The Mediterranean Diet – Questions and Answers about what you eat and drink

In general, what counts as a serving?

The Mediterranean Diet Pyramid lists serving sizes in each of its food categories. The USDA also publishes a list of serving sizes for a variety of food groups. In general, however, one serving from the grain group equals one slice of bread. Note that by “slice of bread,” we are referring to the standard 70-calorie portion size. If your whole-grain bread contains more calories per slice, adjust accordingly. For example, some prepackaged whole-grain breads contain 110 calories per slice, which would equal 11/2 Mediter­ranean Diet grain servings. A serving is also equal to 1 ounce of ready-to-eat cereal or 1/2 cup of cooked grains, in­cluding whole-grain rice, pasta, or cooked cereal.

This serv­ing is fairly small. Drop 1/2 cup of pasta on a plate and you’ll see what we mean. The small serving size (by American standards, where we have become accustomed to “super-sizing” our meals) puts the USDA’s six to eleven serving recommendation from the grain group in perspective. For the carb-concerned, six to eleven servings sounds out of control, and even eight servings sounds like a lot, but eat a cup of whole-grain, sugar-free cereal for breakfast (like hot oatmeal), one sandwich on two slices of whole-grain bread for lunch, and a cup of whole-grain pasta for dinner and you’re there. In general, whole-grain foods will not promote wide fluctuations in insulin levels.

For the vegetable group, 1 cup of raw leafy vegetables or 1/2 cup of chopped or cooked other vegetables or 3/4 cup of vegetable juice equals a serving. One medium piece of fruit or 1/2 cup of chopped or cooked fruit, or 1/2 to 3/4 cup of most fruit juices equals a fruit serving. In the dairy category, 1 cup of milk or yogurt or 11/2 ounces of cheese equals a serving, and in the protein group, 2 to 3 ounces of cooked lean meat equals a serving (that’s not very big, so take note). Note: One egg, 2 tablespoons of peanut butter, 1/ 3 cup of most nuts, or 1/2 cup of cooked lentils equals an ounce of meat.

Does the Mediterranean diet provide enough daily pro­tein for the average adult?

Yes! The Recommended Daily Allowance (RDA) for pro­tein for the average adult male (age twenty-five and up) is 63 grams. For the average adult female (age twenty-five and up and who is not pregnant or lactating), the RDA for protein is 50 grams. If you eat the minimum daily Mediterranean Diet recommendation of 1 cup of legumes (such as chickpeas and red kidney beans) per day, you’ll be eating roughly 14 grams of protein. Add in 1/3 cup of nuts (such as walnuts) and you’ll be consuming 7 grams more. Consume at least three servings of vegetables (such as green beans and carrots), and you are adding about 3 more grams of protein. Two cups of low-fat soy milk equals roughly 16 grams of protein. Eat at least eight servings of whole grains (such as whole-grain bread and couscous), and you are adding about 24 grams of protein. This already puts us up to 63 grams of protein, and we haven’t even left the minimum recommendations of the daily food section of the Mediterranean Diet Pyramid. Toss in an ounce of fish (such as tuna) and you’ll be getting about 7 more grams of protein.

Can a vegetarian eat a Mediterranean diet?

The traditional Mediterranean diet is almost a lacto-ovo vegetarian diet. While both Mediterranean diet pyramids list meat, poultry, and fish to be consumed anywhere from weekly to a few times per month, these items are not, by any means, required. The traditional Mediterranean diet centers around plant foods, with small amounts of cheese and yo­gurt (depending on the country of a recipe’s origin). Many people living in the Mediterranean during the 1950s and 1960s probably were vegetarian by necessity.

Even a vegan (someone who consumes no animal prod­ucts at all) can follow the traditional Mediterranean diet. Al­though cheese, yogurt, and milk, can be added in moderation to a heart-healthy eating plan, they aren’t required. Soy cheeses and milks make delicious substitutes, or try almond milk. Vegans must be careful to eat food from a wide variety of sources, to ensure that all the nutritional bases are cov­ered. Vegans might also consider taking supplements, par­ticularly of vitamin B12, which is most available from animal sources. We strongly recommend that anyone plan­ning to eliminate an entire food group from his or her diet should seek the counsel of a registered dietitian to ensure that the proportions of food eaten are sufficient to meet all nutrient and caloric needs.

Is the Mediterranean Diet Pyramid appropriate for children? What about pregnant or breastfeeding women? What about teenagers?

Yes to all! The Mediterranean diet, when eaten in correct proportions and sufficient amounts, is nutritionally adequate for anyone. Again, however, we recommend that you con­tact a registered dietitian if you have any special nutritional and/or caloric needs such as those of a growing child or a pregnant or breastfeeding woman.

Can someone with a chronic disease such as diabetes or kidney disease safely eat a Mediterranean diet?

People with chronic diseases have unique nutritional and/or caloric needs, so again, we recommend contacting a registered dietitian about the diet that is right for the individ­ual. Certain food items or groups may be prohibited for you. Although you may have to customize certain elements ac­cording to your needs, in general, a Mediterranean diet is a healthy, nutrient-dense diet appropriate for anyone able to eat it.

Are vitamin, mineral, or other dietary supplements nec­essary or beneficial while following the traditional Mediterranean diet?

No, the nutrient-dense Mediterranean diet provides all es­sential nutrients when eaten in sufficient quantities (as de­picted in the Mediterranean Diet Pyramid). If you suspect you aren’t deriving adequate nutrition from your diet or if you have special nutritional needs, seek the advice of a reg­istered dietitian.

Why does the American Heart Association recommend averaging percentages, such as the 30-percent-of-calories­from-fat rule, over a few days or a week rather than on a daily basis?

This concept works for both the AHA-recommended diet and the Mediterranean diet. In the words of the AHA, “Ap­plying the 30 percent standard to single foods greatly limits the variety of foods in the diet and can be misleading. The only way to maintain balance, variety and enjoyment of the AHA eating plan is to interpret the guideline with emphasis on the words ‘total calories.’ ” In other words, occasionally it makes sense to have a day where calories from fat will ex­ceed 30 percent. If days like this are balanced with days where total calories from fat fall below 30 percent, this is more conducive to a varied (and interesting) diet.

Can flaxseed be consumed on a Mediterranean diet?

Absolutely! There has been a lot of exciting news sur­rounding flaxseed and flaxseed products. Flaxseed is an ex­cellent source of health-promoting omega-3 fatty acids, as well as phytochemicals. Although not traditionally a part of the Mediterranean diet, it can definitely be incorporated in a healthy Mediterranean style of eating. Several whole-food manufacturers have started incorporating flaxseed in won­derful breads and ready-to-eat cereals. You, too, can incor­porate flaxseed, or flaxseed meal (which is similar to wheat germ, and can be purchased in most whole foods markets) as part of your daily nut or seed consumption. Sprinkle flaxseed meal in your cereal, yogurt, quick bread and muffin mixtures, and so forth. Another source of flaxseed is flaxseed oil, which can be quite expensive and, like all oils, high in calories. You can try using flaxseed oil as a substitute for olive or canola oil in cooking from time to time, or driz­zle a little on a salad. Keep flaxseed oil in the refrigerator.

Which dairy products besides nonfat or low-fat milk are a sensible addition to a low-saturated-fat diet?

Try some of the many low-fat and nonfat plain yogurts. Stir in some fresh fruit for sweetness. Also, while some cheeses contain a lot of fat, others are relatively low in fat. Check the labels, or look for cheeses made from skim milk (such as mozzarella made with part-skim milk). Pretty much all the cheeses come in reduced or nonfat versions. Cottage cheese, ricotta, feta, gouda, Cheddar—the list seems end­less—are now offered in reduced-fat or nonfat varieties. We recommend organic cheeses, or cheese imported from the Mediterranean region. They may cost a little more, but the taste is so intensely delicious that a little goes a long way.

Where does high-fat cheese fit into the Mediterranean Diet Pyramid?

High-fat cheeses (such as Gruyère, muenster, blue) are full of flavor, so as we mention above, a little goes a long way. Although a dairy product, high-fat cheese is more ap­propriately located with high-fat meats as a high-fat protein source. If you like them, consume high-fat cheese only every month or so and in small amounts.

q Canned beans are much easier to prepare than dried beans. Are they just as healthy?

Yes. For those who are salt-sensitive, however, be careful about the excess sodium. Rinse canned beans in a colander to wash away the salt. Rinsing will also wash away some of the starchy liquid, making your dishes more attractive, as well as reducing the likelihood of developing intestinal gas after bean consumption. If the recipe in which you are using canned beans calls for added salt (not often the case with tra­ditional Mediterranean recipes), you might consider adjust­ing the added salt accordingly.

q Are certain nuts and seeds better than others?

From a nutritional point of view, all nuts and seeds are nutrient-dense plant foods. Some are lower in fat than oth­ers, however, and consequently lower in calories, so these nuts and seeds might be more appropriate for people who are attempting to control their weight. Chestnuts are actually a low-fat food. A 1-ounce serving of roasted (European) chest­nuts (about three and a half nuts) contains less than 1 gram of fat, all unsaturated, and about 70 calories. On the opposite end of the scale, 1 ounce of dry-roasted cashews contains about 13 grams of fat and 163 calories, and 1 ounce of toasted or roasted sesame seeds contains about 14 grams of fat and 160 calories. The key is to get a variety of nuts and seeds to benefit most from the varied nutrients and phyto­chemicals (more on this later). The more variety, the healthier the diet really is. Of course, eating that variety in moder­ation is important, too.

Coconuts are a rare exception to the heart-healthy plant food rule. Coconuts are high in saturated fat and are best avoided most of the time.

The Mediterranean Diet Pyramid lists “four or fewer” eggs at the “weekly” level. Is it okay to eat more eggs if only the whites are consumed?

Yes, by all means. Egg whites do not contain cholesterol, which is found only in the yolks. They are a good source of protein and can be used to cut fat in egg dishes and baked dishes as well. Also, research supports the notion that con­sumption of saturated fat, not dietary cholesterol (some­times called preformed cholesterol), has the most impact on blood cholesterol levels. While some people are very sensi­tive to dietary cholesterol and should limit egg consump­tion, the general population need not be overly concerned about dietary cholesterol. The “four or fewer per week” egg rule is just a general guideline for a Mediterranean-inspired (or any nutritionally sound) eating program, due to the satu­rated fat element in whole eggs.

How can someone lose weight putting olive oil on every­thing?

We certainly don’t recommend putting olive oil on every­thing! Olive oil is fat, and fat in excess contributes to obe­sity, which in turn contributes to many health problems. One common misconception about the Mediterranean diet is that adding olive oil to an already high-fat diet will “fix” the fat problem. On the contrary, olive oil should substitute for other types of fat, not be added to them. Overall fat intake from all sources, including olive oil, should be lower than is typical for Americans. This is why we recommend “driz­zling” olive oil, not pouring it, over our visual representa­tion of a healthy Mediterranean-inspired diet. A little goes a long way.

Are some vegetables better choices than others? What about fruits?

All fruits and vegetables have their “star” qualities. Also, every type of plant food has a unique combination of nutrients and phy­tochemicals. That’s why a variety of plant foods is more im­portant than choosing a few “right” plant foods and eating only those. The more variety in your diet, the more nutri­tionally complete your diet will be.

What about table sugar? Is sugar an acceptable addition to a healthy, Mediterranean diet?

The sugar controversy rages on. Some people proclaim refined sugar as among the worst possible additions to your diet. Others say that, as long as a person maintains a healthy weight and consumes sufficient nutrients, sugar is fine. The truth probably lies somewhere in the middle. Whenever you eat a high-sugar product, you are filling up with empty calo­ries when you could have eaten something more nutrient-dense instead. If you are getting enough to eat but add sugar, you may have trouble maintaining that ideal weight. But, if consumed occasionally in moderation, as part of a healthy diet, sugar is probably just fine—and pretty hard to avoid these days.

What about coffee and tea?

Although not listed on either Mediterranean food pyramid, coffee and/or tea are both integral—albeit nonnutritive— parts of the diets in many Mediterranean countries. In fact, it would be difficult to discuss the Mediterranean region with­out mentioning the infamous Italian espresso, not to mention the thick, sweet, sludgy concoction known as Turkish coffee. Tea is also widely consumed in many Mediterranean coun­tries. However, we suggest that if you enjoy coffee and/or tea, you consume them in moderation like anything else, and not at the expense of more nutritionally complete foods. Re­cent research has linked green and even black tea with cancer prevention, as teas contain antioxidants and other phyto­chemicals that could bolster the body’s immune system and fight cancer-causing free radicals. Of course, caffeine-free herbal teas are a great way to relax with a hot beverage free of caffeine. If you are caffeine-sensitive, we recommend dis­cussing the use of caffeine with your physician.

Is canola oil just as good as olive oil?

Canola oil is, by necessity, more processed than olive oil. Therefore, it loses many of the vital phytochemical compo­nents still present in extra virgin olive oil. However, it is a good source of monounsaturated fat and it is generally cheaper than olive oil.

Can the Mediterranean Diet Pyramid be used as a guide for non-Mediterranean types of cuisine?

Yes! The idea is to apply the Mediterranean concept, not necessarily the particular food ingredients, to all your food choices. You need not limit yourself to pasta primavera, for example. Instead, base your diet around plant foods, focusing on vegetables, whole grains, fruit, primarily beans for pro­tein, fish, and animal meat in moderation. This goal works for just about any cuisine. In fact, bar-and-grill-type Ameri­can restaurants often have grilled vegetable entrées. Most restaurants have salads with small amounts of meat such as grilled chicken or salmon on top. Ask for olive oil and vine­gar as a dressing and you’ve got a great Mediterranean ­inspired meal!

Asian cuisine is right in line with the principles of tradi­tional Mediterranean cuisine. Many foods unique to this cui­sine have distinctive health benefits, such as soy foods like tofu. Rice and vegetables with protein from small amounts of meat or tofu or nuts and seeds (peanut sauce, walnuts, al­monds, cashews, and peanuts are common Asian additions) make an exceptionally healthy meal.

Even an American home barbecue can fit in with the Mediterranean concept if you fill up on green salad, baked beans, coleslaw made with vinaigrette instead of mayon­naise, grilled or raw vegetables, and fruit such as water­melon and fresh fruit salad. You probably won’t even miss the burger and hot dogs!

The Mediterranean Diet Pyramid seems to require a lot of food be consumed, especially in the daily food section. Will I gain weight?

No, not very likely, especially if you incorporate daily ac­tivity into your schedule. If you consume the minimum re­quirement of each of the recommended daily food groups, you will be consuming about 1,385 calories. Add in a table­spoon of olive oil, and you are still talking about only (roughly) 1,500 calories. Factor in a 3-ounce cooked portion of fish, such as salmon, and you’re adding around 200 calories, for a total of 1,700 calories for the day. The average adult can easily maintain weight on such a diet. In fact, many people will lose weight on any diet below 1,800 calo­ries, especially those who are moderately active.

The Mediterranean diet really should not be about num­bers. Rather, the culinary spirit of the traditional Mediter­ranean region should be celebrated and enjoyed for the many benefits it possesses. Again, if your health requires you to gain or lose weight, you should seek the guidance of a registered dietitian or other qualified health care provider for your individual needs. Our pyramid should act only as a general guide to shape your eating habits to closely resem­ble the healthy traditional Mediterranean diet.