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iDieta Mediterránea y Salud: Estudios epidemiológicos de observación y de intervención. Lluís Serra Majem, MD, PhD. Catedrático de Salud Pública de la Universidad de Las Palmas de Gran Canaria Presidente de la Fundación Dieta Mediterranea ¿Dieta mediterránea? ¿Dietas mediterráneas? 1950s Ancel y Margaret Keys Egipcios, griegos, romanos, fenicios, árabes y cartagineses, ingerían alimentos combinados y preparados al estilo que hoy entendemos bajo la noción de dietas mediterráneas. Modelo alimentario prevalente en algunas zonas europeas (Creta,…) a mediados del siglo XX (OldwaysHarvard-OMS). Origen de los principales alimentos EUROPA MEDITERRÁNEO PRÓXIMO ORIENTE INDIA Y ASIA mediterráneos DEL NORTE Remolacha Achicoria Col Colinabo Espárragos Mijo Lentejas Habas Chufas Centeno Espelta Escanda Trigo blando Cebada Centeno Mijo de India Garbanzos Sésamo Pepino Berenjena Alcauciles Rábanos Nabos Apios Chirivías Lechugas Avena Zanahorias Cebollas Ajos Viñas Alcachofa Azafrán Mostaza Albahaca Jengibre Cardamomo Canela Cítricos AMERICA Maíz Judías Patatas Pimientos Calabacines Calabazas Tomate Girasol Cacao Piña Vainilla Olivos Alcachofas Higueras Almendros Ciruelas Melocotones Melones Cerezos Albaricoques Manzanos Perales Castaños Nogales Avellanos Moras Fuente: Adaptada de Igor de Garine “La dieta mediterránea en el conjunto de los sistemas alimentarios”Antropología de la alimentación: ensayos sobre la dieta mediterránea. 1993 SURESTE ASIÁTICA/ OCEANÍA Arroz Caña de azúcar Aves de corral Romero Pimienta Nuez moscada Clavo Canela AFRICA Sandía Palmeras HISTORIA DE LA CERVEZA Edad Media: ordenes monásticas Cerevisia monacorum Galos Hispanos Cervisia Ceria Romanos Cerevisium Fenicios Griegos Mesopotamia Sumerios (4000 a.C.) Sikaru Egipcios Zythum Evolución La confluencia geográfica, histórica, antropológica y cultural de tres continentes: Europa, Asia y África. Un enclave de comunicaciones e influencias de tránsito frecuente, con un hábitat físico hospitalario y en un entorno climatológico templado. Lograron configurarse un patrón alimentario excelente para la vida y la salud Asimila algunas influencias y alimentos foráneos alrededor de sus productos básicos: " el aceite de oliva, el trigo y la vid (uva y vino) " la carne de cerdo y cordero y el pescado. Características ALTO CONSUMO • Pan y derivados del trigo • Verduras, frutas y hortalizas MENOR CONSUMO • Legumbres, frutos secos • Carne • Aceite de oliva • Leche de vaca y mantequilla • Ciertos derivados lácteos como el queso y el yogur • Pescado y vino • Patatas • Licores Patrón histórico de la DM Preferencia de una cierta variedad de alimentos mínimamente procesados y, en la medida de lo posible, frescos, de temporada y cultivados localmente (lo que optimizaría el contenido y propiedades saludables de micronutrientes y antioxidantes en estos alimentos) Població que considera molt saludables els següents aliments. ENCAT 1992-93 Pastanaga Enciam Peix blanc Mel Pa integral Arrós Oli d’oliva Carn vedella Cigrons Peix blau Patates Pasta Pa 45 41 30 28 22 21 17 15 15 14 13 12 11 % Població que considera molt saludables els següents aliments. ENCAT 2002-03 Pastanaga Enciam Peix blanc Mel Pa integral Arrós Oli d’oliva Carn vedella Cigrons Peix blau Patates Pasta Pa 46 46 24 23 25 25 43 8 28 38 12 19 12 % Aliments que considera imprescindibles o molt importants en la definició de Dieta Mediterrània Imprescindible Molt important Llet 25 Brioxeria 1 7 Pasta 16 Cervessa 3 13 Vi 24 Llegums 33 Fruita seca 22 Marisc 15 Peix Hort. i enciam Fruita Oli de girasol 3 15 Oli d'oliva Iogurt 15 Formatge 14 Carn 12 Patates 15 Pa 20 0 10 56 53 42 54 53 44 33 43 37 41 62 57 65 51 20 30 33 54 56 53 40 51 50 60 70 80 90 100 Población española de 2 a 24 años con valores del Índice Kidmed ≥ 8 por regiones geográficas. Estudio enKid (1998-2000) Norte 37,5% Centro 45,7% Noreste 52,1% Levante 45,8% Sur y Canarias 49,3% Distribución de la población infantil y juvenil española según nivel socioeconómico y valor del Test de Calidad de la Dieta Mediterránea. (ENKID 1998-2000) Nivel socioeconómico Bajo Medio Alto 60 % 50 40 30 20 10 0 <=3 4-7 Índice KIDMED >=8 1950 1. Estudis ecològics. Estudi dels Set Països 1970 2. Estudis clínic-epidemiològics sobre aliments de la Dieta: nous, vi, fruites, hortalisses, oli d’oliva, all, ceba, etc. 1980 3. Estudis clínic-epidemiològics sobre nutrients/ingredients de la Dieta: B-carotè, vitamina E, fibra, flavonoids, etc. 2000 4. Estudis epidemiològics sobre el conjunt de la dieta. Utilització de index de dieta saludable/mediterrània. Epidemiological hierarchy in evidence based nutrition Quality of the evidence High Low Systematic Systematic reviews reviews Meta -analysis Meta-analysis Randomized Randomized clinical clinical trials trials Non Non randomized randomized clinical clinical trials trials Cohort Cohort studies studies Case Case –– Control Control studies studies Descriptive Descriptive studies studies Evidence Based Nutrition and Mediterranean Diet Limitations to the application of evidence based medicine to nutritional sciences: • The modification of the diet needs collaboration from the patient and environment • Difficulty in analyzing dietary adherence • Difficulty in developing double blind interventions • Difficulty for making comparisons worldwide Evidence Based Nutrition and Mediterranean Diet • High impact of Mediterranean diet on the public (1,240,000 citations in Google®, 2006) • Medium-low impact in Medline Current Sciences (around 500 citations, 2005; around 725, 2007) • Biased and personal reviews (more than 100) and few systematic reviews. • Scarce clinical trials. None on primary prevention. • Most observational epidemiological studies (ecological, case-control, cohorts). • Relevant cohort studies in recent years and ongoing. Scientific Evidence of interventions on the Mediterranean Diet: Methods Publications about Mediterranean diet since 1984 Search in MEDLINE for articles: • • • • • • • • • • Mediterranean diet Health Cancer Cardiovascular disease Bone disease Prevention Mediterranean diet and health Mediterranean diet and cancer prevention Mediterranean diet and cardiovascular disease Mediterranean diet and bone health,… Scientific Evidence of interventions on the Mediterranean Diet • The term “Mediterranean diet” produced 416 studies in human subjects • 128 of them were review articles • 55 of them were clinical trials, 41 of them randomized • After excluding for language, methodological constraints and studies analyzing a unique Mediterranean food, 43 articles were selected Scientific Evidence of interventions on the Mediterranean Diet Number and type of articles published about the Mediterranean diet 90 80 Publications Clinical trials Reviews 70 60 50 40 30 20 10 0 19 84 19 85 19 86 19 87 19 88 19 89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 Number of articles 100 Year of publication Scientific Evidence of interventions on the Mediterranean Diet • The 43 clinical trials selected corresponded to 35 different studies • Origin: Italy, Spain, France, Great Britain, Chile, Sweden, Canada, Australia, USA, Denmark, Finland, India • Size ranged from 11 to 13,000 subjects • From 28 days to 6,5 years of follow up Scientific Evidence of interventions on the Mediterranean Diet Studies were classified into six groups: Cardiovascular disease: 5 publications Diabetes/lipoproteins/endothelial resistance: 30 pub. Arthritis: 2 publications Cancer: 1 publication Body composition: 3 publications Psychological function: 2 publications Cardiovascular: Author /year pub. Barzi F, 2003 Country Type of study Population Methodology Italy Clinical Sec. trial Prev N=11,323 M/W surviving a MI Subjects received advice to increase consumption of fish, fruit, raw and cooked vegetables and olive oil Singh, 2002 Moradabad RCT, India single blind 499 individuals on a indo-MD and 501 controls on a NCEP diet for 2 years 2y Sec. Prev. N=1000 subjects with major risk factors or previous heart attack N=423 subjects surviving a MI Randomisation to a MD group or control group 46 m Sec. Prev. N= 605 subjects surviving a MI Randomisation to a MD group or control group 27 m Sec. Prev. N= 605 subjects surviving a MI Randomisation to a MD group or control group 27 m Lorgeril M, Lyon, 1999 France Lorgeril M, Lyon, 1996 France Lorgeril M, Lyon, 1994 France RCT, single blind RCT, single blind RCT, single blind Sec. Prev. Follow up 6.5 y Diabetes/lipoproteins/endothelial resistance: Author /year pub. Country Type of study Population Vincent S, Marseille RCT 2004 France Esposito K Naples, RCT, 2004 Italy singleblind Ros E, BCN, R-cross2004 Spain over-CT Pri. Prev. Pri. Prev. Ambring A, 2004 Goulet J, 2004 R-crossover-CT Clinical trial Pri. Prev. Pri. Prev. Flynn G, Australia Clinical 2004 trial Pri. Prev. Urquiaga Santiago I, 2004 de Chile, Chile BravoCórdoba, Herrera Spain MD, 2004 Clinical trial Pri. Prev. N=21, M R-crossover-CT Pri. Prev N=41 Goteborg Sweden Quebec, Canada Pri. Prev. Methodology Follow up N=212, M/W >=1 CV RF N=180, M/W Metabolic syndrome N=21, M/W hypercholesterolemic MD or a traditional 3 m, still low-fat/chol. diet on going Control group following a 24 m prudent diet and interv. group following a MD 4 w. chol. lowering MD / 4w 4 w. diet similar in E. and fat content where walnuts replaced ∼ 32% E from MUFA N=22, M/W 4 w. of a Swedish diet, 4w healthy subj. 4 w. of a MD N= 77, W 12 w. nutrition intervention 12 w healthy with 2 group sessions, 3 individual sessions and 4 24-h recall N=155, M/W 3 m. MD and control group 3m non specific 3 m. MD or western diet. The 2nd m. red wine was added to both diets 3 dietary periods: SAT fat enriched diet, low fat and high CHO diet, MD 3m 3m ... Diabetes/lipoproteins/endothelial resistance: Author Country /year pub. Toobert Oregon, DJ, 2003 USA Type of study Population RCT Sec. Prev N=279 W postmenopausal DM2 R-crossover-CT Clinical trial Sec. Prev. Pri. Prev. Rodríguez V.C, 2003 Goulet J, 2003 Barcelona, Spain Quebec, Canada Sondergaard E, 2003 Svendborg, RCT Denmark Mezzano D Santiago 2003 de Chile, Chile Singh N, London, 2002 U.K. Sec. Prev. Clinical trial Pri. Prev. RCT, doubleblind Perez Cordoba, R-crossJimenez F, Spain over-CT 2001 Mezzano D Santiago Clinical 2001 de Chile, trial Chile Pri. Prev. Pri. Prev. Pri. Prev. Methodology Control: usual care. Interv. group:3-d retreat and 6 m of weekly meetings with diet, PA & stress management modification N=22 M/W 6 w. of a high CHO diet and 6 w. with DM2 on a high MUFA diet or vice versa N=77 W 12 w. nut. interv. with 2 group sessions, 3 individual sessions and 4 24-h R N=115 M/W 12 m. of statin treatment and MD recent/remote intervention group or control MI or unstable group /stable Angor P. N=42 healthy M 21 MD and 21 high-fat diet for 30 days, suppl. with red wine in both groups from day 31 to 60 N=56 healthy 6 w. on a MD or vitamin C M/W supplements or placebo N=59 young M/W 28 days of a SFA enriched diet, followed by 28 d. of a low fat, high CHO diet or a MD and vice versa. N=42 healthy M 21 subjects on a MD and 21 subjects on a high-fat diet for 30 days, suppl. with red wine in both groups from day 31 to 60 Follow up 6m 6w 12 w 12 m 3m 6w 28 d 3m ... Diabetes/lipoproteins/endothelial resistance: Author Country Type of study /year pub. Fuentes F, Cordoba, R-cross- Pri. 2001 Spain over-CT Prev. Muñoz S, Barcelona, R-cross2001 Spain over-CT Zambon Barcelona, R-crossD, 2000 Spain over-CT Madigan Dublin, C, 2000 Ireland R-crossover-CT Ryan M, 2000 Barbagallo CM, 1999 Leighton F, 1999 Dublin, Ireland Palermo, Italy Clinical trial Clinical trial Chile Cinical trial PérezJiménez F, 1999 Córdoba, Clinical Spain trial Population N=22 M hypercholesterolemic Methodology Follow up 28 d 28 days of a SFA enriched diet, followed by 28 days of a low fat, high CHO diet (NCEP-1) or a MD and vice versa. Pri. N=10 M 6 w. of a chol. lowering MD, 6 w. 6w Prev. hyperchoon a diet with walnut replacing lesterolemic 35% E. from MUFA or vice versa Pri. N=49 M/W 6 w. of a chol. lowering MD, 6 w. 6w Prev. hypercholesof a diet with walnut replacing terolemic 35% of the energy from MUFA Sec. N=11 M 2 w. MUFA rich diet (30ml olive 2w Prev. DM2 oil/day) and 2 w. PUFA rich diet (30ml sunflower oil) & vice versa Sec. N= 11 M 2 m. on a PUFA rich diet and 2 m. 2 m Prev. DM2 on a MUFA rich diet (MD) Sec. N=78 M/W renal 24 w. of usual diet and 10-12 w Prev. transplant 10-12 w. of MD recipients Pri. N=21 M 3 m. on a MD or western diet. The 3 m Prev. 2nd m. red wine was added to both diets Pri. N= 25 M 28 days on a low fat NCEP-I-diet, 28 d Prev. or a MUFA-diet (MD) or a SFArich diet ... Diabetes/lipoproteins/endothelial resistance: Author Country Type of study /year pub. Baroni SS, Italy Clinical Sec. 1999 trial Prev. Simoni G, Italy 1995 Clinical trial Salen, 1994 Clinical trial France Methodology Follow up Hypercholeste- MUFA enriched diet vs. a PUFA rolemic patients enriched diet Clinical trial N=15 hypercho2 months on a Gemfibrozil lesterolemic with (600mg) treatment combined ?Lp(a) patients with MD Sec. N=41 M hyper18 months of MD Prev. cholesterolemic heart transplant Pri. N=90 pilots a) Uncontrolled diet & exercise Prev. programme, b) MD & uncontrolled exercise, c) MD & controlled exercise programme Pri. N=48 M/W Shift from a MD to a MD high in Prev. saturated fats and cholesterol Clinical trial Pri. Prev. Moreno Badajoz, Clinical Vazquez Spain trial JM, 1994 FerroItaly , Luzzi 1984 Ehnholm North C, 1982 Karelia, Finland Population Sec. Prev. N=54 MD 2m 18 m 42 d 6w Arthritis: Author Country Type of study /year pub. Sköldstam L, Sweden clinical Sec. 2003 trial Prev. Hagfors L, 2003 Sweden RCT Sec. Prev. Population Methodology Follow up 12 w N= 51 M/W rheumatoid arthritis patients N=51 M/W rheumatoid arthritis patients 12 w. on either MD or control diet 3 m on either MD or control diet 3m Population Methodology N=605 subjects surviving a MI MD group or control group. Follow up 4y Cancer: Author Country Type of study /year pub. Lorgeril M, Lyon, RCT Sec. 1998 France Prev. Body composition: Author /year pub. Flynn G, 2004 Country Type of study Population Methodology Australia clinical Prim. trial Prev. N= 41 individuals 41 individuals followed for 15 m after completing a 3 m MD N=34 M hypercholesterolemics who consumed a diet rich in SAT fat N=101 M/W overweight Each of 17 subjects underwent two dietary periods of 28 days: MD/carbohydrate rich diet 28 d MD versus low fat diet 18 m Population Methodology N=120 M untreated hypercholesterolemic N=176 hypercholesterolemic subjects MD versus simvastatin treatment Follow up 12 w Fernandez Córdoba, clinical Sec. de la Puebla Spain trial Prev. RA, 2003 McManus K, Boston, 2001 USA RCT Prim. Prev. Follow up 3m Psychological function: Author Country Type of study /year pub. Hyyppä MT, Turku, R-cross- Sec. 2003 Finland over-CT Prev. Wardle J, 2000. London, RCT United Kingdom Sec. Prev. 12 w of a low fat diet, or MD or control group 12 w Scientific Evidence of interventions on the Mediterranean Diet. Results The Mediterranean diet produced: ¾ An improvement in lipoprotein levels (especially total cholesterol and LDL-cholesterol) (HIGH) ¾ Favorable effects on endothelial function (HIGH) ¾ An improvement in glycemic control, via plasma glucose, insulin and HbA1 levels and insulin resistance (HIGH) ¾ An improvement in antioxidant capacity (MEDIUM) Scientific Evidence of interventions on the Mediterranean Diet. Results The Mediterranean diet produced (cont.): ¾ Favorable effects on myocardial and cardiovascular mortality in cardiac patients (HIGH) ¾ An improvement in some functional tests for arthritis (LOW) ¾ A lower risk of incidence for some kinds of malignant and nonmalignant tumors (LOW) ¾ An improvement in BMI, % body fat and other anthropometric measures (MEDIUM) ¾ No evidence of mood changes Scientific Evidence of interventions on the Mediterranean Diet Discussion • Scientific evidence for Mediterranean diet is based on observational studies or personal reviews • Most of the trials used a sample of less than 60 subjects • Major differences exist in the methodology used to analyze the intervention (MD) La Jerarquía de la Evidencia Científica para la epidemiología nutricional Calidad de la evidencia Alta Baja Revisiones áticas Revisiones sistem sistemáticas Meta -análisis Meta-análisis Ensayos ínicos aleatorizados Ensayos cl clínicos aleatorizados Estudios Estudios controlados controlados no no aleatorizados aleatorizados Estudios Estudios de de cohorte cohorte Casos Casos -- Controles Controles Serie Serie de de casos casos 1950 1. Estudis ecològics. Estudi dels Set Països 1970 2. Estudis clínic-epidemiològics sobre aliments de la Dieta: nous, vi, fruites, hortalisses, oli d’oliva, all, ceba, etc. 1980 3. Estudis clínic-epidemiològics sobre nutrients/ingredients de la Dieta: B-carotè, vitamina E, fibra, flavonoids, etc. 2000 4. Estudis epidemiològics sobre el conjunt de la dieta. Utilització de index de dieta saludable/mediterrània. Scientific Evidence of interventions on the Mediterranean Diet. Discussion Observational studies: ¾ SUN Cohort Study (Navarra, España): Med diet and different end points (mortality, HTA, obesity,..) (19.000 men and women) ¾ EPIC Study (Several european countries): Med diet, cancer and cardiovascular diseases (650.000 males and females) ¾ HALE study (Several european countries): Med diet and longevity (3.000 elderly males and females). ¾ NURSES study (USA): Med diet and diabetes,… (65.000 women). • Los ancianos en el quintil superior de consumo de cereales tienen más de un 20% de descenso de riesgo cardiovascular (JAMA, 2003) • La ingesta de cereales integrales (2 rebanadas de pan integral por día) supone un riesgo menor de infarto de miocardio o embolia (Am J Geriatr Cardiol, 2004) • Un patrón de ingesta con un elevado consumo de derivados lácteos bajos en grasas, y alimentos ricos en fibra se asocia con un menor IMC en mujeres (Am J Clin Nutr, 2004) • Un aumento en la ingesta total de fibra (12g) se asocia con una disminución en la circunferencia de cintura después de 9 años de seguimiento en hombres (Am J Clin Nutr, 2003) • En la mujeres del estudio EPIC, el consumo de cereales predecía una disminución del peso tras dos años de seguimiento (OR = 1.43; 95% CI, 1.09-1.88), (J Nutr, 2002) • Una dieta rica en fruta, verdura, productos integrales y productos lácteos bajos en grasas y baja en carne roja, comidas preparadas, fast food y soda se asocia con una menor ganancia en el IMC y la circunferencia de cintura (Am J Clin Nutr, 2003) 40 Patrón histórico de la DM: Condimentos Utilización de ajo, cebolla, hierbas y especias • Sabor, higiene y conservación • El perejil, la menta, la albahaca y el cilantro contienen cantidades no despreciables de calcio, hierro y vitaminas A y C • Alto contenido en flavonoides (hinojo, cebollina, etc) • Compuestos aliáceos (ajo, cebolla) – posible efecto cardiosaludable y mejora en funciones cognitivas Disponibilidad de frutos secos (kg/per cápita/año) en distintos países según las hojas de Balance alimentario de la FAO. Año 1990. Venezuela Tailandia Uruguay Japón Reino Unido Marruecos EE.UU. Suecia Dinamarca Portugal Israel Bolivia Italia Túnez Turquía España Suiza Grecia 0 2 4 6 Kg/per cápita/año 8 10 Disponibilidad de frutos secos (kg/per cápita/año) en distintos países según las hojas de Balance alimentario de la FAO. Año 2000. Venezuela Uruguay Tailandia Japón Reino Unido Suecia EE.UU. Marruecos Dinamarca Portugal Turquía Israel Bolivia Italia Túnez España Suiza Grecia 0 2 4 6 Kg/per cápita/año 8 10 Traditional Mediterranean Diet: Fish Weekly intakes in low to moderate amounts of fish, shellfish, poultry and including some eggs per week. • PUFA found in fish oils (eicosapentainoic acid –EPA; docosahexaenoic acid- DHA) • Efficacy regulating haemostatic factors • Protective effect seen for cardiac arrhythmia, and for cancer in animals • Role in maintenance of neuronal function and affects certain psychiatric disorders • 18:3/18:2 Ratio around 1:4 DIETA MEDITERRÁNEA • 90 PACIENTES CON SM SIGUEN DIETA MEDITERRÁNEA, 90 SIGUEN DIETA NORMAL • CON DIETA MEDITERRÁNEA: – 4 KG PÉRDIDA DE PESO (FRENTE 1 KG GRUPO CONTROL) – MENOR RESISTENCIA A INSULINA – 67% DEJAN DE TENER SM (FRENTE 19% GRUPO CONTROL) Esposito K, Marfella R, Ciotola M, Di Palo C, Giugliano F, Giugliano G, D'Armiento M, D'Andrea F, Giugliano D.Effect of a mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomized trial. JAMA 2004;292(12):1440-6. Scientific Evidence of interventions on the Mediterranean Diet. Discussion Ongoing randomised clinical trials: ¾Mediet Project (Italy): Med diet and cancer (115 women) ¾Medi RIVAGE study (France): Med diet, cardiovascular risk and gene polymorphism (212 males and females) ¾PREDIMED study (Spain) Scientific Evidence of interventions on the Mediterranean Diet: PREDIMED study Coordinator: R. Estruch, MD (H. Clìnic, Barcelona) • Parallel group, multi-center, randomized study • N=9000 high risk individuals (55 to 80 years for males and 60 to 80 years for females) • 3 groups: low fat diet (AHA), Mediterranean diet (olive oil), Mediterranean diet (walnuts, hazelnuts, almonds) • Primary outcome: cardiovascular death, non-fatal myocardial infarction, non-fatal stroke/Secondary outcome: death by any cause, incidence of angina leading to revascularization procedure, heart failure, diabetes mellitus, dementia and cancer/Other outcomes: changes in blood pressure, body weight, adiposity measures, blood sugar, lipid profile, markers of inflammation, other intermediate markers of cardiovascular risk Scientific Evidence of interventions on the Mediterranean Diet • Mediterranean diet recommendations need to be evidence based, which implies the development of clinical and observational epidemiology in Mediterranean countries • Objective systematic reviews need to address different areas of associations with health and personal reviews should not be accepted. • Otherwise the promotion of the Mediterranean diet will always have certain shortcomings Scientific Evidence of interventions on the Mediterranean Diet Scientific evidence of interventions on the Mediterranean Diet: A systematic review Serra-Majem L, Roman B, Estruch R Nutrition Reviews, 2005. Evolución social del entorno alimentario mediterráneo • • • • • • • Reducción y modificación de la família Incorporación de la mujer al trabajo Mayor estrés y menor actividad física Incremento comidas fuera de casa y platos precocinados Menos dedicación a la cocina, falta de aprendizaje Cambioss en los patrones de compra y provisión Incorporació de alimentos-costumbres importados Retroceso de las costumbres tradicionales Mediterráneas y Globalización. Pirámides de la alimentación actual PDM Monthly Weekly Optimum MD: Around 1960 Daily - Quantities? - Varieties? - Dairy? - Refined Cereals? - OH in moderation? Wine moderation 62 Muchas gracias por su atención. Lluís Serra Majem, Fundación Dieta Mediterránea
