (2013) xx,1e4 Available online at www.sciencedirect.com Nutrition, Metabolism & Cardiovascular Diseases journal homepage: www.elsevier.com/locate/nmcd