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The elegantly (and deliciously) simple Mediterranean diet is among the most life-saving post-MI interventions. Look beyond statins and bring on the olive oil!

Emergency physicians are trained for heroic procedures. Emergency thoracotomy, cricothyrotomy, post-mortem c-section, Mediterranean diet counseling… we do it all.

Oh. Don’t know that last one?

For decades the heart diet headlines have been dominated by Ornish, Scarsdale, Atkins, and the like. But while they were making headlines, the Mediterranean diet has been making data. A few moderate quality trials for the headliners have suggested that they may be useful in mild to moderate short term weight loss, but none has achieved the holy grail—long term heart benefits. In 1994 the Lyon Diet Heart Study, a rigorous randomized trial performed in post-MI patients, showed that a Mediterranean diet reduced heart attacks and deaths. Moreover, the findings were confirmed in long term follow-up in 1999, and have now been replicated several times.

Here’s the best and most shocking part: In studies that showed the life-saving superiority of a Mediterranean diet the comparator was a diet of reduced cholesterol and fat (the American Heart Association recommended diet). Try to imagine what happens, therefore, when a Mediterranean diet replaces the average American diet.
And yet, even against an AHA diet the raw life-saving numbers for the Mediterranean diet are astounding, particularly next to interventions that are much better known and routinely trumpeted by doctors, lay people, and health authorities. The Number-Needed-to-Treat to prevent one MI, i.e. the number of people who need to use this diet for five years in order to prevent one heart attack, is 18. And to save a life the number is 30. Compare that to the NNTs for a few of the best known cardiac interventions (figure 1).

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Admittedly, the diet loses to defibrillation—but then, so does everything else. And note that five years of a Mediterranean diet is three times more powerful than five years of taking a statin (without the statin side effects). These numbers mean that the Mediterranean diet is among the most powerful interventions ever studied for heart disease. Moreover, in a Spanish study published last month, the diet reduced cardiovascular outcomes even in people without heart problems. And again the raw numbers dwarf most other interventions for preventing a first cardiovascular event.

How can we use these data in the ED? One of the more vexing rituals in EM is the anemic discharge instructions we give to our patients after a negative cardiac work-up. ‘See your doctor if the chest pain continues and, um, come back if you drop dead.’ Perhaps it is time to start adding a new instruction, an active endeavor to avoid the problem that worries them most. Here’s what we can say:

  1. Eat more fruits (3 servings a day)
  2. Eat more vegetables (2 a day, including a salad).
  3. Use olive oils abundantly, including for salad dressings and for cooking.
  4. Eat less red meat and more white meat
  5. Indulge in plenty of fish (3 a week).
  6. Snack on legumes like nuts and beans.
  7. Eat red sauces.
  8. If you’re so inclined, enjoy a glass of wine with dinner.

If you’re like me, this sounds more like an oceanside vacation than a health intervention. Or, perhaps, it’s a heroic discharge instruction that might save some lives.


David H. Newman, MD Author of Hippocrates’ Shadow: Secrets From The House Of Medicine



 

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