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What mental images does the word “Mediterranean” conjure up for you?

Is it stunning white-sand beaches running down to piercingly blue water?

Or maybe picturesque cliff-towns overlooking sun-kissed islands?

Or even tumbled-down ancient ruins and the relics of forgotten empires (I’ve been listening to a lot of Roman history podcasts lately if you can tell)?

How about an inordinate amount of wrinkly old people?

Here at Longevity Advice that’s certainly what we think of when we hear the word Mediterranean.

That’s because people living in some areas of the Mediterranean tend to have surprisingly little cardiovascular disease, cancer, and even Alzhiemer’s disease, and (if the birth records are to be believed) are also some of the longest-lived people on the planet.

In fact, two of the five “blue zones” (places with high numbers of centenarians) discussed in National Geographic writer Dan Buettner’s book of the same name (see our piece on longevity and the blue zone diet) happen to be in the Mediterranean (Ikaria, Greece, and Sardinia, Italy).

And what do these long-lived, largely disease-free people have in common?

A diet that’s been hypothesized to increase lifespan while protecting against age-related diseases: the Mediterranean Diet.

What is the Mediterranean Diet?

At its most basic, the Mediterranean Diet (also referred to in studies as the Med Diet, MeDi, and a whole host of other silly initialisms and abbreviations) is simply the traditional diet of people who live near the Mediterranean sea.

Of course, technically this encompasses everything from Greek olives to Italian pizza to Tunisian couscous, so we need to get a little more specific.

Originally the Mediterranean Diet was used to refer specifically to the eating patterns of people in Crete, Corfu, Crevalcore, Montegiorgio, and Dalmatia in the 50s and 60s, when the famous Seven Countries Study was done by physiologist Ancel Keys (whom you might remember from his other famous research on caloric restriction; the Minnesota Starvation Experiment).

But other Mediterranean countries shared similar diet patterns, and so the definition expanded beyond just those five regions.

And because nutrition science is confusing and difficult and we can’t have nice things, of course almost every study on the Mediterranean Diet uses a different definition of what that diet consists of.

In fact, a 2018 editorial in The Journals of Gerontology laments that, “Greater clarity on how this diet is defined, in both interventions and observational studies, will be critical in the aim of achieving a consensus on how to optimally apply this dietary pattern towards maximizing healthy aging.”

Some studies include potatoes as vegetables, while others don’t include fish, and still others include dairy while entirely different studies explicitly exclude dairy. It’s a bit of a cluster (or “charlie foxtrot” as my military friends would say) on the specifics, but the general definition of a Mediterranean Diet seems to cover some roughly agreed-upon categories.

For instance a 2017 review concludes that the Mediterranean Diet consists of:

1. A variety of minimally processed whole grains and legumes as the staple food 
2. Plenty of a huge diversity of fresh vegetables consumed on a daily basis 
3. Fresh fruits as the typical daily dessert; sweets based on nuts, olive oil, and honey consumed only during celebratory occasions 
4. Cold pressed extra-virgin olive oil, nuts and seeds as the principal source of fat 
5. Moderate consumption of fish 
6. Dairy products (mainly local cheese and yogurt) consumed in low amounts; butter, cream and milk never used, except for milk in coffee (caffé macchiato) or for infants 
7. Red and processed meat consumed in very low frequency (only once every week or two) and amounts; 
8. Wine consumed in low to moderate amounts only with meals

And a 2008 meta analysis describes the Mediterranean Diet as:

“Vegetables, fruits, legumes, cereals, fish, and a moderate intake of red wine during meals.”

A 2015 review defines the Mediterranean Diet as:

“…three to nine serves of vegetables, half to two serves of fruit, one to 13 serves of cereals and up to eight serves of olive oil daily.”

Other descriptions of the diet include drinks like coffee and herbal tea, and moderate consumption of eggs and poultry.

The Mediterranean Diet is not a high-carb diet, but is what is referred to as a “moderate carb diet” with around 40% of calories coming from generally low-glycemic-index carbs (ones that won’t spike blood sugar) like bread made from whole grains, or beans like lentils. Vinegars and lemon juice, which help lower the glycemic index of meals, are also used in cooking in the Mediterranean Diet.

And, really, you gotta eat lots of extra virgin olive oil on this diet: like, a minimum of four tablespoons consumed (not just cooked with) daily.

But can doing shots of olive oil on the Mediterranean Diet really help with longevity? Let’s see what the science says!

The science in favor of the Mediterranean Diet for longevity

There’s a lot of positive science around the Mediterranean Diet. In fact, unlike with low-carb diets, the Mediterranean Diet seems to be somewhat of a media and scientific establishment darling. Everyone loves the “MeDi,” and, to see the research, for good reason.

Also, contrary to the other dietary interventions we’ve looked at for life extension like caloric restriction, intermittent fasting, and low-carb diets, there seem to be relatively few animal studies for the Mediterranean Diet (especially regarding longevity) and relatively more human studies.

In fact, I could only find a couple animal studies examining the Mediterranean Diet, and only one that looked at longevity or lifespan directly.

In that study, from 2020, roundworms were given two different polyphenols found in olive oil, one of which extended average lifespan by 14.1%. Since olive oil is a key part of the Mediterranean Diet, the researchers hypothesized, “extra virgin olive oil polyphenols could be among the main determinants of the beneficial effect of the MD.”

Other animal studies looked at beneficial health effects of the Mediterranean Diet, but didn’t study life extension specifically.

For instance, one 2014 mouse study showed the Mediterranean Diet protected against hypertension, while a 2019 one indicated it could protect mice from colorectal cancer development.

In monkeys, the “MD” seemed to delay age-related increases in cortisol and stress markers, according to a 2020 study on macaques.

Beyond the few animal studies, a ton of epidemiological and long-term longitudinal human studies have been done regarding the Mediterranean Diet, and even a few randomized controlled trials (the gold-standard of scientific studies).

That said, I have noticed most studies are careful to point out that a Mediterranean Diet “is associated with” a variety of beneficial health effects, not that it has demonstrably been proven to improve health. This is because many studies on the Mediterranean Diet in humans are retrospective population and epidemiological studies, which can’t definitively show causation because they may not have accounted for all the variables impacting the health outcomes they study.

So do keep that in mind.

In terms of studies that have specifically looked at the Mediterranean Diet and longevity in humans, quite a few have suggested it lowers all-cause mortality risk, and several recent ones have even shown biological age reduction.

In 1999 the Lyon Diet Heart Study showed a 45.4% lower all-cause mortality for people on the Mediterranean Diet compared to controls.

The 2005 European Prospective Investigation into Cancer and Nutrition (EPIC) study linked higher adherence to the Mediterranean Diet with increased survival among people over 60 (a 7-8% reduction in overall mortality). And a 2011 EPIC follow-up in Spain found, “In this Spanish cohort, following an olive oil-rich MD was related to a significant reduction in all-cause mortality [of 6%], and reduced the risk of mortality from CVD [cardiovascular disease].”

A 2011 study of Swedish 70-year-olds found that, after 8.5 years, those with higher adherence to a Mediterranean Diet had 80% survival rates, while those with lower adherence had only 67% survival rates.

The famous 2013 PREDIMED (Prevención con Dieta Mediterránea) study in Spain showed a 30% reduction in risk for “major cardiovascular events” like strokes. However, the study had methodological issues (not all subjects were assigned diets at random) and had to be retracted and then republished. While more recent analyses have concluded PREDIMED’s issues didn’t affect its results, it may still be reason for skepticism.

Some meta-analyses also showed promising results for longevity with the Mediterranean Diet, with a 2018 review of 19 different studies finding, “The decreased risk of CVD ranged from 9% to 52%, and the decreased risk in total mortality ranged from 7% to 47% for increased adherence to a Mediterranean dietary pattern.”

And a 2019 review of nine studies found that adherence to “diets similar to that of the Mediterranean diet were associated with 269% greater likelihood of successful ageing and 33% reduction in mortality risk.”

In a study released in 2021, higher adherence to a Mediterranean Diet in Italian subjects increased lifespan by 9.9%.

Beyond actual mortality risk, several recent studies have examined how the “MedDiet” impacts different aging and longevity biomarkers.

In 2011, a study of overweight men concluded, “Prolonged adherence to a Mediterranean-style diet, with or without caloric restriction, in overweight or obese men is associated with significant amelioration of multiple risk factors, including a better cardiovascular risk profile, reduced oxidative stress, and improved insulin sensitivity.”

A 2021 review looked at the nine different hallmarks of aging and found “evidence that the MedDiet as a whole, or individual elements of this dietary pattern, may influence each hallmark positively.”

The Mediterranean Diet is also associated with longer telomere length (though telomere length may not be the best indicator of biological age).

Finally, two recent studies have examined Mediterranean or Mediterranean-like diets and their effect on the epigenome, changes in which form the basis for epigenetic clocks which can predict lifespan and chronological age with incredible accuracy.

A 2020 study showed a Mediterranean Diet was associated with DNA methylation patterns that are themselves associated with lower risk for all-cause mortality.

And, excitingly, echoing the results of the famous 2019 TRIIM Trial, a 2020 paper, using data from the European NU-AGE diet study, showed an actual biological age reversal of 1.47 years as measured by an epigenetic clock.

Of course, none of the above even touches on the numerous studies showing the Mediterranean Diet may lower cardiovascular disease risk, protect against Alzheimer’s and improve brain health, improve the gut microbiome while reducing frailty, and protect against all kinds of cancer.

Even the moderate red wine drinking of the traditional Mediterranean Diet may be good for you and was found to increase the lifespan of fruit flies by 7%.

The science against the Mediterranean Diet for longevity

So with all this mountain of positive scientific evidence in favor of the Mediterranean Diet increasing longevity and improving health, what could possibly be the cons of the Mediterranean Diet?

I will say: I had to do a lot of digging to find scientific evidence against the Mediterranean Diet, which honestly makes me a little wary. 

That there are so few negative claims about the Mediterranean Diet means either it really is as great as everyone says, or that there’s some serious groupthink going on in the scientific community and important problems with the diet are being overlooked or are not getting studied.

There’s some circumstantial evidence that this could be the case, given that most of the biggest studies showing the benefits of the Mediterranean Diet are funded by governments of Mediterranean countries like Greece, Italy, and Spain. One might suspect such governments have a vested interest in their country’s traditional diet being labelled healthy. Perhaps they support such research findings for reasons of national pride, tourism, or even increasing global demand for their food exports.

The problems with Spain’s 2013 PREDIMED study suggest there could be cause for concern on this front. As mentioned above, the study was retracted in 2018 because of data and methodological problems, and then republished with largely the same conclusions after applying statistical analyses to deal with the discovered issues. But the very existence of the methodological issues in the first place suggests the study may not have been very rigorously run or that researchers may have influenced (even subconsciously) the study to get the conclusions they wanted. For instance, “Effect sizes were probably inflated because the trial was stopped early after interim analyses showed benefit.”

With issues like this in one of the pre-eminent studies of the Mediterranean Diet (cited by over 3,300 other scientific papers) it’s possible some of the positive conclusions formed about the diet may be overblown.

Some smaller issues with the Mediterranean Diet have also been identified.

For instance, a 2017 study of Spanish children found inadequate calcium intake even among those with high adherence to a Mediterranean Diet (possibly due to a lack of dairy in the diet).

Another 2017 study suggested the Mediterranean Diet doesn’t provide cardiovascular disease protection for those in lower socioeconomic groups, possibly because of a difference in ingredient quality and variety.

A 2021 study concluded that the Mediterranean Diet was not as good as a low-fat vegan diet for lowering LDL cholesterol levels or losing weight.

Additionally, a lot of studies we covered in our article on low-carb diets showing the negative impact of carbs could be used to imply the moderate-carb Mediterranean Diet might have negative side-effects. For instance, some research suggests carbohydrates may accelerate aging in everything from roundworms to rodents.

Finally, almost all definitions of the traditional Mediterranean Diet include moderate red wine drinking with meals, but recent research, like this 2021 pre-print (not yet peer-reviewed) study on over 25,000 people in the UK, has found that for certain markers of health like brain volume and grey matter density, there is no “safe” dose of alcohol.

Other studies question the health impact of red wine, including one from 2011 showing it acutely impaired heart function and increased total cholesterol in the aorta in young healthy subjects.

How does the Mediterranean Diet increase lifespan?

But if the Mediterranean Diet does work for life extension, it’s still a little bit unclear just how.

While tons of the studies mentioned above have concluded you’ll be healthier and live longer with the Mediterranean Diet, very few of these have looked at the specific mechanisms that may be extending life and health. Is it some specific food or combination of foods? Is it how it’s prepared? Or maybe how or when it’s eaten? 

Is it activating autophagy like caloric restriction and intermittent fasting, or is it perhaps minimizing free radical damage or accelerating DNA repair? Or something else entirely?

We have some isolated studies that offer tantalizing hints, but little more than that and very few firm conclusions.

The main theories seem to be that the Mediterranean Diet extends lifespan through the molecular properties of the specific foods it includes. Meaning that, unlike the previous dietary interventions we’ve looked at, the timing of when you eat, or how much you eat, or even the macronutrient ratios of fat to carbs to protein may not be as important as what you eat.

Several foods on the MeDi have emerged as primary candidates for its health effects:

• Olive oil is a rich source of lots of different beneficial polyphenols, including oleic acid which might activate sirtuins, the DNA repair enzymes present in cells.
• Fresh, leafy wild greens like dandelion, and seasonal vegetables like mushrooms and broccoli are rich in nutrients and full of beneficial compounds like spermidine and sulforaphane that seem to have anti-aging effects.
• Low glycemic index carbohydrates like whole grains could protect against cancers and inflammation through the presence of healthy polyphenols and fiber, which can remove damaged cells from the digestive tract, dilute carcinogens, and positively alter the gut microbiome.
• Red wine, as mentioned above, may have cardioprotective effects through beneficial phytochemicals like resveratrol that can prevent oxidative stress and positively alter gut bacteria.
• Greek-style boiled coffee can improve the function of blood vessels, also likely because of specific polyphenols within it.

It may be that the Mediterranean Diet just happens to combine a lot of generally healthy food types and ingredients in one place that act together, and in various different ways, to slow the damage and diseases associated with aging.

It also seems eminently possible to combine the Mediterranean Diet with several of the previous interventions we’ve discussed before, like caloric restriction, intermittent fasting, and even a low-carb version, and possibly reap synergistic effects.

How do I start a Mediterranean Diet?

 First off, don’t start any diet intervention without first consulting your doctor, especially if you may have health conditions (like genetic nutrient deficiencies) or comorbidities that could make it dangerous, or if you’re pregnant.  

I’ve definitely been convinced by my research to incorporate a lot of Mediterranean Diet aspects into my own longevity-focused diet, including a healthy amount of olive oil, some low-glycemic index carbs like lentils, plus lots of veggies like mushrooms and leafy greens (we’re growing kale and chard in the backyard!).

If you’re also interested in getting started with the “MedDiet” there are some resources out there to help.

Though, unfortunately, because the definition of the Mediterranean Diet is so wishy-washy, there aren’t a ton of online calculators or other similar tools to help you. 

A 2009 study did develop something called the “relative Mediterranean Diet” score or “rMED” which seems to be the one most used by other studies to measure adherence to a Mediterranean Diet. I was able to find an online calculator for calculating your own rMED score, but frankly it’s way too technical and not user-friendly for me.

That said, some good, more accessible resources for starting a Mediterranean Diet are available online, including:

• This less-technical Mediterranean Diet score questionnaire.
• This solid Mediterranean Diet for beginner’s guide with links to recipes and meal plans and lists of ingredients.
• The great infographics and brochures of Oldways, a non-profit dedicated to education about traditional dietary patterns.
• This 101 guide to the Mediterranean Diet complete with the Mediterranean Diet food pyramid.
• A list of life extension kitchen products that might help cooking for the Mediterranean Diet easier.

Have you followed a Mediterranean Diet for longevity or anti-aging reasons? What’s been your experience? Let us know in the comments!