2. Methodological Steps to Address Each Specific Aim
2.1. Step One: Identification of the Nutrient Composition Profile of Previous MD Interventions Delivered to Mediterranean and Australian Populations
2.2. Step Two: Identification of the Key Food-Based Components of a MD with Strong Published Evidence of Health Benefits
2.3. Step Three: Development of a Two-Week Meal Plan Based on the Nutrient Composition Profile and the Key Food Intake Recommendations Identified in the Previous Steps
2.4. Step Four: Identification of Potential Barriers and Proposal of Strategies for Translating MD into the Australian Population
3. Practical Strategies Related to Each Specific Aim
3.1. Nutrient Composition Profiles of Other MD Interventions Delivered to Mediterranean and Australian Populations
3.2. Macronutrient Profile of the MD Model
Monounsaturated Fatty Acids
Polyunsaturated Fatty Acids
Saturated Fatty Acids
3.3. Identification of the Key Food-Based Components of a MD with Strong Published Evidence of Health Benefits
3.3.1. Food Groups
3.3.3. Herbs and Spices
3.3.5. Eating Together
3.3.6. Being Mindful
3.3.7. Biodiversity and Seasonality, Local and Eco Friendly
3.4. A Two-Week Meal Plan Based on the Nutrient Composition Profile and the Key Food Intake Recommendations Identified in the Previous Steps
3.5. Potential Barriers and Proposed Strategies for Translating MD into the Australian Population
4. General Overview and Future Implications
Conflicts of Interest
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|Trials||7 Countries Study||Diabetes Cross Over||PREDIMED||The Medi-RIVAGE||NAFLD Cross Over|
|Keys et al.  (Cohort)||Itsiopoulos et al.  (Intervention)||Estruch et al.  (Intervention)||Vincent et al.  (Intervention)||Ryan et al.  (Intervention)|
|Dietary data||Prospective cohort||Feeding trial, full provision of diet. Data is recommended diet ^||Data is from diet consumed *||Data is from recommended diet ^||Feeding trial, full provision of diet. Data is the recommended diet ^|
|Population||Mediterranean||Non-Mediterranean (Australia)||Mediterranean (Spain)||Mediterranean (Spain)||Non-Mediterranean (Australia)|
|Total Fat (%E)||36.1||40.2||41.3||35–38||44.3|
|Fibre (g/d)||-||46.7||-||>25 g||36.4|
|Linoleic acid n-6 (g)||-||15.6||14.1||-||15.1|
|α-linolenic acid n-3 (g)||-||1.5||1.6||-||1.6|
|Total LCN3s (mg)||-||-||-||-||200.3|
|Key outcome||All-cause mortality CHD||HbA1c||↓CVD complications||↓CVD risk||liver fat insulin resistance|
|Nutrients||Australian Mediterranean Diet Composition|
|Added sugar (%E)||5.2|
|Total fat (%E)||41.8|
|Linoleic acid n-6 (g)||18.7|
|α linolenic acid n-3 (g)||4.9|
|Total LCN3s (mg)||932|
|Recommendation||Practical Dietary Applications||Key Components||Evidence Based Benefits|
|Use extra virgin olive oil (EVOO) as the main added fat.||Minimum 3–4 tablespoons (60–80 mL) per day||The highest proportions of MUFAs and polyphenols squalene and α-tocopherol are available in extra virgin olive oil.||Prevention of CHD, cancers and modification to immune and inflammatory responses have been attributed to EVOO.|
The high antioxidant content of EVOOs contributes to health of the vascular system through improved endothelial function  and has been shown to inhibit LDL oxidation .
EVOO consumption has also been proposed to improve bone mineralisation .
|Eat vegetables with every meal.||Include 100 g leafy greens, and 200 g all other vegetables daily (cauliflower, zucchini, eggplant, capsicum etc.).|
use onion and garlic daily;
include 100 g tomatoes daily; fresh or sofrito (tomato-based sauce).
|Vegetables are the most significant source of phenolic compounds. They contain carotenoids, folic acid, fibre and phytosterols.|
Garlic, onion, herbs and spices also have key benefits. See Section 3.3.2 for importance of combining and/or cooking ingredients.
|Flavonoids, are essential bioactive compounds that provide health benefits due to their antioxidant effects and have been associated with improvements in cognitive function and mood .|
Traditional diets which are predominantly plant-based are associated with lower rates of chronic diseases and increased longevity .
Carotenoids, folic acid and fibre play important roles in CHD prevention .
Phytosterols contribute to reduced serum cholesterol and CVD risk .
Garlic, onions, herbs and spices contain large amounts of flavonoids or allicin which have cardiovascular benefits and also improve cognitive function .
Vegetables which are high in potassium, magnesium and calcium tend to reduce arterial blood pressure [34,36].
|Include at least two legume meals per week.||Canned or dry legumes are acceptable; this may include tofu (1 serve = 250 g).|
This should replace meat on days when meat is not consumed.
|Legumes are high in fibre, protein, B vitamins, iron, zinc, calcium, magnesium, selenium, phosphorus, copper and potassium . They provide a nutritious, nourishing meat alternative.||Legumes are linked to longevity, and are a strong predictor of survival .|
Vegetables have been shown to reduce serum homocysteine concentrations and thus coronary events, especially in high risk individuals .
An inverse association between the risk of T2DM and CHD and legume intake has been reported [44,45].
|Eat at least three servings of fish or shellfish per week.||Fish (1 serve = 100–150 g);|
shellfish (1 serve = 200 g).
Include oily fish at least 1–2 times per week.
|Marine long chain omega-3 polyunsaturated fatty acids provide eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).||EPA and DHA effectively regulate haemostatic factors and protect against cardiac arrhythmias, cancer and hypertension and help to maintain neural functions [34,40]. A high intake of fish and seafood has also been shown to reduce systolic blood pressure [34,36]. Immunomodulatory effects may improve inflammatory conditions .|
|Eat red meat less often and choose smaller portions. Choose white meat.||150–200 g weekly of beef, lamb and, pork.|
200–250 g per week of poultry.
Choose lean varieties, wild, free range and grass fed varieties are encouraged.
|Meat is a bioavailable source of vitamin B12, and iron, selenium, and zinc and are a good source of protein.|
Excessive amounts of red meat have been linked to adverse health outcomes and excess saturated fatty acids—unfavourable fat ratios and displacement of more nutritious alternatives.
Wild, free range and grass fed varieties are preferred due to the improved n-6:n-3 ratio .
|Red meat is a good source of protein which assists with satiety . Red and processed meats, especially when consumed in excess, are associated with total CVD and cancer mortality .|
Excessive SFA intake from meat is also linked to adverse health outcomes .
|Eat fresh fruit every day.||300g or 2 serves.||Fruit provides fibre, potassium, vitamins A and C, B vitamins, folate, flavonoids and terpenes providing protection against oxidative processes.||Consumption of fruit has been shown to reduce the risk of CVD and cancers .|
Fibre, vitamins, minerals, flavonoids and terpenes may provide protection against oxidative processes which drive the onset and exacerbate chronic diseases .
Flavonoids have also been associated with improvements in cognitive function and mood .
|Eat a serve of nuts every day and dried fruit as a snack or dessert.||Nuts-1 serve = ~30 g or 1/4 cup or a small handful daily.|
Dried fruit—2 tablespoons or 30 g.
|Nuts are a good source of monounsaturated fats, fibre, vitamin C and E, selenium, magnesium, providing an abundance of antioxidants including flavonoids, resveratrol, polyphenols and tocopherols .||Monounsaturated fats, phenols, phytosterols, phytic acid and fibre are abundant in nuts and are associated with a reduction in plasma lipids and reduced incidence of CVD . Nut consumption has been associated with the prevention and reversal of oxidative stress [50,51].|
|Eat dairy every day.||2 serves per day including milk-1 serve = 250 mL or 1 cup.|
Yoghurt preferably Greek style yoghurt 1 serve = 150 g or ¾ cup.
|Dairy is a good source of calcium, vitamin D, phosphorus, magnesium, zinc, potassium, vitamins A and B12, and lactic acid bacteria confer probiotic effects .|
Choose mostly fermented dairy which are higher in potent beneficial bioactive compounds from milk such as lactic acid bacteria .
|Bioactive milk components have been shown to be protective in several diseases, including hypertension, coronary vascular diseases, obesity, osteoporosis and cancer .|
Lactic acid bacteria confer probiotic effects, including improvements in gastrointestinal health and immune response. Yogurt, specifically, may induce desirable changes in faecal bacterial flora, potentially reducing the risk of colon cancer. Yoghurt is also likely to regulate mouth-to-caecum transit time .
|Eat cheese in moderation, about 3 times per week and preferably feta.||1 serve = 30 g or the size of a matchbox.|
|Include wholegrain breads and cereals with meals, such as wholegrain bread, rice, pasta and potato.||1 serve = 1 slice of bread or; ½ cup or; 50–60 g cooked pasta/rice or; 1 small 100 g potato.||Wholegrains are a good source of fermentable carbohydrates including fibre, resistant starch, and oligosaccharides. They contain phytochemicals, antioxidants including trace minerals, phenolic compounds, lignans and B group vitamins including folate, vitamin E, minerals iron, magnesium, copper and selenium .||Components such as fibre, antioxidants and vitamins and minerals promote health and may be protective against cancer, CVD, T2DM and obesity [56,57].|
Production of short chain fatty acids through indigestible carbohydrates promote reduced serum cholesterol levels and decrease cancer risk .
|Have sweets or sweet drinks in moderate amounts and on special occasions only.||Preferably home made.||Homemade varieties have key ingredients that are encouraged in the MD, such as nuts, EVOO and milk and are less refined and lower in SFA.||Liver fat accumulation may be attributed, at least in part, to excess dietary sugar consumption, especially from fructose, which increases the levels of enzymes involved in hepatic de-novo lipogenesis [59,60].|
|Consume up to 3 eggs per week.||Free range or omega-3 varieties.||Eggs are a good source of protein, choline, selenium, vitamin B12, riboflavin, phosphorus and fat soluble vitamins A, D and E. They are a bioavailable source of carotenoids; lutein and zeaxanthin, . Free range and omega-3 enriched varieties have higher amounts of omega-3 fatty acids .||The benefits of eggs, including the provision of protein and micronutrients including vitamins, minerals and carotenoids may prevent age related macular degeneration and some cancers .|
A limit to egg consumption is set to achieve the desired fat ratios in line with other MD guidelines .
Consume wine in moderation.
|Choose red wine. Have 0–2 glasses per day, (100 mL per glass) and always with meals. Do not get drunk.||Red wine contains phenolic compounds with high antioxidant properties. For example, red wine has higher amounts of the stilbene polyphenol, resveratrol, compared with white wine .||Red wine provides polyphenols whose antioxidant activity may contribute to the cytoprotective effects. Resveratrol has been found to protect the heart and kidneys from ischaemia-reperfusion injury and has a likely positive effect on endothelial function (vasodilation) with prolonged moderate consumption [64,65].|
|Cuisine||Greek (Cretan)||Middle Eastern||Indian||Chinese||Western|
|Meal||Fasolatha||Mujadara||Dhal||Mapo Tofu||Homemade Baked beans|
|Key ingredients||Legumes, onions, garlic, tomato, herbs, EVOO||Lentils, rice, onions, spices, EVOO||Lentils onion, garlic, tomatoes, ghee||Tofu, garlic scallions, peppers, ginger, soy sauce +/− pork, peanut +/− sesame oils||Legumes, onion, garlic, tomato, vegetable oil|
|Fat Modifications||-||-||Replace part or all added fat with EVOO|
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