Review Article
Med Diet 4.0: the Mediterranean diet with four sustainable benefits
S Dernini
1,2,3
, EM Berry
1,4,
*, L Serra-Majem
1,5,6
, C La Vecchia
1,7
, R Capone
1,8
,
FX Medina
1,9
, J Aranceta-Bartrina
1,10
, R Belahsen
1,11
, B Burlingame
1,12
, G Calabrese
1,13
,
D Corella
1,14
, LM Donini
1,6,15
, D Lairon
1,16
, A Meybeck
1,3
, AG Pekcan
1,17
, S Piscopo
1,18
,
A Yngve
1,19
and A Trichopoulou
1,20
, on behalf of the Scientific Committee of the
International Foundation of Mediterranean Diet
1
International Foundation of Mediterranean Diet (IFMeD), London, UK:
2
Forum on Mediterranean Food Cultures,
Rome, Italy:
3
Food and Agriculture Organization of the United Nations, Rome, Italy:
4
Department of Human Nutrition
& Metabolism, Braun School of Public Health, Hebrew University–Hadassah Medical School, Jerusalem 91120,
Israel:
5
University of Las Palmas of Gran Canaria, Las Palmas, Spain:
6
Inter-University International Centre of
Mediterranean Food Cultures Studies (CIISCAM), Rome, Italy:
7
Department of Clinical Sciences and Community
Health, University of Milan, Milan, Italy:
8
International Centre for Advanced Mediterranean Agronomic Studies
(CIHEAM), Bari, Italy:
9
Universitat Oberta de Catalunya/Open University of Catalonia, Barcelona, Spain:
10
University of Navarra, Navarra, Spain:
11
Chouaib Doukkali University, El Jadida, Morocco:
12
Massey University,
Palmerston North, New Zealand:
13
University of Turin, Turin, Italy:
14
Department of Preventive Medicine, University
of Valencia and CIBER Fisiopatologia de la Obesidad y Nutricion, Valencia, Spain:
15
NORT/Aix-Marseille
University, INRA, INSERM, Marseille, France:
16
Sapienza University of Rome, Rome, Italy:
17
Department of Nutrition
and Dietetic, Hacettepe University, Ankara, Turkey:
18
Department of Health, Physical Education & Consumer Studies,
Faculty of Education, University of Malta, Malta:
19
School of Hospitality, Culinary Arts and Meal Science, Örebro
University, Örebro, Sweden:
20
Hellenic Health Foundation, Athens, Greece
Submitted 19 February 2016: Final revision received 18 October 2016: Accepted 25 October 2016: First published online 22 December 2016
Abstract
Objective: To characterize the multiple dimensions and benefits of the Mediterranean
diet as a sustainable diet, in order to revitalize this intangible food heritage at the
country level; and to develop a multidimensional framework – the Med Diet 4.0 – in
which four sustainability benefits of the Mediterranean diet are presented in parallel:
major health and nutrition benefits, low environmental impacts and richness in
biodiversity, high sociocultural food values, and positive local economic returns.
Design: A narrative review was applied at the country level to highlight the multiple
sustainable benefits of the Mediterranean diet into a single multidimensional
framework: the Med Diet 4.0.
Setting/subjects: We included studies published in English in peer-reviewed
journals that contained data on the characterization of sustainable diets and of the
Mediterranean diet. The methodological framework approach was finalized
through a series of meetings, workshops and conferences where the framework
was presented, discussed and ultimately refi ned.
Results: The Med Diet 4.0 provides a conceptual multidimensional framework to
characterize the Mediterranean diet as a sustainable diet model, by applying
principles of sustainability to the Mediterranean diet.
Conclusions: By providing a broader understanding of the many sustainable
benefits of the Mediterranean diet, the Med Diet 4.0 can contribute to the
revitalization of the Mediterranean diet by improving its current perception not
only as a healthy diet but also a sustainable lifestyle model, with country-specific
and culturally appropriate variations. It also takes into account the identity and
diversity of food cultures and systems, expressed within the notion of the
Mediterranean diet, across the Mediterranean region and in other parts of the world.
Further multidisciplinary studies are needed for the assessment of the sustainability of
the Mediterranean diet to include these new dimensions.
Keywords
Mediterranean diet
Sustainable diets
Sustainable food systems
Public health nutrition
Food security and nutrition
Sustainability
Public Health Nutrition: 20(7), 1322–1330 doi:10.1017/S1368980016003177
*Corresponding author: Email elliotb@ekmd.hiji.ac.il © The Authors 2016
https://doi.org/10.1017/S1368980016003177 Published online by Cambridge University Press
In recent years, within the international debate on sus-
tainability, food security and nutrition
(1,2)
, sustainable diets
have emerged as a challenging public health nutrition
issue
(3–7)
as well as a critical issue for sustainable food
systems
(8–10)
.
The incorporation of sustainability aspects into dietary
guidelines has been increasingly discussed over the past
decades to make diets healthier for consumers as well as
for the environment. After the publication of the first
dietary guidelines for sustainability in 1986
(11)
, criticisms
have continued to ignite controversial debates, as reported
12 years later
(12)
. For example, the recent proposals
by the US Department of Agriculture Dietary Guidelines
Advisory Committee to include sustainability issues into
the 2015 Dietary Guidelines for Americans
(13)
were met
with criticism, largely deemed political, and were ulti-
mately rejected
(14)
. In the meantime, several countries
such as Qatar, Brazil, Sweden and the Netherlands
have already incorporated sustainability in their national
dietary recommendations
(15–18)
. The German Council for
Sustainable Development has produced a ‘sustainable
shopping basket’ to guide consumers to shop for food in a
more sustainable way
(19)
.
The degradation of ecosystems and the negative impact
in relation to poverty and health are making a compelling
case for re-examining food systems and diets within
the sustainable development agenda. The concept of
sustainable diets acknowledges the interdependencies of
food production and consumption with food requirements
and nutrient recommendations, and at the same time
reaffirms the notion that human health cannot be isolated
from that of ecosystems
(20)
. Sustainable diets, which are
ecosystem-specific, offer a practical way of applying sus-
tainability to food security and nutrition. In this overall
context, sustainability becomes the long-term component
of all the levels and dimensions of food security – the
well-established and accepted determinant of a nation’s
health and well-being
(1)
. Supporting the implementation
of the Post-2015 Sustainable Development Agenda, ending
malnutrition in all its forms is an imperative to drive
sustainable development
(21)
.
The FAO has estimated that by 2050, in order to satisfy
the needs of a growing and richer world population with
increased demand for animal products, food production
will have to increase by at least 60 %
(22)
. This will be a
major challenge for food security and sustainability, con-
sidering that natural resources are already increasingly
stressed and degraded, with the additional negative effects
of climate change. Today, a main concern is to conserve
natural resources for future generations while simulta-
neously providing enough food, in quantity and quality, to
meet the nutritional requirements of a growing global
population. Radical changes in food production and con-
sumption will be required over the coming decades
(23)
.
Therefore, there is an urgent need for transdisciplinary
measures to address both undernutrition and overnutrition,
diversify diets, reduce waste and minimize environmental
damage
(24)
. There is growing scientific evidence on the
environmental impacts of diets, linking public health
nutrition and sustainability
(24–29)
, but there are still many
challenges in understanding the full complexity of sus-
tainable diets, their assessments and determinants
(30–32)
.
The Mediterranean diet as a case study for
sustainable diets
Within the international debate on a shift towards more
sustainable food systems and diets, interest in the Medi-
terranean diet as a model of a sustainable dietary pattern has
increased
(1,20,33)
. The notion of the Mediterranean diet has
undergone a progressive evolution over the past 50 years,
from that of a healthy dietary pattern for the heart
(34)
to
the model of a sustainable diet
(1,20,35–37)
. From the early
1990s, taking into account increasing concerns regarding
environmental sustainability, the Mediterranean diet as a
plant-centred diet began to be researched as a sustainable
dietary pattern
(35)
, with lower environmental impacts
(25–29)
.
Despite the fact that the Mediterranean diet is well
documented and acknowledged as a healthy diet
(38)
,
paradoxically, it is being abandoned, mainly by the young
generations in most Mediterranean countries
(33)
. Southern
and Eastern Mediterranean countries are passing through
a ‘nutritional transition’ in which problems of under-
nutrition coexist with overweight, obesity and diet-related
chronic diseases
(39)
. The erosion of the Mediterranean
diet heritage, by the loss of its adherence among Medi-
terranean populations, is alarming as it has undesirable
impacts not only on health but also on social, cultural,
economic and environmental trends in the Mediterranean
region
(33)
.
In 2009, an international conference on ‘The Mediterra-
nean Diet as a Sustainable Diet Model’ was organized to
present the Mediterranean diet as a sustainable dietary
pattern; and to update the Mediterranean diet pyramid in the
light of current lifestyle changes, with serving sizes based on
frugality and local habits, as well as with new characteristic
elements such as biodiversity, seasonality, culinary activities,
traditional, local and eco-friendly food products, conviviality,
adequate rest and regular physical activity
(40,41)
.Asafollow-
up in 2010, at an international scientific symposium on
‘Biodiversity and Sustainable Diets: United against Hunger’,
heldattheFAOinRome,anagreementwasreachedonthe
following definition of ‘sustainable diets’
(20)
:
‘Sustainable diets are those diets with low environ-
mental impacts which contribute to food and
nutrition security and to healthy life for present and
future generations. Sustainable diets are protective
and respectful of biodiversity and ecosystems, cultu-
rally acceptable, accessible, economically fair and
affordable; nutritionally adequate, safe and healthy;
while optimizing natural and human resources.’
Med Diet 4.0 1323
https://doi.org/10.1017/S1368980016003177 Published online by Cambridge University Press
On this occasion, an entire session was devoted to the
Mediterranean diet, as a model of sustainable diet
(20)
.In
2011, the FAO and the International Centre for Advanced
Mediterranean Agronomic Studies (CIHEAM) started a
joint collaboration for assessing the sustainability of the
Mediterranean diet as a case study towards the improve-
ment of Mediterranean sustainable food systems
(42)
.In
2012, at the ninth CIHEAM meeting of the Ministers of
Agriculture in Malta, this led to the acknowledgement of
the role of the Mediterranean diet as ‘adriverofsustainable
food systems in the Mediterranean’
(42)
. From 2011 to 2015,
through a series of international workshops and meetings,
a methodological approach was developed and a first
ensemble of potential indicators to assess the sustainability
of the Mediterranean diet was identified , as reported in
Table 1
(42–44)
. Each indicator’s information has been detailed
concerning definition, methodolo gy, background, data
sources, limitations of the indicator and references
(42,44)
.
Each of these indicators requires appropriate data, not
all presently available at country level, to evaluate inter-
actions and correlations between the various indicators as
well as intra- and inter-dimension weightings necessary for
the future development of a composite index.
Development of the Med Diet 4.0 framework
The Med Diet 4.0 framework was developed between
2014 and 2015 as a follow-up of these previous efforts and
further implemented by ‘longstanding’ collaborations
among the co-authors as members of the scientific com-
mittee of the International Foundation of Mediterranean
Diet (IFMeD). In keeping with the 2010 agreed definition
of ‘sustainable diets’
(20)
, and in continuation of previous
studies on the characterization of the Mediterranean diet
as a sustainable diet model
(20,35,36)
and on its sustainability
assessment
(42,43)
, the following four sustainable benefits of
the Mediterranean diet were highlighted and incorporated
into one single comprehensive Med Diet 4.0 framework:
(i) major health and nutrition benefits; (ii) low environ-
mental impacts and richness in biodiversity; (iii) high
sociocultural food values; and (iv) positive local economic
returns. By taking into account the diversity of
Mediterranean food cultures and systems, expressed
within the notion of the Mediterranean diet, the
conceptual multidimensional framework of the Med Diet
4.0 was conceived to allow appropriate country-specific
variations, as exemplified in Fig. 1.
The Mediterranean diet is a highly diversified heritage,
in which food cultures and systems vary from country to
country. Although different they may be considered as
variants of a basic Mediterranean dietary pattern
(45)
.No
attempts were made to cover systematically all sustain-
ability assessment issues of the Mediterranean diet.
A narrative review was applied to allow for incorporating
together, within the multidimensional framework of the
Med Diet 4.0, the four identified sustainable benefits of the
Mediterranean diet.
Table 1 Potential indicators for assessing the sustainability of the Mediterranean diet
Thematic area Proposed indicators
A. Nutrition and health A1. Diet-related morbidity/mor tality
A2. Fruit and vegetable consumption/intake
A3. Vegetable:animal protein consumption ratio
A4. Average dietary energy adequacy
A5. Dietary diversity score
A6. Dietary energy density score
A7. Nutrient density
A8. Food biodiversity composition and consumption
A9. Nutritional anthropometry
A10. Physical activity/physical inactivity prevalence
A11. Adherence to the Mediterranean dietary pattern
A12. Rate of local/regional foods and seasonality
A13. Rate of eco-friendly food production and/or consumption
B. Environment B1. Water footprint
B2. Carbon footprint
B3. Nitrogen footprint
B4. Biodiversity
C. Economy C1. Food consumer price index (FCPI): cereals, fruit, vegetables, fish and meat
C2. Cost of living index (COLI) related to food expenditures: cereals, fruit, vegetables, fish and meat
C3. Distribution of household expenditure per groups: food
C4. Food self-sufficiency: cereals, fruit and vegetables
C5. Intermediate consumption in the agricultural sector : nitrogen fertilizers
C6. Food losses and waste
D. Society and culture D1. Proportion of meals consumed outside home
D2. Proportion of already prepared meals
D3. Consumption of traditional products (e.g. proportion of product under PDO or similar recognized
traditional foods)
D4. Proportion of mass media initiatives dedicated to the knowledge of food background cultural value
PDO, Protected Designation of Origin.
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First benefit: Major health and nutrition benefits
Since the pioneer Seven Countries Study by Keys
(34)
,
much scientific evidence has highlighted the protective
effect of the Mediterranean diet on CVD and its
health benefits in preventing a number of chronic and
degenerative diseases
(46–55)
. Data from a series of cohort
and case–control studies have shown that a high intake
of foods typical of the traditional Mediterranean diet
pattern (MDP) is associated with a reduced risk for
developing various types of cancers, including upper
digestive tract, stomach, colorectal, pancreas, liver, and
selected hormone-related cancers such as endometrial
cancer
(56–60)
.
In support of all these diet–health connections, recent
studies have clearly underlined the nutritional quality of an
MDP. Persons who adhere closely to an MDP fulfil their
micronutrient requirements much better than persons on a
typical Western diet
(61,62)
. Computer-assisted modelling of
individual diets identified that the most important foods
that enable people to fulfil nutritional requirements
(except for vitamin D) are those characteristic of the
MDP
(63)
. Surveys have repeatedly shown that adherence
to an MDP is also associated with a healthier body
weight
(64,65)
, reduced waist circumference as a marker of
central obesity
(66)
, and lower incidence of the metabolic
syndrome
(67)
and type 2 diabetes
(68,69)
. The Mediterranean
diet may positively in fluence the ageing process
(70)
by
delaying the evolution of cognitive decline linked to
Alzheimer’s disease
(71)
and vascular dementia, which is
often documented a long time before the clinical diagnosis
of dementia
(72)
. The Mediterranean diet appears to have
numerous other health advantages that are still under
study, such as lower peripheral artery disease
(73)
, decreased
inflammation and improved endothelial function
(74)
,
improved respiratory fitness
(75)
and immunity
(76)
, decreased
mental disorders such as depression
(77)
, as well as improved
quality of life
(78)
. This substantial body of scientific evi-
dence links the Mediterranean diet to the prevention of the
main chronic non-communicable diseases. Considering
the increasing global trends in overweight and obesity and
the finding that most deaths attributable to overweight
and obesity are cardiovascular deaths
(79)
, the adoption of
an MDP can be an important cost-effective health-care
measure development strategy
(80)
.
Second benefit: Lower environmental impacts and
richness in biodiversity
Many studies have shown that the Mediterranean diet has
a lower environmental impact than other dietary patterns.
This is because it is mainly a plant-based diet with low
consumption of animal products and thus has a smaller
water footprint and lower greenhouse gas emissions,
compared with other current dietary patterns
(25–29)
.
Increased adherence of the Spanish population to the
MDP was reported to have a marked impact on all stan-
dard environmental footprints: reduce greenhouse gas
emissions, land use and energy consumption, and to a
lower extent water consumption, while on the contrary,
adherence to a Western dietary pattern increases all these
parameters
(81)
. In an Italian study, adherence to the MDP
was shown to significantly reduce the food environmental
footprint on natural resources especially for water con-
sumption
(82)
. The Mediterranean basin has long been
identified as a ‘hotspot’ of biodiversity, an area featuring
exceptional concentrations of endemic species and
experiencing exceptional loss of habitat
(83)
. The loss of
indigenous knowledge on the use of local crops in favour
Environment
Environment
SUSTAINABILITY
FOOD SECURITY AND NUTRITION
MED DIET
4.0
Three dimensions of
sustainabilty
Benefit: Benefit:
Benefit: Benefit:
Low
environmental
impacts and rich
in biodiversity
Positove local
economic returns
Major health
and nutrition
benefits
High
sociocultural
food values
Economy
Economy
Social
Med
Diet
Pyramid
4.0
Country-specific variations
Health
Society and
culture
Fig. 1 The Med Diet 4.0 framework that applies the principles of sustainability to the four sustainable dimensions of the
Mediterranean diet
Med Diet 4.0 1325
https://doi.org/10.1017/S1368980016003177 Published online by Cambridge University Press
of a small number of non-native species and varieties has
affected traditional food production systems and biodiversity
across the Mediterranean area
(84)
. The Mediterranean diet
encourages the use of a wide range of cereals, fruits and
vegetables, not only cultivated products but also wild
species, thus sustaining them together with the local,
indigenous and traditional knowledge about their use.
Therefore, safeguarding and promoting the Mediterranean
diet is of paramount importance for the conservation of
the extraordinarily rich biological diversity in the region
and vice versa
(85)
. The seasonal consumption of fresh and
local products, biodiversity, variety of foods (especially
fruits and vegetables of different colours), traditional
culinary activities, conviviality and frugality represent the
cornerstone of conserving the Mediterranean diet heritage
(86)
.
Third benefit: High sociocultural food value
In 2010, the United Nations Educational, Scientific and
Cultural Organization acknowledged the Mediterranean
diet as an Intangible Cultural Heritage of Humanity,
described as follows
(87)
:
‘The Mediterranean Diet, from the Greek word
‘díaita’‘diet’ means ‘way of life–lifestyle’ , a set of
skills, knowledge, rituals, symbols and traditions,
ranging from the landscape to the table. Eating
together is the foundation of the cultural identity
and continuity of communities throughout the
Mediterranean basin. The Mediterranean diet
emphasizes values of hospitality, neighbourliness,
intercultural dialogue and creativity, and a way of
life guided by respect for diversity.’
Frugality as an overarching principle of the Mediterranean
diet expresses the care in food preparation, moderation in
portion size and avoiding waste, and is linked to the high
cultural, social and economic value that food has for all
Mediterranean peoples
(88)
. In the Mediterranean cultures,
eating is important over and above the physiological need
for energy
(89)
. Family and communal meals are a moment
of conviviality and importance, as well as fun and pleasure
(more or less explicit), and represent a daily opportunity
for social exchange and communication. The Mediterra-
nean diet is a sociocultural historical heritage intimately
linked to the lifestyles of the Mediterranean peoples
throughout their history, with a myriad of food
traditions, religious and cultural differences, and the
succession of different dominant civilizations
(90)
. The
Mediterranean diet is an expression of the diversity of
Mediterranean food cultures, acknowledged as equivalent
to the Mediterranean cultural food systems or Mediterra-
nean culinary systems
(91)
. Thus, the Mediterranean diet is a
complex web of sociocultural aspects, and must always be
considered as an integral part of interdependent Medi-
terranean food system(s) and never as an independent
entity
(91)
. Consumption, as part of the Mediterranean diet,
cannot be separated from production or social and cultural
factors that have built historically around food in the
Mediterranean region. The Mediterranean diet is a concept
that embraces biodiversity, sustainability, quality, palat-
ability, health and cultural heritage. Safeguarding the
Mediterranean diet should be the driving force behind
responsible, local and sustainable consumption, as a
model of a sustainable development
(92,93)
. The Mediterra-
nean diet, with its characteristic intra- and inter-cultural social
similarities and distinctions, encourages mutual awareness
and understanding. The Mediterranean diet is an example, at
the local, national and international levels, of mutual multi-
cultural appreciation mediated through the culinary and
social value of food.
Fourth benefit: Positive local economic returns
The Mediterranean diet, as a system that respects local
specificities, ensures the conservation and development of
traditional activities and crafts, thereby guaranteeing the
balance between the territory and the people
(84)
. Whereas
the ‘fame’ of the Mediterranean diet is well established in
industrialized countries
(94)
, it is still hardly known in parts
of the Mediterranean region, especially in Southern and
Eastern countries
(39)
. The existing worldwide media
recognition of the Mediterranean diet as a healthy diet
could be used as a leverage tool for a very effective
marketing campaign for the promotion of the Mediterra-
nean foods associated with the Mediterranean diet, in
order to drive positive economic returns locally
(95)
. Thus,
the Mediterranean diet may become a catalyst for sus-
tainable development of Mediterranean small rural areas,
especially through the valorization of typical and traditional
Mediterranean food products
(96)
. Particularly for North
African and Near East countries, a greater adherence to the
MDP could produce economic benefits by reducing their
very heavy dependence on agricultural and food imports
(97)
.
This requires the valorization of local food products and
empowerment of their producers; improved transparency
and protection of the traditional and typical Mediterranean
food products, through geographic labelling, quality
standards and product origin identification
(96)
, as well as
combining tradition, innovation and sustainability
(98)
.Pro-
moting the Mediterranean diet by highlighting the frugality
that is at its core, as a traditionally ‘food-saving culture’,can
contribute to reducing the amount of food wasted
(99)
.
Discussion
The Med Diet 4.0 framework can have a very important
educational and communicational role towards the revi-
talization of the Mediterranean diet. In the Mediterranean,
there is widespread awareness of the social, cultural,
economic and health aspects of ‘food’, and this is
shared by all Mediterranean people. However, the current
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