obesity reviews doi: 10.1111/j.1467-789X.2008.00503.

Obesity and the Mediterranean diet: a systematic

review of observational and intervention studies

G. Buckland1, A. Bach2,3 and L. Serra-Majem2,4

1
Unit of Nutrition, Environment and Cancer.
Epidemiological Research Programme.
Catalan Institute of Oncology-IDIBELL,
Barcelona, Spain; 2Mediterranean Diet
Foundation, University of Barcelona Science
Park, Barcelona, Spain; 3Department of Public
Health, University of Barcelona, Barcelona,
Spain; 4Department of Clinical Sciences,
University of Las Palmas de Gran Canaria,
Las Palmas de Gran Canaria, Spain
Received 23 November 2007; revised 5 May
2008; accepted 7 May 2008
Address for correspondence: G Buckland,
Unit of Nutrition, Environment and Cancer,
Epidemiological Research Programme,
Catalan Institute of Oncology (ICO), Gran Via
s/n Km 2,7 Hospitalet. 08907, Barcelona,
Spain. E-mail: gbuckland@iconcologia.net
Summary
World Health Organization projections estimate that worldwide approximately
one-third of adults are overweight and one-tenth are obese. There is accumulating
research into the Mediterranean diet and whether it could prevent or treat obesity.
Therefore, the purpose of this paper was to systematically review and analyse the
epidemiological evidence on the Mediterranean diet and overweight/obesity. We
identified 21 epidemiological studies that explored the relationship between the
Mediterranean diet and weight. These included seven cross-sectional, three cohort
and 11 intervention studies. Of these, 13 studies reported that Mediterranean diet
adherence was significantly related to less overweight/obesity or more weight loss.
Eight studies found no evidence of this association. Exploring the relationship
between the Mediterranean diet and overweight/obesity is complex, and there are
important methodological differences and limitations in the studies that make it
difficult to compare results. Although the results are inconsistent, the evidence
points towards a possible role of the Mediterranean diet in preventing overweight/
obesity, and physiological mechanisms can explain this protective effect. Despite
this, more research is needed to substantiate this association. Epidemiological
studies should use a consistent universal definition of the Mediterranean diet, and
address common methodological limitations to strengthen the quality of research
in this area.

Keywords: Mediterranean diet, obesity, review.

obesity reviews (2008) 9, 582–593

(especially red), often with meals; (v) consumption of fresh

Introduction
Epidemiological studies have noted increased longevity and
reduced morbidity in Mediterranean countries compared
with the USA or Northern Europe (1). These health benefits
have largely been attributed to the dietary pattern found in
these Mediterranean countries in the early 1960s, before its
‘westernisation’.
Although there are variations in the components of the
traditional Mediterranean diet (MD) (2,3) both between
and within Mediterranean countries, the pattern commonly
consists of (i) a high consumption of plant-based foods,
such as fruit, vegetables, legumes, nuts and seeds and
wholegrain cereals; (ii) the use of seasonally fresh and
locally grown foods; (iii) olive oil as the main source of
dietary lipids; (iv) a frequent but moderate intake of wine
fish and seafood; (vi) a moderate consumption of dairy
products, poultry and eggs and (vii) red and processed meat
consumed in low frequency and amounts.
Dietary patterns have been studied through component
and cluster analysis and many a priori MD indices (4),
which have been used to explore the relationship between
MD patterns and health parameters, such as mortality or
chronic disease risk. As a result, there is increasing epide-
miological evidence of the health benefits from the MD, as
supported by a systematic review of intervention studies
using the MD (5) and a review of the MD and cardiovas-
cular diseases (6). There is also growing research on the
relation between the MD and obesity, with an increas-
ing number of epidemiological studies examining this
association.

582 © 2008 The Authors

Journal compilation © 2008 International Association for the Study of Obesity. obesity reviews 9, 582–593

obesity reviews
Although there have been reviews of specific types of
epidemiological studies researching dietary patterns and
weight (7,8), there has not been a systematic review of
epidemiological studies, including both clinical trials and
observational studies, which have examined the association
between the MD and overweight/obesity specifically.
Obesity contributes towards approximately 30–40% of
cardiovascular diseases, a large proportion of type 2 dia-
betes and metabolic syndrome and, with a lack of exercise,
up to 30% of some cancers (9). World Health Organization
projections estimated that worldwide, in 2005, approxi-
mately 1.6 billion adults were overweight and 400 million
adults were obese. The increasing trends in obesity in the
USA and Europe are particularly striking, and Mediterra-
nean countries are also affected although to a lesser extent,
with adult obesity in Spain increasing from 15% to 21%
between 1994–1995 and 1999–2000 (10).
There has been a decrease in adherence to the MD in
Southern European countries throughout a similar period
(11,12), as well as a tendency to lead more sedentary lif-
estyles. However, it is not clear whether and to what extent
the changing dietary patterns account for the increases in
obesity. As there is an increasing prevalence of overweight/
obesity, with its life-threatening co-morbidities worldwide,
it is important to question whether the MD could be used
to prevent or treat obesity, or conversely whether the MD
could contribute to obesity, because of its moderately high
fat content (13). Therefore, the aim of this study was to
systematically review and analyse epidemiological studies
on the MD and overweight/obesity.
Methodology
A MEDLINE search was carried out up to July 2007
to identify epidemiological studies on the MD and
overweight/obesity, using the term ‘MD’ along with other
key word(s): ‘obesity’, ‘overweight’, ‘body mass index
(BMI)’, ‘weight’, ‘body fat’ or ‘weight loss/gain’. All human
epidemiological studies with full text were considered. The
search was narrowed to include only articles examining the
effect on weight of an MD as a whole (combined effect of
key components). Studies were included if the authors
described the use of an MD, without restricting its defini-
tion to include specific foods or nutrients. In addition,
studies were included if the main outcome was either
weight related (overweight/obesity or weight change), a
chronic disease or metabolic alterations, but with weight
as a secondary outcome.
Results
A total of 21 studies were identified that met all the search
criteria. The studies were classified according to study type,
resulting in seven cross-sectional studies (14–20), three
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Obesity and the Mediterranean diet G. Buckland et al. 583
cohort studies (21–23) and 11 intervention studies, of
which three were without a control group (24–26), and
eight included a control group (27–34). Information
regarding the methodology and weight-related results for
these studies is summarized in Tables 1 and 2.
Characteristics of study sample
The studies were carried out between 2000 and 2007
in eight different countries. Although the majority of the
studies (13 out of 21) were from Mediterranean countries
(Italy, Spain, Cyprus and Greece), eight studies were also
from non-Mediterranean countries (Germany, Canada, the
USA and Hong Kong). The health status of the subjects
varied between studies, and could be grouped into three
main categories: (i) apparently healthy individuals without
chronic diseases; (ii) overweight/obese individuals and (iii)
individuals with chronic diseases, such as cardiovascular
disease or its risk factors.
Association between the MD and obesity
Out of the 21 studies identified, 13 reported that adherence
to an MD significantly reduced the probability of
overweight/obesity, promoted weight loss, or resulted in
more weight loss than a control diet (14–16,20,21,24–
26,29,30,32–34). In contrast, eight studies found that there
was no significant association between MD adherence and
overweight/obesity (17–19,22,23,27,28,31).
Cohort studies
Out of the three cohort studies, only the Spanish study
from the European Prospective Investigation into Cancer
and Nutrition (21) provided evidence of a significant pro-
tective effect of the MD against obesity incidence. After
excluding obese participants at baseline and taking into
account participant’s different energy intakes, as well as
possible dietary under-reporting, overweight individuals
with a high MD adherence were 27% (in women) and 29%
(in men) less likely to become obese. Although results from
the Seguimiento Universidad de Navarra–Follow-up Uni-
versity of Navarra study did not find any association
between weight and the MD (22), there was a significant
reduction in waist circumference as MD adherence
increased (35).
Cross-sectional studies
Out of the seven cross-sectional studies, four (14–16,20)
found that a higher adherence to an MD had a significantly
negative association with overweight/obesity. The strongest
association was reported in the ATTICA study by Panagio-
takos (15), where individuals with a higher adherence to an
MD were 51% less likely to be overweight/obese. Other
studies found that individuals with a high MD adherence
 584

Table 1 Epidemiological studies on the Mediterranean diet and overweight/obesity

Author, year Country Sample MD definition (components) Anthropometrics Follow-up Results

Population characteristics Diets and other interventions
n* (sex) Age

Cross-sectional studies n = 7
Rossi et al. (17), Italy Patients MDS (+): cereals, vegetables, fruit, legumes, Self-reported cs • ↑ Adh MD (+1p):
2007 n = 6 619 MUFA/SFA, (+m): alcohol (-): meat, milk and 씹 ↑BMI (b coef 0.05 [CI: -0.05, 0.14]), NS
(3 090 씹, 3 529 씸) dairy products 씸 ↓BMI (b coef -0.04 [CI: -0.15, 0.07]), NS
Obesity and the Mediterranean diet

58 years†
Panagiotakos Cyprus General population MDS: wholegrain cereals, vegetables, fruit, Measured cs • ↑ Adh MD (+10p): ↓Ob (OR = 0.88), S, (P = 0.001)
et al. (16), 2007 n = 150 (senior), without legumes, fish, olive oil, dairy products, chicken,
(53 씹, 97 씸) CVD nuts and seeds, olives, potatoes, eggs, sweets,
65–100 years red meat and meat products
Panagiotakos Greece General population, MDS: wholegrain cereals, vegetables, fruit, Measured cs • ↑ Adh MD (+5p): ↓Ow/Ob (OR = 0.49
et al. (15), 2006 n = 3 042 without CVD legumes, nuts and seeds, fish, olive oil, olives, [CI: 0.42, 0.56]), S
1 514 씹 (18–87 years) dairy products, chicken, potatoes, eggs, sweets, • ↑ Adh MD: ↓BMI (-4 kg m-2)‡, S, (P = 0.001)
G. Buckland et al.

1 528 씸 (18–89 years) wine, red meat and meat products, MUFA/SFA
Shubair et al. (14), Canada General population MDP (principal component analysis) (+): fruit and Self-reported cs • ↑ Adh MD: ↓BMI (b coef -0.186)
2005 n = 759 vegetables, olive oil and garlic, fish and shellfish, All ages, S, (P = 0.027)
(265 씹, 494 씸) Non MDP (-): meats and poultry, high SFA and Pop 40–49 years, S, (P = 0.011)
18–65 years TFA, foods high in added sugar and low in Pop 30–39 years, NS, (P = 0.056)
nutrients Pop 18–29 years, NS, (P = 0.999)
Trichopoulou et al. Greece General population, MDS (+): cereals, vegetables, fruit and nuts, Measured cs • ↑ Adh MD (+2p energy adjusted):
18, 2005 n = 23 597 healthy legumes, fish, MUFA/SFA, (+m): ethanol, (-): 씹 ↑BMI (b coef 0.08 [CI: -0.03, 0.20]), NS
(9 612 씹, 13 985 씸) meat and meat products, dairy products 씸 ↓BMI (b coef -0.06 [CI: -0.16, 0.04]), NS
20–86 years • ↑ Adh MD (+2p, not energy adjusted):
씹 ↑BMI (b coef 0.21 [CI: 0.10, 0.32]), S
씸 ↑BMI (b coef 0.05 [CI: -0.04, 0.15]), NS
Fung et al. (19), USA Nurses, healthy MDS (+): wholegrain cereals, vegetables (without Self-reported cs • ↑ Adh MD: ↓BMI (26.5 ⫾ 6.1 kg m-2)†
2005 n = 660 (씸) potatoes), fruit, nuts, legumes, fish, MUFA/SFA vs.
43–69 years (+m): alcohol, (-): red and processed meat • ↓ Adh MD: ↑BMI (27.1 ⫾ 6.8 kg m-2)†, NS,
(P = 0.43)
Schroder et al. (20), Spain General population MDS (+): cereals, vegetables, fruit, legumes, Measured cs • ↑ Adh MD: ↓Ob (OR = 0.61), S, (P = 0.01)
2004 n = 2 871 nuts, fish, (+m): red wine, (-): meat, high fat • ↑ Adh MD (+5p):
(1 403 씹, 1 468 씸) dairy products 씹 ↓BMI (-0.43 kg m-2)‡, S (P = 0.030)
25–74 years 씸 ↓BMI (-0.68 kg m-2)‡, S, (P = 0.007)

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 Table 1 Continued

© 2008 The Authors

Author, year Country Sample MD definition (components) Anthropometrics Follow-up Results
Population characteristics Diets and other interventions
n* (sex) Age
obesity reviews

Cohort studies n = 3
Mendez et al. (21), Spain General population, MDS (+): cereals, vegetables, fruit, legumes, 0 years: 3.3 years • ↑ Adh MD:
2006 n = 27 827 normal weight fish, MUFA/SFA, (+m): ethanol, (-): meat measured 씸 ↓Ob (OR = 0.73 [CI: 0.57, 0.93]), S
(10 589 씹, 17 238 씸) or overweight 3.3 years: 씹 ↓Ob (OR = 0.71 [CI: 0.55, 0.93]), S
29–65 years self-reported 씸 ↓Ow (OR = 0.99 [CI: 0.78, 1.25]), NS
씹 ↑Ow (OR = 1.11 [CI: 0.81, 1.52]), NS
Sanchez-Villegas Spain University MDP (+): cereals, vegetables, fruit, legumes, Self-reported 2.4 years • ↑ Adh MD: ↓Ow/Ob (OR = 0.90 [CI: 0.59, 1.38]),
et al. (22), n = 6 319 (씸 씹) graduates, nuts, fish, olive oil, (+m): red wine, (-): meat and NS
2005 healthy meat products, whole fat dairy products • ↑ Adh MD: ↑BMI (+0.23 kg m-2)‡
vs.
↓Adh MD: ↑BMI (+0.26 kg m-2)‡, NS, (P = 0.279)
Woo et al. (23), Hong Kong General population MDS (+): cereals, vegetables, fruit and nuts, Measured 5–9 • ↑ Adh MD (+1SD): ↑Ow (OR = 1.35 [CI: 0.94,
2000 n = 1 010 (씸 씹) (Chinese), normal legumes, fish, MUFS/SFA, (+m): ethanol, (-): years 1.93]), NS
25–74 years BMI meat, poultry, dairy products

Intervention studies – without control group n = 3

Andreoli et al. (26), Italy Patients, obese but MD moderately hypo-caloric (+): vegetables, Measured 4m • Adh MD: ↓weight (m0: 80.4 ⫾ 15.8 kg to m4:
2007 n = 47 (씸) otherwise healthy fruit, pasta, bread, legumes, fish, olive oil, 75.2 ⫾ 14.7 kg)†, S, (P < 0.001)
25–70 years (+m): red wine, meat, dairy products • Adh MD: ↓BMI (m0: 30.7 ⫾ 6.0 kg m-2 to m4:
MD + PA Programme 28.7 ⫾ 5.6 kg m-2)†, S, (P < 0.001)
Bautista-Castaño Spain Patients, MD hypo-caloric (35% energy from fat): cereals, Measured 5.7 m • Adh MD (completers):
et al.§ (25), 2004 n = 1 018 overweight and vegetables, fruit, legumes, nuts and seeds, ↓weight (-11.82 ⫾ 6.6 kg)‡

Journal compilation © 2008 International Association for the Study of Obesity. obesity reviews 9, 582–593
(230 씹, 788 씸) obese fish, olive oil, wine, dairy products, chicken, ↓BMI (30.1 ⫾ 4.4 kg m-2)†
14–76 years eggs, sweets, red meat vs.
MD + PA Programme • Adh MD (non-completers):
↓weight (-6.57 ⫾ 4.9 kg)‡
↓BMI (32.4 ⫾ 5.4 kg m-2)†
Difference between groups S (P < 0.001)
Goulet et al. (24), Canada General population MD: cereals, fruit, vegetables, legumes, nuts and Measured 3m • Adh MD: ↓BMI (m0: 25.8 ⫾ 3.9 kg m-2 to m3:
Obesity and the Mediterranean diet

2003 n = 73 (씸) (French Canadians) seeds, fish, olive oil, wine, dairy products, 25.6 ⫾ 3.8 kg m-2)†, S, (P < 0.01)
30–65 years without metabolic chicken, eggs, sweets, red meat • Adh MD: ↓weight (m0: 67.7 ⫾ 11.9 kg to m3:
diseases and with MD + Mediterranean style cooking classes 67.3 ⫾ 11 kg)†, S, (P < 0.01)
stable weight
G. Buckland et al.
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 586

Table 1 Continued

Author, year Country Sample MD definition (components) Anthropometrics Follow-up Results

Population characteristics Diets and other interventions
n* (sex) Age
Obesity and the Mediterranean diet

Intervention studies – with control group n = 8

Estruch et al. (27), Spain Patients, without MDS (+): fruit, vegetables, legumes, nuts, olive Measured 3m • Adh MD (olive oil):
2006 n = 772 CVD, but with CVD oil, fish and shellfish, poultry, cereals, (+m): ↓weight (-0.19 kg [CI: -0.46, 0.07])‡, NS
씹 55–80 years risk factors wine, (-): red and processed meat, animal fat, ↓BMI (-0.12 kg m-2 [CI: -0.24, 0.06])‡, NS
씸 60–80 years sugary drinks, sweets and pastries vs.
Two MD Groups: MD material (menus/cooking • Adh MD (nuts):
recipes) + MD+1L week-1 of olive oil (free) ↓weight (-0.26 kg [CI: -0.59, 0.08])‡, NS
(n = 257) ↓BMI (-0.09 kg m-2 [CI: -0.24, 0.05])‡, NS
G. Buckland et al.

vs. vs.
MD + 30 g d-1 of nuts and seeds (free) (n = 258) • Diet-C:
vs. ↓weight (-0.24 kg [CI: -0.48, 0.01])‡, NS
Diet-C: low fat (n = 257) ↓BMI (-0.21 kg m-2 [CI: -0.38, -0.05])‡, S
Difference between all groups, NS
Michalsen et al. Germany Patients with a MD (+): wholegrain cereals, fruit, vegetables, fish Measured 1 year • Adh DM vs. Diet-C: ↓BMI (-0.10 kg m-2)‡, NS,
(28), 2006 n = 101 (78 씹, 23 씸) history of CHD (fatty), poultry, olive oil, nuts and flaxseeds, (P = 0.969)
59 ⫾ 8.6 years† (+m): red wine, (-): meat (including
processed)
MD + healthy lifestyle programme (100 h)
vs.
Diet-C: written information about a healthy diet
Vincent-Baudry France Patients with one MD (35–38% energy from fat), (+): wholegrain Measured 3m • Adh DM: ↓BMI (-1.5 kg m-2)‡, S, (P = 0.010)
et al. (29), 2005 n = 212 (씸 씹) CVD risk factor cereals, vegetables, fruit, legumes, nuts, fish, vs.
18–70 years olive oil, poultry and sheep, (+m): wine, dairy • Diet-C: ↓BMI (-1.2 kg m-2)‡, S, (P = 0.010)
products (sheep and goat), (-): red meat Difference between groups NS
MD vs. Diet-C (30% of total energy from fat)

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 Table 1 Continued

Author, year Country Sample MD definition (components) Anthropometrics Follow-up Results

Population characteristics Diets and other interventions
n* (sex) Age

© 2008 The Authors

Intervention studies – with control group n = 8
Esposito et al. (30), Italy Patients with MD (+): wholegrain cereals, vegetables, fruit, Measured 2 years • Adh DM:
2004 n = 180 (99 씹, 81 씸) metabolic nuts (walnuts), legumes, olive oil ↓BMI (-1.2 ⫾ 0.3 kg m-2)‡, S, (P < 0.001)
MD: 44.3 ⫾ 6.4 years syndrome MD + healthy lifestyles programme ↓weight (-4.0 ⫾ 1.1 kg)‡, S, (P < 0.001)
obesity reviews

Diet-C: 43.5 ⫾ 5.9 vs. vs.

years Diet-C: prudent diet • Diet-C:
↓BMI (-0.4 ⫾ 0.4 kg m-2)‡, NS, (P = 0.06)
↓weight (-1.2 ⫾ 0.6 kg)‡, S, (P = 0.02)
Difference between groups:
BMI: S, (P < 0.001)
Weight: S, (P = 0.01)
Fernández de la Spain Patients, m0: Diet-SFA Measured 28 d • m0: Diet-SFA → m1: DM-MUFA: ↓% body fat, S,
Puebla et al. (31), n = 34 (씹) hypercholesterolemia vs. (each (P < 0.05)
2003 18–63 years m1: MD-MUFA, rich in olive oil (38% energy diet) • m0: Diet-SFA → m1: Diet-C: ↓% body fat S,
from fat) (P < 0.05)
or • Adh DM: no change in BMI, weight, waist/hip, NS
m1: Diet-CHO, low in fat
Toobert et al. (32), USA Postmenopausal MD (+): bread, vegetables (roots, green), fruit, Measured 6m • Adh DM: ↓BMI (m0: 35.34 ⫾ 7.9 kg m-2 to m6:
2003 n = 279 (씸) women with type 2 legumes, fish, olive/canola oil, poultry, (-): red 34.97 ⫾ 7.9 kg m-2)†
<75 years Diabetes Mellitus meat, butter, cream vs.
MLP: MD + healthy lifestyle programme (n = 163) • Diet-C: ↑BMI (m0: 34.87 ⫾ 8.2 to m6:
vs. 35.07 ⫾ 8.4 kg m-2)†
Diet-C: standard treatment for diabetes (n = 116) Difference between groups, S, (P = 0.015)
Esposito et al. (33), Italy Pre-menopausal MD: hypo-caloric (<30% energy from fat) + PA Measured 2 years • Adh DM: ↓weight (-14 kg)‡, ↓BMI (-5.2 kg m-2)‡,
2003 n = 120 (씸) patients, obese but Programme (n = 60) S, (P < 0.001)
20–46 years without chronic vs. vs.
diseases Diet-C: information about a healthy diet + PA • Diet-C: ↓weight (-3 kg)‡, ↓BMI (-1 kg m-2)‡, S,

Journal compilation © 2008 International Association for the Study of Obesity. obesity reviews 9, 582–593
advise (n = 60) (P < 0.05)
• Adh DM vs. Diet-C: ↓weight (-11 kg)‡, ↓BMI
(-4.2 kg m-2)‡, S, (P < 0.001)
McManus et al. USA General population, MD: hypo-caloric (35% energy from fat) + healthy Measured 2.5 years • Adh DM: ↓weight (-4.1 ⫾ 6.5 kg)‡, ↓BMI
(34), 2001 n = 101 overweight and lifestyle programme (n = 50) (-1.6 ⫾ 2.5 kg m-2)‡, S, (P < 0.001)
(10 씹, 91 씸) obese, without vs. vs.
18–70 years chronic diseases Diet-C: low fat + healthy lifestyle programme • Diet-C: ↑weight (+2.9 ⫾ 7.7 kg)‡, ↑BMI
Obesity and the Mediterranean diet

(n = 51) (+1.4 ⫾ 3.3 kg m-2)‡, S, (P < 0.001)

Difference between groups, S, (P < 0.001)

*Number of subjects analysed.

†
Mean/median of group.
‡
Difference between groups/time.
§
Before-after (quasi experimental design).
G. Buckland et al.

Healthy, without chronic diseases or metabolic disorders (cholesterol, hypertriglyceridemia); CVD, cardiovascular diseases; CHD, coronary heart diseases; MD, Mediterranean diet; MDS, Mediterranean
diet score; MDP, Mediterranean diet pattern; MLP, Mediterranean lifestyle programme; (+), positive components; (-), negative components; (+m), components positive in moderation; Diet-C, diet-control;
SFA, saturated fatty acid; MUFA, monounsaturated fatty acid; TFA, trans fatty acid; CHO, carbohydrates; PA, physical activity; cs, cross-sectional; Adh, adherence; Ob, obesity; Ow, overweight; BMI,
587

body mass index; ↓, decrease; ↑, increase; S, significant; NS, not significant; OR, odds ratio; CI, confidence interval (95%); b coef, b coefficient; SD, standard deviation; m, month.

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588 Obesity and the Mediterranean diet G. Buckland et al. obesity reviews

Table 2 Summary of results of epidemiological studies on the Mediterranean diet and overweight/obesity

Author Sample Size Follow-up Type of analysis Results (adherence to MD and

overweight/obesity)

Cross-sectional studies n = 7
Rossi et al. (17) 6 619 cs b coef, BMI (CI) 씹 0.05 (-0.05, 0.14)
씸 -0.04 (-0.15, 0.07)
Trichopoulou et al. (18) 23 597 cs 씹 0.08 (-0.03, 0.20)
씸 -0.06 (-0.16, 0.04)
Shubair et al. (14) 759 cs -0.186 (0.027)
Panagiotakos et al. (16) 150 cs OR (CI or P value) 0.88 (0.001)
Panagiotakos et al. (15) 3 042 cs 0.49 (0.42, 0.56)
Schroder et al. (20) 2 871 cs 0.61 (0.01)
Fung et al. (19) 660 cs Difference in BMI (kg m-2) 0.6 (0.43)
Cohort studies n = 3
Mendez et al. (21) 27 827 3.3 years OR (CI) 씸 0.73 (0.57, 0.93)
씹 0.71 (0.55, 0.93)
Sanchez-Villegas et al. (22) 6 319 2.4 years 씹 0.90 (0.59, 1.38)
Woo et al. (23) 1 010 5–9 years 1.35 (0.94, 1.93)
Intervention studies n = 11
Andreoli et al. (26) 47 4 months Difference in BMI (kg m-2) (CI or P value) -2 (<0.001)†
Bautista-Castaño et al.* (25) 1 018 5.7 months -2.3 (<0.001)‡
Goulet et al. (24) 73 3 months -0.2 (<0.01)†
Estruch et al. (27) 772 3 months -0.12 (-0.24, 0.06)†
-0.09 (-0.24, 0.05)†
Michalsen et al. (28) 101 1 years -0.10 (0.969)§
Vincent-Baudry et al. (29) 212 3 months -1.5 (0.010)†
Esposito et al. (30) 180 2 years -1.2 (0.001)†
†
Fernández de la Puebla et al. (31) 34 28 days NS
Toobert et al. (32) 279 6 months -0.57 (0.015)§
Esposito et al. (33) 120 2 years -5.2 (0.001)†
-4.2 (0.001)§
McManus et al. (34) 101 2.5 years -1.6 (0.001)†

Results highlighted in grey are statistically significant at P < 0.05 level.

*Before-after (quasi experimental design).
†
Difference between BMI in Mediterranean diet group before and after intervention.
‡
Difference in BMI between MD completers and non-completers.
§
Difference in BMI between Mediterranean group and Control group at end of intervention.
MD, Mediterranean diet; BMI, body mass index; OR, odds ratio; CI, confidence interval (95%CI); b coef: b coefficient; cs, cross-sectional.

were 39% less likely to be obese (20) or 12% less likely be
obese (16). All of the three studies that used a subjects
self-reported weight (14,17,19) did not find any association
between MD adherence and weight, apart from a study by
Shubair (14). This study reported that there was a decrease
in BMI with MD adherence, but only significant within the
older age groups.
Intervention studies
There were two types of intervention studies: (i) all the
subjects followed an MD (n = 3) or (ii) the subjects were
divided into groups, and instructed to either follow an MD
or a control diet (n = 8) with or without additional non-
dietary interventions. Over two-thirds of all of these inter-
vention studies (eight out of 11) found that adherence to an
MD significantly decreased weight/BMI (24–26,29,30,32–
34), although in two of these studies (25,32), this was
compared with a control diet, and the significance of the
weight loss within the MD group was not specified. Half of
the studies (four out of eight), which compared the weight
loss after following an MD and a control diet, found that
the MD group lost significantly more weight than the
control group (30,32–34).
Of the four studies whose study sample consisted of
overweight/obese individuals, (25,26,33,34), all found the
MD effective for losing weight, and also reported the most
pronounced reductions in weight. The greatest weight loss
was a group average of 14 kg, in a small group of Italian
obese patients following a 2-year hypo-caloric MD as well
as a healthy lifestyle programme (33). The two studies,
which specifically recruited individuals with type 2 diabetes
mellitus and metabolic syndrome (30,32), both closely
related to obesity, also found a significant reduction in
obesity after following an MD.

© 2008 The Authors

Journal compilation © 2008 International Association for the Study of Obesity. obesity reviews 9, 582–593

obesity reviews
Anthropometrics, follow-up/intervention periods
and sample size
The majority of the studies (16 out of 21) measured the
participant’s weight and/or other anthropometrics as
opposed to using a participant’s self-reported weight (only
two cohort and three cross-sectional studies). The follow-up
periods to evaluate weight change varied across studies:
from 2.4 years to 5–9 years within cohort studies and from
28 d to 2.5 years within interventions. The longest cohort
study did not find any association between the MD and
obesity (23); however, it was carried out in a non-
Mediterranean country. All MD interventions, lasting 2
years or more (30,33,34), reported a significant reduction
in weight.
Definition and evaluation of the MD
The number of components used to define the MD varied
between studies. The majority of the studies included at
least nine common key components: a high consumption of
cereals, vegetables, fruit, legumes, nuts and seeds, fish, olive
oil or ratio of monounsaturated to saturated fatty acids, a
moderate consumption of alcohol (especially wine) and a
low consumption of meat (generally red and processed).
Cohort and cross-sectional studies
The cohort and cross-sectional studies (with one exception
(14) used a priori definitions of the MD, and defined an
individual’s level of adherence to an MD using indices with
linear scoring systems. The original eight-component index
(and various adaptations of it) developed by Trichopoulou
(36) was the most commonly applied index. However, five
of the seven studies using this index did not find an asso-
ciation between the MD and overweight/obesity. Two
studies by Panagiotakos (15,16) used a different scoring
system based on an MD pyramid which used the intake
frequency of food components to define MD adherence.
Both these studies reported that individuals with a high
adherence to an MD were less likely to be overweight/
obese. There were variations between studies in the
methods used to collect dietary data, which also varied in
level of detail and how they were filled in (interviewer- or
self-administered). Many of the studies used validated
dietary collection methods, e.g. with 4-d food records (22)
or 24-h dietary recalls (18,21).
Intervention studies
The intervention studies recommended different variations
of the MD, partly because of the use of different definition
sources as a reference. Four of the MD interventions were
hypo-caloric (25,26,33,34), and all reported significant
weight losses. The MD intervention varied in terms of level
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Obesity and the Mediterranean diet G. Buckland et al. 589
of detail of the MD recommendations and amount of time
spent explaining the MD.
Control diets and additional
non-dietary interventions
Nearly all the interventions (nine out of 11) involved non-
dietary interventions, such as MD-style cooking classes,
weight loss counselling, physical activity programmes or a
combination of these in multidisciplinary healthy lifestyle
programmes (24–28,30,32–34). Five out of these nine
studies found that weight loss was significant in the MD
intervention group (24,26,30,33,34), one did not find any
significant weight loss (27), and three did not specify the
significance of the weight loss in the MD group (25,28,32).
The majority of the intervention studies (eight out of 11)
involved a control diet which varied from the participants
following a prudent diet (30), usual patient treatment (32),
a low fat diet (27,29,31,34) or receiving general healthy
dietary information (28,33). Four of these studies found
that there was significantly more weight loss after following
an MD, compared with a control diet (30,32–34). Out of
the studies that involved both a control group and addi-
tional non-dietary interventions, four reported significantly
more weight loss in the MD group compared with the
control group (30,32–34), and two reported no difference
(27,28). However, only the intervention by McManus (34)
gave the non-dietary intervention to the control group, as
well as the MD group.
Statistical methodology
The number of potential confounders taken into account in
the logistic regression models in the cohort studies varied
considerably, ranging from 17 variables in one cohort study
(21) to four variables in another (23). Around half (six out of
11) of the cross-sectional and cohort studies (17–22) took
into account differences between participants total energy
intake. One study (22) also took into account changes in diet
throughout the follow-up, and other studies excluded under-
and/or over-reporters of dietary intake (20,21). Nearly all
the intervention studies used some method to measure the
participants’ compliance to the MD, although only one
study (25) presented a separate analysis for compliers and
non-compliers. The results were also expressed in different
statistical measures depending on the study (Table 2).
Discussion
Epidemiological evidence assessing the association between
MD adherence and overweight/obesity is limited and con-
flicting. Only 21 epidemiological studies have assessed this
relationship, and the majority of these were intervention
and cross-sectional studies, with few cohort studies. No

590 Obesity and the Mediterranean diet G. Buckland et al.
studies reported that an MD significantly increased obesity.
Just over half of the studies provided evidence that the
adherence to an MD was associated with less overweight/
obesity or promoted weight loss. The extent of the protec-
tive effect of the MD was reasonably strong in some
studies. For example, in a cohort study (21), men with a
high MD adherence were up to 29% less likely to become
obese. An even stronger protective effect was seen in cross-
sectional studies, with up to 51% less probability of being
overweight or obese (15). In addition, some intervention
studies reported important weight losses, of up to 14 kg in
one study (33).
There are several physiological explanations that could
explain why key components of MD might protect against
weight gain. The MD is rich in plant-based foods that
provide a large quantity of dietary fibre. This has been
shown to increase satiety and satiation through mecha-
nisms, such as prolonged mastication, increased gastric
detention and enhanced release of cholecystokinin (38).
Energy density has an important role in weight gain, as
palatable energy-dense food leads to poor appetite control
and consequently to over-consumption. The MD has a low
energy density (38) and a low glycaemic load (39) com-
pared with many other dietary patterns. These characteris-
tics, together with its high water content, lead to increased
satiation and a lower calorie intake, and thus help to
prevent weight gain.
Some studies reported the percentage of total energy
derived from fat within the MD, and in most instances, it
was consistent with the moderately high fat content char-
acteristic of the traditional MD (30–40% of energy from
fat). However, some intervention studies (26,30,31,33) did
use an MD with 25–30% of energy from fat. The conse-
quences of diets with a relatively high total fat content have
been a topic of concern partly because of the possible
effects on weight gain (13). However, there is some evi-
dence that high fat diets are not the major cause of obesity
(39), as important cohort studies (1,40) and long-term
trials (33,34) have found no significant relation between
higher fat diets and obesity.
The MD and a low-fat diet could both possess similarly
favourable effects on prevention of weight gain, because of
the high fibre content and the low energy density of the
components. However, the MD has several advantageous
characteristics that also protect against obesity.
Firstly, the quality of fat is a key factor, as it is low in
cholesterol-rising fats (saturated and trans fats) and high in
monounsaturated fats (approximately 67% of fat energy)
as found in oleic acid in olive oil. This fatty acid profile has
a range of important health benefits (6,13,38).
Secondly, although fat is believed to be the least satiating
of the macronutrients, study findings have not always been
consistent. For instance, a recent intervention study found
no differences in hunger or satiety sensations or in ad
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obesity reviews
libitum energy intake between four trial meals rich in either
fat, carbohydrate, protein or alcohol (41).
Thirdly, the habitual use of olive oil in salads and veg-
etable and legume dishes enhances palatability of these
foods. This increases consumption of foods high in dietary
fibre and low in energy density, resulting in greater satia-
tion and satiety.
Fourthly, diets rich in monounsaturated fat have been
found to improve glucose metabolism (42), and increase
postprandial fat oxidation, diet-induced thermogenesis and
overall daily energy expenditure (43,44), compared with
diets higher in saturated fats. This may provide physiologi-
cal explanations of why olive oil consumption is less prone
to cause weight gain (22,45).
Finally, the MD is highly palatable and, therefore, well
liked and tolerated among dieters, and compliance with the
MD has been found to be reasonably high (27,29,34).
As well as the favourable fatty acid profile of the MD, the
variety in vegetable products and higher consumption of
plant-based foods, compared with that of animal products,
provide a diet rich in both non-nutritional factors and
micronutrients (especially antioxidants). These all give
additional health benefits, such as reducing risk of cardio-
vascular disease and type 2 diabetes (6,38).
Despite the physiological mechanistic evidence that can
explain how the MD can protect against weight gain, the
epidemiological evidence for this relationship is inconsis-
tent. Exploring the relationship between the diet and
obesity is complex, and methodological differences may
partly explain the incoherency between studies.
In terms of cohort and cross-sectional studies, a key
issue is the use of inconsistent definitions of the MD.
Several studies, in their definition, do not include key
characteristic components of a traditional MD, such as
olive oil or ‘wholegrain’ cereals. The methodology used to
construct MD indices could be a further issue because the
use of cut-offs, such as medians to indicate a high adher-
ence, may not reflect a traditional MD. In non-
Mediterranean countries, such as the USA or Hong Kong,
the intakes of certain components of the MD, such as
olive oil or legumes, may be considerably lower. This
would result in low median intakes of these components,
and therefore, show uncharacteristically low cut-offs to
define MD adherence.
In Mediterranean countries, recent research has shown
that the traditional MD is disappearing (2), and therefore,
using intake medians to define a high adherence to an MD
would again be influenced by current dietary patterns,
and may not reflect a traditional MD. The comparison of
weight outcomes of studies carried out in different coun-
tries using different MD definitions, not surprisingly, gen-
erates contradictory results.
Another important methodological issue is the assess-
ment of diet in obese participants, as they are more prone
© 2008 The Authors

obesity reviews
to under-report dietary intakes in comparison with lean
participants (37). In addition, they may have changed
their previous dietary habits because of treatment of
obesity-related co-morbidities. These factors could dilute
the association between MD and obesity. The use of
studies that prospectively explore the effect of an MD on
weight can overcome these issues by excluding at baseline
obese participants and individuals with a poor concor-
dance of reported energy intakes to expenditures. This
methodological approach was used in two of the three
cohort studies (21). An additional advantage of cohort
studies is that they are more capable of exploring
obesity causality, which is a limitation of cross-sectional
studies.
The use of different anthropometric measures, with
nearly half the cross-sectional studies using participants’
self-reported weight as opposed to measured weight,
creates similar issues to those mentioned above. Obese
individuals are more likely to under-report weight com-
pared with lean individuals, again this could dilute the
relationship between the MD and obesity. Although self-
reported weight was validated in most studies, only one of
the studies using participants’ self-reported weight reported
that the MD was inversely associated with obesity. Dif-
ferences in the statistical analyses in cohort and cross-
sectional studies, such as number of confounders taken into
account in regression models, measuring intake of MD
components as a percentage of total energy intake or using
validated dietary questionnaires, could also influence the
reported MD–obesity relationship.
In terms of intervention studies, it is well known that it is
very difficult to change dietary habits. Therefore, the many
methodological factors that affect the level of compliance
and effectiveness of an MD can also contribute to the
differences in weight loss. Several of these factors are:
health status of participants, type of recommended MD,
length of MD intervention and additional healthy lifestyle
interventions. Again, this makes it difficult to compare the
results between studies.
The countries where the intervention studies took place
could affect the availability, affordability or acceptability
of MD food used in the intervention. Consequently, greater
compliance would be expected in Mediterranean compared
with non-Mediterranean countries, such as Germany or
Hong Kong.
Regarding the health status of participants, all MD inter-
ventions carried out on overweight/obese participants or
participants with closely related disorders, reported signifi-
cant weight losses. The MD appears to be more successful
at promoting weight loss when it is targeted at these
groups, possibly because it varies more from their usual
diet, or because they are more motivated for health reasons.
The way the MD intervention was delivered varied
considerably between studies. In general, the longer the
© 2008 The Authors
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1467789x, 2008, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2008.00503.x by Universidad Nacional Autonoma De Mexico, Wiley Online Library on [09/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Obesity and the Mediterranean diet G. Buckland et al. 591
intervention and the more time spent explaining the
intervention to the participants, the greater the weight
loss. The use of non-dietary approaches, especially mul-
tidisciplinary healthy lifestyle programmes, promoted
greater weight losses than studies that did not use these
additional interventions. For example, the study by
Esposito (33), which combined an MD with physical
activity programmes, reported a mean weight loss of
14 kg. However, in studies such as these, it is difficult to
establish whether the weight loss is a consequence of the
MD or the non-dietary interventions. A further compli-
cation is that in the majority of intervention studies the
additional non-dietary interventions (when used) were
only given to the MD group and not the control group
(except in one study). Therefore, in these studies, com-
paring the effectiveness of the MD with a control diet is
confounded by these differences. However, the study by
McManus (34), which did give similar non-dietary treat-
ment to both the MD and control group, found that the
MD group lost more weight, providing some evidence for
the effectiveness of the MD on weight loss compared with
other diets.
Finally, differences in statistical methods between inter-
vention studies can have important effects on the results.
Differences include the analysis of weight changes of all
participants, using an intention to treat method or analysis
of only participants who completed the intervention. The
sample sizes varied considerably within the different
studies, which could alter the statistical power to detect
significant associations, and contribute to the inconsisten-
cies in results. However, the effects of these differences are
not clear-cut.
Although the epidemiological evidence regarding the
relationship between the MD and overweight/obesity is
inconsistent, it reveals that the MD is not related to any
increased risk of overweight/obesity. It actually points
towards a possible role of the MD in preventing
overweight/obesity, and physiological mechanisms could
explain this protective effect. However, further research is
needed to substantiate these findings because of the incon-
sistency of the results. Cohort or intervention studies that
are able to provide better evidence of causality, together
with the use of a consistent universal definition of the MD,
are necessary. MD interventions should provide the same
non-dietary interventions to comparison groups, if the aim
is to assess which diet is more effective for weight loss.
Longer interventions, which also assess compliancy, are
required to evaluate the long-term efficacy of the MD for
promoting and preventing overweight/obesity.
Conflict of Interest Statement
No conflict of interest was declared.

592 Obesity and the Mediterranean diet G. Buckland et al.
Acknowledgements
Grant Support: By the Spanish Ministry of Health
[(RED): Alimentación saludable en la prevención primaria
de enfermedades crónicas: la Red Predimed. Dentro de las
Redes Temáticas de Investigación Cooperativa Sanitaria
(RETICs)].
References
1. Keys A, Menotti A, Karvonen MJ, Aravanis C, Blackburn H,
Buzina R, Djordjevic BS, Dontas AS, Fidanza F, Keys MH, Krom-
hout D, Nedeljkovic S, Punsar S, Seccareccia F, Toshima H. The
diet and 15-year death rate in the seven countries study. Am J
Epidemiol 1986; 124: 903–915.
2. Serra-Majem L, Trichopoulou A, Ngo de la Cruz J, Cervera P,
Garcia AA, La Vecchia C, Lemtouni A, Trichopoulos D. Does the
definition of the Mediterranean diet need to be updated? Public
Health Nutr 2004; 7: 927–929.
3. Trichopoulou A, Lagiou P. Healthy traditional Mediterranean
diet: an expression of culture, history, and lifestyle. Nutr Rev
1997; 55: 383–389.
4. Bach A, Serra-Majem L, Carrasco JL, Roman B, Ngo J, Ber-
tomeu I, Obrador B. The use of indexes evaluating the adherence
to the Mediterranean diet in epidemiological studies: a review.
Public Health Nutr 2006; 9: 132–146.
5. Serra-Majem L, Roman B, Estruch R. Scientific evidence of
interventions using the Mediterranean diet: a systematic review.
Nutr Rev 2006; 64: S27–S47.
6. de Lorgeril M, Salen P. The Mediterranean-style diet for the
prevention of cardiovascular diseases. Public Health Nutr 2006; 9:
118–123.
7. Malik VS, Hu FB. Popular weight-loss diets: from evidence to
practice. Nat Clin Pract Cardiovasc Med 2007; 4: 34–41.
8. Togo P, Osler M, Sorensen TI, Heitmann BL. Food intake
patterns and body mass index in observational studies. Int J Obes
Relat Metab Disord 2001; 25: 1741–1751.
9. International Association for the Study of Obesity. Obesity and
cancer. [WWW document]. URL http://www.iotf.org/cancer.asp
(accessed October 2007).
10. Schroder H, Elosua R, Vila J, Marti H, Covas MI, Marrugat
J. Secular trends of obesity and cardiovascular risk factors in a
Mediterranean population. Obesity (Silver Spring) 2007; 15: 557–
562.
11. Serra-Majem L, Helsing E. Changing patterns of fat intake in
Mediterranean countries. Eur J Clin Nutr 1993; 47(Suppl. 1):
S13–20.
12. Ferro-Luzzi A, Sette S. The Mediterranean diet: an attempt
to define its present and past composition. Eur J Clin Nutr 1989;
43(Suppl. 2): 13–29.
13. Ferro-Luzzi A, James WP, Kafatos A. The high-fat Greek diet:
a recipe for all? Eur J Clin Nutr 2002; 56: 796–809.
14. Shubair MM, McColl RS, Hanning RM. Mediterranean
dietary components and body mass index in adults: the peel nutri-
tion and heart health survey. Chronic Dis Can 2005; 26: 43–
51.
15. Panagiotakos DB, Chrysohoou C, Pitsavos C, Stefanadis C.
Association between the prevalence of obesity and adherence to
the Mediterranean diet: the ATTICA study. Nutrition 2006; 22:
449–456.
16. Panagiotakos DB, Polystipioti A, Papairakleous N, Polychro-
nopoulos E. Long-term adoption of a Mediterranean diet is asso-
Journal compilation © 2008 International Association for the Study of Obesity. obesity reviews 9, 582–593
1467789x, 2008, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2008.00503.x by Universidad Nacional Autonoma De Mexico, Wiley Online Library on [09/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
obesity reviews
ciated with a better health status in elderly people; a cross-sectional
survey in Cyprus. Asia Pac J Clin Nutr 2007; 16: 331–337.
17. Rossi M, Negri E, Bosetti C, Dal Maso L, Talamini R, Giacosa
A, Montella M, Franceschi S, La Vecchia C. Mediterranean diet in
relation to body mass index and waist-to-hip ratio. Public Health
Nutr 2008; 11: 214–217.
18. Trichopoulou A, Naska A, Orfanos P, Trichopoulos D. Medi-
terranean diet in relation to body mass index and waist-to-hip
ratio: the Greek European Prospective Investigation into Cancer
and Nutrition Study. Am J Clin Nutr 2005; 82: 935–940.
19. Fung TT, McCullough ML, Newby PK, Manson JE, Meigs JB,
Rifai N, Willett WC, Hu FB. Diet-quality scores and plasma con-
centrations of markers of inflammation and endothelial dysfunc-
tion. Am J Clin Nutr 2005; 82: 163–173.
20. Schroder H, Marrugat J, Vila J, Covas MI, Elosua R. Adher-
ence to the traditional mediterranean diet is inversely associated
with body mass index and obesity in a spanish population. J Nutr
2004; 134: 3355–3361.
21. Mendez MA, Popkin BM, Jakszyn P, Berenguer A, Tormo MJ,
Sanchez MJ, Quiros JR, Pera G, Navarro C, Martinez C, Lar-
ranaga N, Dorronsoro M, Chirlaque MD, Barricarte A, Ardanaz
E, Amiano P, Agudo A, Gonzalez CA. Adherence to a Mediterra-
nean diet is associated with reduced 3-year incidence of obesity.
J Nutr 2006; 136: 2934–2938.
22. Sanchez-Villegas A, Bes-Rastrollo M, Martinez-Gonzalez MA,
Serra-Majem L. Adherence to a Mediterranean dietary pattern and
weight gain in a follow-up study: the SUN cohort. Int J Obes
(Lond) 2006; 30: 350–358.
23. Woo J, Cheung B, Ho S, Sham A, Lam TH. Influence of
dietary pattern on the development of overweight in a Chinese
population. Eur J Clin Nutr 2008; 62: 480–487.
24. Goulet J, Lamarche B, Nadeau G, Lemieux S. Effect of
a nutritional intervention promoting the Mediterranean food
pattern on plasma lipids, lipoproteins and body weight in
healthy French-Canadian women. Atherosclerosis 2003; 170:
115–124.
25. Bautista-Castano I, Molina-Cabrillana J, Montoya-Alonso JA,
Serra-Majem L. Variables predictive of adherence to diet and
physical activity recommendations in the treatment of obesity and
overweight, in a group of Spanish subjects. Int J Obes Relat Metab
Disord 2004; 28: 697–705.
26. Andreoli A, Lauro S, Di Daniele N, Sorge R, Celi M, Volpe SL.
Effect of a moderately hypoenergetic Mediterranean diet and exer-
cise program on body cell mass and cardiovascular risk factors in
obese women. Eur J Clin Nutr 2007; 1–6 [Epub ahead of print].
27. Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado
J, Ruiz-Gutierrez V, Covas MI, Fiol M, Gomez-Gracia E, Lopez-
Sabater MC, Vinyoles E, Aros F, Conde M, Lahoz C, Lapetra J,
Saez G, Ros E. Effects of a Mediterranean-style diet on cardiovas-
cular risk factors: a randomized trial. Ann Intern Med 2006; 145:
1–11.
28. Michalsen A, Lehmann N, Pithan C, Knoblauch NT, Moebus
S, Kannenberg F, Binder L, Budde T, Dobos GJ. Mediterranean
diet has no effect on markers of inflammation and metabolic risk
factors in patients with coronary artery disease. Eur J Clin Nutr
2006; 60: 478–485.
29. Vincent-Baudry S, Defoort C, Gerber M, Bernard MC, Verger
P, Helal O, Portugal H, Planells R, Grolier P, Amiot-Carlin MJ,
Vague P, Lairon D. The Medi-RIVAGE study: reduction of cardio-
vascular disease risk factors after a 3-mo intervention with a
Mediterranean-type diet or a low-fat diet. Am J Clin Nutr 2005;
82: 964–971.
30. Esposito K, Marfella R, Ciotola M, Di Palo C, Giugliano F,
Giugliano G, D’Armiento M, D’Andrea F, Giugliano D. Effect of
© 2008 The Authors

obesity reviews
a Mediterranean-style diet on endothelial dysfunction and markers
of vascular inflammation in the metabolic syndrome: a randomized
trial. JAMA 2004; 292: 1440–1446.
31. Fernandez de la Puebla RA, Fuentes F, Perez-Martinez P,
Sanchez E, Paniagua JA, Lopez-Miranda J, Perez-Jimenez F. A
reduction in dietary saturated fat decreases body fat content in
overweight, hypercholesterolemic males. Nutr Metab Cardiovasc
Dis 2003; 13: 273–277.
32. Toobert DJ, Glasgow RE, Strycker LA, Barrera M Jr, Radcliffe
JL, Wander RC, Bagdade JD. Biologic and quality-of-life outcomes
from the Mediterranean Lifestyle Program: a randomized clinical
trial. Diabetes Care 2003; 26: 2288–2293.
33. Esposito K, Pontillo A, Di Palo C, Giugliano G, Masella M,
Marfella R, Giugliano D. Effect of weight loss and lifestyle changes
on vascular inflammatory markers in obese women: a randomized
trial. JAMA 2003; 289: 1799–1804.
34. McManus K, Antinoro L, Sacks F. A randomized controlled
trial of a moderate-fat, low-energy diet compared with a low fat,
low-energy diet for weight loss in overweight adults. Int J Obes
Relat Metab Disord 2001; 25: 1503–1511.
35. Tortosa A, Bes-Rastrollo M, Sanchez-Villegas A, Basterra-
Gortari FJ, Nunez-Cordoba JM, Martinez-Gonzalez MA. Medi-
terranean diet inversely associated with the incidence of metabolic
syndrome: the SUN prospective cohort. Diabetes Care 2007; 11:
2957–2959.
36. Trichopoulou A, Kouris-Blazos A, Wahlqvist ML, Gnardellis
C, Lagiou P, Polychronopoulos E, Vassilakou T, Lipworth L,
Trichopoulos D. Diet and overall survival in elderly people. BMJ
1995; 311: 1457–1460.
37. Mendez MA, Wynter S, Wilks R, Forrester T. Under- and
over-reporting of energy is related to obesity, lifestyle factors and
© 2008 The Authors
Journal compilation © 2008 International Association for the Study of Obesity. obesity reviews 9, 582–593
1467789x, 2008, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2008.00503.x by Universidad Nacional Autonoma De Mexico, Wiley Online Library on [09/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Obesity and the Mediterranean diet G. Buckland et al. 593
food group intakes in Jamaican adults. Public Health Nutr 2004;
7: 9–19.
38. Schroder H. Protective mechanisms of the Mediterranean diet
in obesity and type 2 diabetes. J Nutr Biochem 2007; 18: 149–160.
39. Willett WC, Leibel RL. Dietary fat is not a major determinant
of body fat. Am J Med 2002; 113(Suppl. 9B): 47S–59S.
40. Seccareccia F, Lanti M, Menotti A, Scanga M. Role of body
mass index in the prediction of all cause mortality in over 62 000
men and women. The Italian RIFLE Pooling Project. Risk factor and
life expectancy. J Epidemiol Community Health 1998; 52: 20–26.
41. Raben A, Agerholm-Larsen L, Flint A, Holst JJ, Astrup A.
Meals with similar energy densities but rich in protein, fat, carbo-
hydrate, or alcohol have different effects on energy expenditure
and substrate metabolism but not on appetite and energy intake.
Am J Clin Nutr 2003; 77: 91–100.
42. Due A, Larsen TM, Hermansen K, Stender S, Holst JJ, Toubro
S, Martinussen T, Astrup A. Comparison of the effects on insulin
resistance and glucose tolerance of 6-mo high-monounsaturated-
fat, low-fat, and control diets. Am J Clin Nutr 2008; 87: 855–862.
43. Soares MJ, Cummings SJ, Mamo JC, Kenrick M, Piers LS. The
acute effects of olive oil v. cream on postprandial thermogenesis
and substrate oxidation in postmenopausal women. Br J Nutr
2004; 91: 245–252.
44. Piers LS, Walker KZ, Stoney RM, Soares MJ, O’Dea K. Sub-
stitution of saturated with monounsaturated fat in a 4-week diet
affects body weight and composition of overweight and obese
men. Br J Nutr 2003; 90: 717–727.
45. Bes-Rastrollo M, Sanchez-Villegas A, de la Fuente C, de Irala
J, Martinez JA, Martinez-Gonzalez MA. Olive oil consumption
and weight change: the SUN prospective cohort study. Lipids
2006; 41: 249–256.