The Mediterranean pyramid: 30 years later, still relevant - European Journal

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Thirty Years On, the Mediterranean Diet Reaches for the Liver, Kidneys and Mind, but the Proof Thins Out Past the Heart

This narrative review marks three decades since the 1995 Mediterranean Diet Pyramid and asks whether the diet’s benefits extend beyond its established territory of cardiovascular disease, diabetes, cancer and cognitive decline. The authors survey the last ten years of work on fatty liver disease, chronic kidney disease and depression. They conclude that the evidence is growing in all three areas but admit that the wider potential “remains largely unexplored.” The paper presents no new data, uses no systematic search, and reports almost no effect sizes for the newer indications. Its firmest numbers are still the cardiovascular results from PREDIMED and CORDIOPREV.

The Mediterranean diet is the most studied eating pattern in history. A simple PubMed search returns 15,667 papers, against 2,205 for the DASH diet and 206 for the Nordic diet. Three researchers closely tied to that literature, including the lead investigator of the landmark PREDIMED trial, now ask what the diet can do beyond protecting the heart.

Their starting point is solid. PREDIMED randomized about 7,400 high-risk Spanish adults and found roughly 30 percent fewer major cardiovascular events in those given extra virgin olive oil or nuts on top of Mediterranean diet advice, compared with low-fat advice. CORDIOPREV later found a 26 percent lower risk of repeat events in people who already had heart disease. Few dietary patterns have randomized evidence on hard outcomes at all.

The review then moves to three newer areas. For fatty liver disease, now called MASLD and the most common chronic liver condition worldwide, several meta-analyses of randomized trials suggest the diet improves markers of disease severity. The authors argue its palatability makes it easier to sustain than restrictive diets. They also flag an unresolved problem: wine is part of the traditional pattern, yet alcohol is a liver toxin. A large trial called UNATI, running to 2028, is testing abstention against moderation within the diet.

For the kidneys, the picture is mixed. One trial in heart attack survivors found better preservation of kidney function. But a two-year Israeli weight-loss trial found the Mediterranean diet no better than low-fat or low-carbohydrate diets, and PREDIMED found no reduction in diabetic kidney disease after six years. The authors concede that few well-powered trials exist.

For depression, pooled observational studies link the highest adherence to a 33 percent lower risk of developing the condition. The randomized evidence is much weaker. PREDIMED’s depression results were, in the authors’ words, “basically null,” and a later trial in recovered patients was disrupted by the pandemic, showing gains only in quality-of-life scores.

The proposed mechanisms are familiar: olive oil phenols, fiber, unsaturated fats, potassium and magnesium acting on inflammation, oxidative stress, insulin sensitivity and gut microbes. The authors make one practical point here. Olive oil has only modest effects on cholesterol, so the phenol content of the oil matters, and cheap refined oil is not a substitute.

The review closes on cost and climate. Healthy diets remain more expensive than unhealthy ones, and climate change is already affecting olive, fruit and vegetable production.

The big idea is that one dietary pattern may act as a general chronic disease strategy. The evidence in this paper supports that for the heart and plausibly for the liver. For kidneys and mood it remains a hypothesis.

Actionable Insights

The strongest take-home message is cardiovascular. In PREDIMED, about 11 of every 1,000 people in the control group had a heart attack, stroke or cardiovascular death each year. In the olive oil and nut groups it was about 8. That is 3 fewer events per 1,000 people per year, a 30 percent relative drop but a small absolute one for any individual. For people with existing heart disease the payoff was larger: 17 percent had a repeat event over seven years on the Mediterranean diet versus 22 percent on low-fat, so about 1 in 20 avoided an event.

Practical steps supported by those trials:

  • Use extra virgin olive oil as the main fat, around 4 tablespoons a day in PREDIMED. Choose high-phenol oils.
  • Eat about 30 g of mixed nuts daily.
  • Keep red meat, processed meat and junk food minimal.
  • If you have fatty liver, the diet is a reasonable first-line choice, but skip the wine.

For depression, the 33 percent lower risk comes from observational studies and may reflect healthier people choosing better diets. For kidney protection, the diet has not beaten other sensible diets in trials. Treat both as possible bonuses.

Context and Source

  • Full title: The Mediterranean pyramid: 30 years later, still relevant
  • Institutions: University of Padova (Italy); IMDEA-Nutrition, Clínica Universidad de Navarra, University of Navarra and CIBERObn (Spain); Harvard T.H. Chan School of Public Health (USA)
  • Journal: European Journal of Nutrition (Springer), Published online 24 September 2026.
  • Impact evaluation: The impact score of this journal is 4.5, evaluated against a typical high-end range of 0–60+ for top general science and medical journals, therefore this is a Medium impact journal.

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One of the biggest things with this pattern of eating is that it’s enjoyable and reality straightforward to implement in a variety of contexts in our modern world.

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Sometimes we get it right. A beautiful diet in so many ways. Simplicity, versatility, adaptability, ease, cooking fun, sociability, and – above all – taste!

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And now a new report on the Nordic Diet (Northern Mediterranean)…

Whole Grains, Fatty Fish and Canola: The Nordic Pattern Tied to a Lower Risk of Dying

Researchers used 24 years of data on 64,406 middle-aged and older Swedes to estimate what would have happened had everyone followed a healthy Nordic diet (HND), the official Nordic Nutrition Recommendations 2023 (NNR23), or their usual diet. Neither diet clearly reduced major adverse liver outcomes (decompensated cirrhosis, liver cancer, transplantation). The HND was associated with a lower estimated risk of death from any cause: 39.9 percent versus 42.5 percent.

A diet built around rye bread, oats, berries, cabbage, fatty fish and rapeseed oil has been promoted across Scandinavia as the northern answer to the Mediterranean diet. A one-year Swedish trial recently showed it could strip fat from the liver in people with diabetes or prediabetes. The obvious next question is whether that translates into fewer of the liver outcomes that kill people: decompensated cirrhosis, liver cancer and transplantation. A new analysis of 64,406 Swedes followed for 24 years says the answer, for now, is no.

The team, based at Aarhus University with colleagues at the Karolinska Institutet, could not run the ideal experiment. Nobody can hold thousands of people to an assigned diet for a quarter of a century. Instead they used target trial emulation. They wrote the protocol for the trial they wished they could run, then applied statistical modeling to two long-running cohorts to estimate what would have happened under three scenarios: the Nordic diet, the official Nordic recommendations, or no change.

Serious liver outcomes were rare. Only 405 occurred in 24 years. The model put the risk at 0.53 percent on the Nordic diet against 0.64 percent with usual eating, a gap small enough that chance cannot be ruled out. The official recommendations did no better than doing nothing, and possibly slightly worse.

The more striking figure concerns death from any cause. The estimated 24-year risk of dying was 39.9 percent on the Nordic diet versus 42.5 percent with usual eating. That is a 6 percent relative reduction. The Nordic diet also beat the official recommendations by about 1.7 percentage points.

Three details change how these numbers should be read.

First, the diet tested was a watered-down version. Almost nobody in 1990s Sweden ate the real thing, so the researchers lowered the bar. Fatty fish three times a week became once a fortnight. The produce target was halved to 125 grams a day. The processed meat allowance was raised fivefold. The study therefore describes a modest nudge toward Nordic eating, not the full regimen.

Second, when foods were removed from the model one at a time, the liver signal depended almost entirely on rapeseed oil. Without it, the apparent benefit disappeared. Only 19 percent of participants used rapeseed oil in 1997, and those early adopters may differ from everyone else in ways a questionnaire does not capture.

Third, the official recommendations seem to have been dragged down by their cap of four cups of coffee a day. Coffee is consistently linked to healthier livers, and removing the coffee rule erased the apparent penalty.

The only clear liver result came when near-abstinence from alcohol was added to the Nordic diet, which cut estimated risk by 30 percent.

The authors state plainly that a causal reading requires no unmeasured confounding, no selection bias and no measurement error. Diet was recorded just three times in 24 years. The mortality result fits earlier observational work, but it is a secondary outcome from a model, not a trial result.

Actionable Insights

For liver protection, alcohol is the lever that matters. Diet alone produced no clear benefit. Diet plus keeping alcohol under about 6 grams a day (roughly 3.5 glasses of wine a week) cut the estimated risk of serious liver disease by 30 percent. In absolute terms that is about 19 fewer cases per 10,000 people over 24 years, because these outcomes are rare to begin with.

Do not cut coffee for your liver’s sake. The guideline that capped coffee at four cups performed worse, and removing that cap fixed it.

Swapping your cooking fat for rapeseed (canola) oil is cheap and low risk. It drove the entire liver signal here, though that could reflect the kind of person who used it in 1997 as much as the oil itself.

For overall survival, the modest Nordic pattern was linked to about 26 fewer deaths per 1,000 people over 24 years (425 versus 399). Put another way, roughly 37 people would need to eat this way for 24 years for one of them to avoid dying in that window. The average person would gain something on the order of weeks to a couple of months of life over a decade.

The bar tested was low: two servings of whole-grain bread daily, some oats or rye porridge, 125 grams of berries, apples or cabbage, and fatty fish every other week.

Context and Source

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