What does the

evidence say about the

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Mediterranean diet?

By Sharon A. Watts, DNP, FNP-BC, CDE;

Carl Stevenson, BSN, RN; and
Julianne Patterson, MSN, RN, CDE

OVER 84 MILLION adults in the United States with prediabe-

tes need lifestyle education to prevent the onset of diabetes.1,2
(See Startling statistics.) Nurses can take steps to help mitigate
the harm of both prediabetes and diabetes that are fueled by
fast, inexpensive, and overly processed food. This article re-
views what generally constitutes the Mediterranean diet (MD),
presents the evidence about the role the MD plays in type 2
diabetes mellitus (T2DM) preven-
tion, and suggests how nurses can Startling statistics1
present the concept of this diet to
The CDC estimates that from 2009 to
patients and their families.
2012, 86 million U.S. adults age 20 or
older had prediabetes, or 37% of the
Defining terms U.S. population. For those age 65 or
Primary prevention aims to older, the proportion with prediabetes
prevent disease or injury before it rose to 51%. The CDC’s findings are
occurs in the population at large. based on fasting glucose or A1C lev-
Examples of primary prevention els. Additionally, 12.6% of adults age
include preventing exposures to 20 or older already had diabetes.
hazards that cause disease or in-
jury, altering unhealthy or unsafe behaviors that can lead to
disease or injury, and increasing resistance to disease or injury
should exposure occur.3 Nurses could teach patients about the
prevention of diabetes by diet and exercise, an important pri-
mary prevention.
Secondary prevention aims to reduce the impact of a
disease or injury that’s already occurred through evidence-
IGPHOTOGRAPHY /iSTOCK

based interventions. Examples of secondary prevention in-

clude treating disease or injury as soon as possible to halt or
slow its progress, encouraging personal strategies to prevent
reinjury or recurrence, and implementing programs to

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www.Nursing2018.com March l Nursing2018 l 51

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

return people to their original rine, and other solid fats are rarely
health and function and to prevent used. Solid fats are high in saturated
long-term problems.3 An example and trans fats, which damage arteries
of secondary prevention would be a and can contribute to dyslipidemia.7-9
change in diet and exercise that Reducing saturated fat improves in-
would help lower the hemoglobin sulin sensitivity, although this hasn’t
A1C (A1C) in a patient who’s been been well studied in individuals with
diagnosed with diabetes. diabetes.10 Olive oil is a good source
Prediabetes is a risk factor for of monounsaturated fat, or healthy
cardiovascular disease. (See Resources fat, that can help improve choles-
about diabetes.) However, risk factor terol levels when used instead of
modification, including diet, is saturated fats.7-9
known to reduce the progression of Although the MD was traditionally
prediabetes to diabetes.2 Until the part of the lifestyle of poor rural resi-
past decade, the typical dietary ad- dents in the MD region before the
vice has been to lose 7% to 10% mid-1960s, regular physical activity
of body weight by eating a well- was also integral to this lifestyle.
balanced diet (along with increased The MD is much more than a di-
physical activity) based on the etary plan; the physically active
Diabetes Prevention Trial, a multi- lifestyle of these residents is an im-
center, randomized controlled trial portant factor in the recommenda-
(RCT; N = 3,234) conducted from tions for spreading the traditional
1996 to 2001 in the United States.4 Risk factor modification, MD to non-MD countries.6
Emerging evidence now points to including dietary Mattioli and colleagues conduct-
the MD as a healthy eating option changes, can reduce ed a review of 17 research trials
to help patients reduce their risk of the progression of and defined the MD as the eating
developing T2DM. For those who habits found in populations living
already have diabetes, this diet im- prediabetes to diabetes. around the Mediterranean Sea
proves glycemic control and pro- (Crete and southern Italy) after
vides cardiovascular protection.2,5 MD and the impact each part of the World War II. During that time,
diet has on health and reduction of food was in short supply and
What constitutes the MD? total mortality.6 (See How do compo- nutrition was “characterized by
The MD doesn’t have a single defini- nents of the MD compare?) Certain a relatively high consumption of
tion; the studies discussed in this parts of the diet have a more positive inexpensive and [unprocessed]
article used variations of the MD impact on health than others. For foods such as cereals, vegetables,
found in the countries surrounding example, the high intake of plant legumes, nuts, fish, fresh fruits,
the Mediterranean Sea.5 The term foods such as vegetables, fruits, and olive oil as the principal source
MD is often used to describe the nuts, and legumes (fleshy, colorful of fat. The consumption of meat
consumption of common healthy plant seeds such as beans, peas, and was low, whereas the consumption
foods of the region. lentils) has the largest impact.7-9 of milk, dairy products, and wine
Trichopoulou and colleagues Olive oil is the staple fat used for was low–moderate.”5
compared various ingredients of the cooking in this diet.8 Butter, marga- The components of the traditional
MD are like those in other modern
healthy diet trends (such as the
Resources about diabetes Healthy Eating Index or the Dietary
• For the definitions of diabetes and prediabetes, see American Diabetes Association. Approaches to Stop Hypertension)
2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2018. with two unique elements: moderate
Diabetes Care. 2018;41(suppl 1):S13-S27 at http://care.diabetesjournals.org/content/ intake of red wine during meals and
diacare/suppl/2017/12/08/41.Supplement_1.DC1/DC_41_S1_Combined.pdf. abundant fat intake, provided that
• For detailed recommendations for teaching about the MD, including foods or food the fat comes from virgin olive oil,
groups, recommended intake, tips, and the Mediterranean-style plate method, see tree nuts, and/or fatty fish.5,11
the Veterans Affairs Nutrition and Food Services website: www.nutrition.va.gov/
Trichopoulou and colleagues stat-
docs/UpdatedPatientEd/Mediterraneandiet.pdf.
ed that future research is needed to

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clarify whether red wine should be
distinguished from other types of How do components of the MD compare?
alcohol intake as part of the MD’s
health benefits.6 Gepner and col-
leagues studied 54 individuals in
Israel who had T2DM. They compared
Other Vegetables
A1C levels between two groups:
12.1% 16.2%
Group one drank 150 mL of dry red
wine with dinner, and group two
drank mineral water. Both groups Olive Oil
were advised to adhere to the MD, 10.6%
Fruits & Nuts
without caloric restriction. They 11.3%
found that those who drank red wine
had an A1C of 6.6 ± 0.9, and those Low Meat
who drank mineral water had an 16.6% Legumes
A1C of 6.9 ± 1.4.12 9.7%

Primary prevention Moderate Alcohol

A meta-analysis by Bloomfield and
colleagues (N = 7,447) showed that
individuals who adhered to the MD
had a 30% decrease in the risk of
developing T2DM.13 More recently,
Dinu and colleagues published a
meta-analysis review of 10 articles
that revealed a 17% drop in the
incidence of diabetes for individuals
following the MD.14
23.5%
This pie chart shows how much the individual components of the MD are respon-
sible for improving health and reducing mortality. For instance, moderate alcohol
intake has a greater impact than using olive oil, but eating more vegetables, fruits,
nuts, and legumes (combined) has more of an impact than any single element.
Source: Trichopoulou A, Martínez-González MA, Tong TY, et al. Definitions and potential health benefits of the
Mediterranean diet: views from experts around the world. BMC Med. 2014;12:112.

Secondary prevention
In a systematic review of 20 RCTs and
3,073 participants with T2DM, Ajala
and colleagues compared the MD with
other dietary interventions (such as
low-fat, high-glycemic index, American
Diabetes Association [ADA], European
Association for the Study of Diabe-
tes, and low-protein diets) that lasted
6 months or longer.15 They found a
weighted mean difference in A1C of
−0.47% in favor of the MD. The MD
was also effective in helping patients
lose weight.15
Huo and colleagues conducted a
meta-analysis of RCTs to explore the
effects of the MD on glycemic control,
weight loss, and cardiovascular risk
factors in 1,178 patients with T2DM.16
The MD and control diets with which
they were compared weren’t consistent
across the studies. The control diets
were a low-fat diet; usual dietary
habits; nonrestricted-calorie, low-
carbohydrate diet; the 2003 ADA
diet; or a high-carbohydrate diet.
Compared with control diets, the MD
led to greater reductions in A1C,
fasting plasma glucose, fasting insulin,
body mass index, and body weight.16
Recently, Esposito and colleagues
published a meta-analysis of the
MD for patients with T2DM.17
They found that the MD is associ-
ated with better glycemic control in
patients with T2DM (A1C reduc-
tion ranging from 0.3% to 0.47%).
They propose that the MD may
protect patients from T2DM due to
its anti-inflammatory and antioxi-
dative effects. The protective nutri-
ents in the diet, such as fiber,
vitamins, minerals, and polyphe-
nols, as well as the absence of
proinflammatory nutrients such as
saturated and transfatty acids, refined
sugars, and starches, are thought
to account for the diet’s beneficial
effects.17 The evidence supports
the use of the MD to help patients
reduce the risk of T2DM.
What nurses can do
Due to the increasing number of pa-
tients diagnosed with T2DM, nurses
need to be prepared to teach patients
about healthy food choices. Many
nurses are the “first responders” to
newly admitted or clinic patients who
may be challenged by needing to bal-
ance diabetes management with that
of other complex medical problems.18
Completely changing one’s diet
can be overwhelming. Nurses
can suggest patients make small
changes to their diet to gradually
incorporate more MD elements.
For example, they can encourage
patients to use more olive oil rath-
er than butter or margarine. Indi-
vidualize teaching and nutrition
plans based on each patient’s

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needs.19 Advise them to consume
more fruits and vegetables as
snacks instead of processed or
prepackaged items.7
Extra virgin and virgin olive oils
are high in monounsaturated fatty
acids and can be used in cooking and
baking as an alternative to butter and
other oils, which are higher in satu-
rated and trans fats.7,20 Teach patients
to choose whole wheat instead of
white bread, pasta, and rice and
to use these in moderation.7
Encourage them to use vinaigrette
dressings as a vegetable dip instead
of sour cream-based dips. Another
healthy choice is to sprinkle on seeds,
nuts, and vinaigrette dressings in-
stead of using cheese, croutons, and
creamy dressings.7,21,22
Incorporating more legumes,
vegetables, and fruit into a diet
plan with less meat is consistent
with the MD-style diet plan. Con-
suming a moderate amount of
poultry and fatty fish such as salm-
on and tuna are recommended as
well as consuming a small amount
of lean meat.7
A simple, easy-to-understand tool is
the MD plate method, which can be
useful when low literacy issues are a
concern.22 Refer patients to a regis-
tered dietitian nutritionist and to
diabetes self-management education
classes for more in-depth clarification
of what constitutes healthy eating.2
Finally, encourage all patients to
maintain regular physical activity in
conjunction with making healthy diet
choices.2,6,10,19
Knowledge is power
Nurses can familiarize themselves
with the MD and its impact on the
health of patients with prediabetes
and T2DM. Encourage patients to
progressively adjust their diets to
include more of the items in the tra-
ditional MD.2,6,10,19 All nurses play
an important role in teaching pa-
tients how to reduce their risk for
developing T2DM and improving
54 l Nursing2018 l Volume 48, Number 3
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
The Mediterranean
diet is effective in
helping patients
achieve weight loss.
glycemic control in patients with
preexisting T2DM. ■
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around the world. BMC Med. 2014;12:112.
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Mediterranean-style diet on glycemic control,
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type 2 diabetes individuals: a meta-analysis. Eur J
Clin Nutr. 2015;69(11):1200-1208.
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Chiodini P, Panagiotakos D, Giugliano D. A
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gov/metabolicsyndrome.html.
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Fernandez S, et al. Characterization of lipid profile
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Sharon A. Watts is an NP in endocrinology at the
Louis Stokes Cleveland VA Medical Center in
Cleveland, Ohio, and is the Metabolic Syndrome
and Diabetes Advisor for the Office of Nursing
Services Veterans Affairs in Washington, D.C. Carl
Stevenson is a staff RN at the Boise VA Medical
Center in Boise, Idaho. Julianne Patterson is an RN
certified diabetes educator at the VA Central Iowa
Health Care System in Des Moines, Iowa.
The authors have disclosed no financial relationships
related to this article.
The opinions expressed herein are those of the au-
thors and do not necessarily reflect those of the U.S.
Government, or any of its agencies.
DOI-10.1097/01.NURSE.0000530407.38450.a3
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