Is the Mediterranean diet recommended routinely to people with chronic conditions in a non-Mediterranean setting?
Substantial evidence supports the Mediterranean diet pattern for management of chronic diseases, however, it is unclear whether this dietary pattern is recommended by health professionals in setting outside of the Mediterranean region. We conducted a survey of dietitians across Australia and found an evidence-practice gap1. Fewer than 50% of surveyed dietitians routinely counselled patients with cardiovascular disease (CVD), type 2 diabetes or non-alcoholic fatty liver disease (NAFLD) on the Mediterranean diet. Principles of the Mediterranean diet which were frequently recommended, included increasing fruit and vegetables and limiting processed foods. However, other key dietary principles, such as liberal use of extra virgin olive oil, cooking with herbs and spices, and limiting red meat were not routinely included in counselling. Dietitians need greater access to practical professional development and patient education materials to support routine use of the full Mediterranean diet pattern in practice.
Why the Mediterranean diet?
The Mediterranean diet is recognised as a cardioprotective dietary pattern and is recommended within practice guidelines and recent dietary position statements for management of CVD, type 2 diabetes and NAFLD internationally2-8. However, there remains debate surrounding whether evidence for this traditional European eating pattern can feasibly be translated into routine care in non-Mediterranean settings9-11.
What did we do?
To understand whether the Mediterranean diet is routinely recommended in a non-Mediterranean setting, we conducted a survey of dietitians who manage patients with CVD, type 2 diabetes or NAFLD throughout Australia. Close to 200 dietitians who worked across community, hospital, public and private health care settings responded to the online survey. Questions included how often they counsel patients on the Mediterranean diet, which core principles of the diet they recommend most and least often and what they see as barriers or enablers to including this diet approach in their routine practice.
Is the Mediterranean diet part of routine care?
As shown in Figure 1, the proportion of dietitians who selected they ‘most of the time’ or ‘always’ counsel on the Mediterranean diet was less than half for each patient group – 47% for people with CVD, 31% for people with NAFLD and 26% for people with type 2 diabetes. Interestingly, the dietitians who identified that they personally follow a Mediterranean diet were more likely to routinely recommend this approach to their patients. Open-ended responses also identified that some participants are reluctant to use the term ‘Mediterranean diet’, with a comments such as ‘I rarely say “Mediterranean diet” to a client, however would encourage the principles via dietary change recommendations and small changes the client felt they were able to manage’.
The principles of a Mediterranean diet which dietitians reported they most frequently ‘always’ recommended to patients included limiting sugary drinks, processed snacks and meats, and increasing daily intake of vegetables and fruits. The principles recommended least often related to reducing red meat, and regular intake of yoghurt/cheese, tomatoes, onion and garlic, or herbs/spices in cooking. Interestingly, participants frequently recommended extra virgin olive oil as the main dietary fat, but did not frequently recommend liberal use (3-4 tablespoons per day).
What are barriers and enablers to recommending the Mediterranean diet?
Frequently reported barriers to recommending the Mediterranean diet to patients included a limited number and duration of dietetics consultations. Dietitians also shared their perceptions of patient specific barriers to implementing the Mediterranean diet. These barriers included limited cooking skills, limited time for food preparation, unfamiliar foods and differing taste preferences, lack of willingness to try, diet information overload and a lack of social support.
Dietitians highlighted that enablers to recommending the Mediterranean diet would include greater access to or awareness of evidence and practice guidelines, and practical based professional development and patient education materials that are easily accessible. It was acknowledged that ‘Some people like to ‘follow’ a diet and the Mediterranean Diet offers that’ and that it is a diet which is palatable and applicable to the whole family. It was also raised that more media attention and public health campaigns for the Mediterranean diet would help.
The bottom line
In our national survey we found that an evidence-practice gap exists in Australian dietetic practice with less than half of participants routinely counselling their CVD, type 2 diabetes or NAFLD patient groups on the Mediterranean diet. Strategies to support dietitians to counsel on the Mediterranean diet within limited consultations are needed. This should include available in-person and online education and consumer-friendly practical resources that are accessible to student and clinical dietitians in varying work locations and settings.
Author: Dr Hannah Mayr