COMMENTARY

Mediterranean Diet's Benefits May Extend to Multiple Diseases

William F. Balistreri, MD

Disclosures

November 07, 2018

In This Article

What We Don't Know

A few remaining questions must be considered regarding the cited studies, the mechanistic pathways, and the implementation of specific diets to reverse the morbidity and mortality of obesity and its consequences.

What are the costs and the ease of access to the components of the Mediterranean diet? Long-term commitment and adherence to this diet as a healthy dietary pattern presents challenges to some.

What specific components of the Mediterranean diet are responsible for the observed favorable effects? Are these effects directly due to the benefits of Mediterranean diet or to the inherent reduction in the evils of the excluded foods? For example, several studies have suggested a significant association between consumption of high- fructose corn syrup and red and processed meats with a higher risk for NAFLD and nonalcoholic steatohepatitis.[43,44]

What are the validity and reproducibility of the studies? A recent review of the clinical evidence on the impact of the Mediterranean diet in patients with NAFLD concluded that although the diet has the potential to improve liver status, the literature is limited.[20] Small sample sizes, short-term follow-ups, heterogeneous designs, variable time points of data collection, and reliability of the methodology for determining the liver outcome limit the generalizability of the results. Anania and colleagues[20] encourage adequately powered randomized dietary intervention trials comparing the Mediterranean diet with a control diet in a large sample of the general population, along with a validation in the heterogeneous patient population with NAFLD.

Is it possible, as mentioned above, that the effects are not due to a specific dietary component, but attributable to a confounding effect on the gut microflora? Certain clusters of bacterial species within the gut microenvironment have been correlated with obesity, fatty liver, and cardiometabolic disease risk.[45] These bacteria produce metabolic products, such as short-chain fatty acids, secondary bile acids, and trimethylamine, which may affect the microbial community and risk for disease. The Mediterranean diet components have a direct favorable impact on the gut microenvironment, providing substrates to and promoting the colonization of resident bacteria, which in turn reduce disease risk.[45] For example, Bajaj and colleagues[46] reported that a Mediterranean diet may prove beneficial in maintaining a healthy gut microbiome, possibly improving the outcome of patients with cirrhosis. Thus, the gut microbiome may be the key mediator between these dietary patterns, healthy outcomes, or disease risk.

As we await the answers to these questions, I see no significant downside to adopting the Mediterranean diet pattern and would recommend this approach to my patients. I would, however, also emphasize the role of exercise as a component of the healthy lifestyle.

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