You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


Moderate Wine, Little Meat, Many Vegetables May Be Key Mediterranean Diet Items Linked to Longer Life

  • Authors: News Author: Marlene Busko
    CME Author: Désirée Lie, MD, MSEd
  • CME/CE Released: 7/2/2009
  • Valid for credit through: 7/2/2010
Start Activity

Target Audience and Goal Statement

This article is intended for primary care clinicians, cardiologists, nurses, and other specialists who care for patients at risk for cardiovascular disease.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Describe the association between adherence to the Mediterranean diet and mortality.
  • Describe the contribution of components of the Mediterranean diet to reduced mortality rates.


As an organization accredited by the ACCME, MedscapeCME requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

MedscapeCME encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


  • Marlene Busko

    Marlene Busko is a freelance writer for Medscape and Heartwire.


    Disclosure: Marlene Busko has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    Brande Nicole Martin is the News CME editor for Medscape Medical News.


    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

Nurse Planner

  • Laurie E. Scudder, MS, NP

    Accreditation Coordinator, Continuing Professional Education Department, MedscapeCME; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC; Nurse Practitioner, School-Based Health Centers, Baltimore City Public Schools, Baltimore, Maryland


    Disclosure: Laurie E. Scudder, MS, NP, has disclosed that she has no relevant financial relationships.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California


    Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

Accreditation Statements

    For Physicians

  • MedscapeCME is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

    MedscapeCME designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity. Medscape Medical News has been reviewed and is acceptable for up to 350 Prescribed credits by the American Academy of Family Physicians. AAFP accreditation begins 09/01/08. Term of approval is for 1 year from this date. This activity is approved for 0.25 Prescribed credits. Credit may be claimed for 1 year from the date of this activity.

    Note: Total credit is subject to change based on topic selection and article length.

    AAFP Accreditation Questions

    Contact This Provider

    For Nurses

  • Medscape is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

    Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; none of these credits is in the area of pharmacology.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. MedscapeCME encourages you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.

*The credit that you receive is based on your user profile.


Moderate Wine, Little Meat, Many Vegetables May Be Key Mediterranean Diet Items Linked to Longer Life

Authors: News Author: Marlene Busko CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME/CE Released: 7/2/2009

Valid for credit through: 7/2/2010


July 2, 2009 — A population-based cohort study of individuals in Greece has teased out items in the Mediterranean diet that appear to contribute to the increased longevity associated with this diet [1].

The largest effects on reduced mortality came from drinking moderate amounts of alcohol, eating little meat, eating lots of vegetables, eating fruits and nuts, and using olive oil. However, the individual components of the Mediterranean diet had an additive protective effect.

"Overall diet is more important than individual components, with emphasis on moderate--but not excessive--wine consumption, particularly during meals, preference for olive oil as the main added lipid, low consumption of meat, and high consumption of vegetables, fruits, and legumes," author Dr Dimitrios Trichopoulos (Harvard School of Public Health, Boston, MA) told heartwire .

The researchers examined data from healthy individuals in Greece who participated in the European Prospective Investigation into Cancer and Nutrition (EPIC) trial.

Although this study did not examine causes of death, previous studies in this cohort showed that the Mediterranean diet has the greatest effect on cardiac mortality, Trichopoulos said.

The study is published online June 24, 2009 in BMJ.

A Toast to Long Life

To investigate the relative importance of each of the components of the Mediterranean diet on longevity, the researchers looked at data from the Greek segment of EPIC, from over 23 000 healthy men and women aged 20 to 86 at enrollment.

The researchers calculated a Mediterranean diet score from a diet questionnaire filled in by the participants at study entry.

The diet score was based on nine components of the Mediterranean diet: vegetables, legumes, fruit and nuts, dairy products, cereals, meat and meat products, fish and seafood, monounsaturated-to-saturated lipid ratio, and ethanol consumption.

High consumption of a beneficial food, low consumption of a harmful food (meat or dairy products), and moderate consumption of alcohol were each assigned a value of 1; other levels of consumption were assigned a value of 0, for a score of 0 to 9.

The researchers compared longevity for individuals with scores above or below the median, where the median was about five servings of vegetables and three to four servings of fruits and nuts a day, said Trichopoulos. Moderate intake of alcohol was one to five small glasses of wine (10 g/day to less than 50 g/day) for men and half that for women.

As is typical in the Greek population, many individuals were overweight or obese and many men were smokers. Most were moderately active.

After a mean follow-up of 8.5 years, more deaths occurred in the participants with low vs high Mediterranean-diet scores.

The contribution of each of the diet components to lower mortality were: moderate consumption of alcohol (23.5% of the effect), low consumption of meat (16.6%), high consumption of vegetables (16.2%), high consumption of fruits and nuts (11.2%), high monounsaturated-to-saturated lipid ratio (10.6%), and high consumption of legumes (9.7%).

Eating lots of cereal products and few dairy products contributed to only 5% of the effect, and consumption of fish was associated with a nonsignificant increase in mortality.

Trichopoulos was not surprised that the study found that moderate consumption of alcohol--mostly wine drunk with meals--was such a prominent contributor to longevity. Wine consumed in the Greek diet is comparable to wine consumption that is part of the "French paradox," he noted.

The researchers acknowledge that the long follow-up means that diets could have changed over the study. In addition, the effects of each food might be synergistic.

No Single Miracle Food

Commenting on the study for heartwire , Dr Teresa T Fung (Harvard School of Public Health, Boston, MA), who was not involved with the study, said that she was surprised that moderate consumption of alcohol--which is known to reduce risk of cardiac disease--had such a strong contribution to reduced risk of mortality.

Importantly, this work confirms that it is not one single component of the Mediterranean diet that is driving reduced risk of mortality, she added. "In order to promote longevity, people have to do several things at the same time. They just can't focus on one food--just eat blueberries or take a folic-acid pill. It's a whole lifestyle, whole diet approach for health promotion."

However, the study does not indicate whether each of the components of the Mediterranean diet linked to decreased risk of mortality are also linked to reduced risk of incidence of the diseases that cause the mortality, Fung added.

The authors disclosed having no conflict of interest. The study was supported by the Europe Against Cancer Program of the European Commission, the Greek Ministries of Health and Education, and a grant to the Hellenic Health Foundation by the Stavros Niarchos Foundation.


  1. Trichopoulou A, Bamia C, Trichopoulos D. Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study. BMJ; 2009: 338:b2337. Abstract

Clinical Context

Adherence to the Mediterranean diet has been shown to be protective for mortality. The effects have been stronger in Mediterranean countries vs western European countries and Sweden, but the relative contribution of each component of the Mediterranean diet to overall survival duration is not well known.

This is a prospective longitudinal cohort study of the Greek segment of the EPIC study that examined the role of biological, dietary, lifestyle, and environmental factors to cancer and other chronic diseases.

Study Highlights

  • The EPIC study consisted of participants from 23 research centers in 10 European countries.
  • The Greek cohort consisted of 28,572 health men and women aged 20 to 86 years recruited between 1994 and 1997.
  • Trained interviewers administered diet and lifestyle questionnaires, and health professionals made anthropometric measurements.
  • Dietary intakes during the year before enrollment were assessed, and 150 foods and beverages commonly consumed in Greece were examined with use of standard portion sizes.
  • 9 nutritional components of the Mediterranean diet were evaluated: vegetables, legumes, fruits and nuts, dairy products, cereals, meat and meat products, fish and seafood, monounsaturated-to-saturated lipid ratio, and ethanol.
  • Conformity to the Mediterranean diet was assessed with a 10-unit scale.
  • Ethanol is consumed as part of meals in Greece; median consumption was awarded 1 unit or more, and less than the median consumption was given 0 units.
  • Median consumption of alcohol was defined as 10 to 50 g per day for men and 5 to 25 g for women.
  • For other components, a score of 1 unit was assigned to consumption of desirable components above the median and 0 for consumption below the median.
  • The reverse designation was given for undesirable components such as meat and meat products.
  • The total score was summed with a range from 0 to 9 for adherence to the Mediterranean diet, with a higher score representing closer adherence.
  • Physical activity was represented as metabolic equivalent of task products representing amount of energy per kilogram of body weight.
  • The final sample consisted of 23,349 men and women who were healthy and without cancer, diabetes, or cardiovascular disease at baseline.
  • Follow-up occurred for a mean of 8.5 years and a total of 199,726 person-years.
  • One third were 45 years and younger at baseline, half had little education, 28% were current smokers, and 30% had moderate ethanol intake.
  • A high proportion was overweight or obese (three quarters) and smoked, and the sample had more women than men.
  • 1075 deaths occurred in the cohort, of which 652 occurred among 12,694 with Mediterranean diet scores of 0 to 4 and 423 in those with diet scores of 5 or higher.
  • The mortality rate was higher in those with lower Mediterranean diet scores.
  • There was a significant reduction in total mortality rates per 2-unit increase in Mediterranean diet score (adjusted mortality ratio, 0.864).
  • Moderate ethanol consumption contributed the largest portion to this protective effect (23.5%) followed by low consumption of meat and meat products (16.6%) and high vegetable consumption (16.2%).
  • High fruit and nut consumption contributed 11.2%, high monounsaturated oil consumption 10.6%, and high legume consumption 9.7%.
  • Fish and seafood consumption was associated with a nonsignificant increase in mortality rates, and the authors speculated that this was because of the very low consumption of these items in the Greek population.
  • Of 28 two-by-two combinations of components, there was a clear additive effect of 2 or more components in 13 combinations.
  • Moderate ethanol consumption, high lipid ratio, and low consumption of meat and meat products were each present 5 times in the 26 possible entries.
  • The authors concluded that adherence to the Mediterranean diet was associated with a reduction in mortality rates and the components that contributed the most were moderate ethanol consumption; low intake of meat and meat products; and high intake of vegetables, fruits and nuts, and olive oil and legumes.

Clinical Implications

  • Greater adherence to the Mediterranean diet is associated with a decrease in mortality rates.
  • The reduction in mortality rates seen with adherence to the Mediterranean diet is attributable to moderate ethanol; low meat and meat product consumption; and high vegetable, fruit, and nut consumption.