The Mediterranean Eating Plan

Each year in the United States, approximately 140,000 people are diagnosed with colorectal cancer and more than 50,000 people die of the disease. Being overweight or obese and having a diet high in refined grains, saturated fat, added sugars, and sodium and low in vegetables, fruits, whole grains, and low-fat dairy foods can contribute to poor health and chronic disease and increase the risk of developing colorectal cancer. The most recent dietary guidelines from the Centers for Disease Control and Prevention focus on disease prevention through the adoption of healthier eating patterns. Diets that aim to improve glucose, blood pressure, and lipids (fats)- such as the Mediterranean diet are recommended to improve overall health. Diet and nutrition interventions that promote healthy eating patterns are needed to reduce the risk of developing colorectal cancer.

The Mediterranean Eating Plan is a diet intervention using nutritional counseling that targets adults who are at increased risk of colon cancer. Using an exchange list approach to meal planning, the intervention encourages adherence to a Mediterranean diet, an eating pattern shown to be a protective factor for developing colorectal cancer. This approach aims to improve dietary intake goals in specific food categories while maintaining current calorie intake. The intervention is based on Bandura's social cognitive to address self-efficacy, self-monitoring, social support, goal setting, and the development of problem-solving strategies.

The diet plan includes olive oil, fish, legumes, whole grains, and fruits and vegetables. It is low in n-6 polyunsaturated fats (PUFA) and high in plant-based foods and monounsaturated fats (MUFA). Specifically, the daily dietary goals are to consume seven to 10 high-MUFA foods, one to two servings of dark green vegetables, one to two servings of orange and yellow vegetables, one to two servings of red vegetables, one to two servings of other vegetables, one serving of dark green culinary herbs, a liberal portion of allium vegetables, two servings of fruit (one serving of vitamin C fruit and one serving of other fruit), and three or more servings of whole grains. In addition, foods high in omega-3 should be consumed at least twice per week.

Participants track their dietary intake for 3 days, including 1 weekend day, and a registered dietician reviews the food record to derive each participant's current calorie intake. Participants then attend individualized counseling sessions with the dietician. Counseling sessions occur weekly for the first month, biweekly for the next 2 months, and monthly for the last 3 months. The first session and the session at month 3 are conducted face to face, with the remaining sessions being completed through 20-minute structured telephone calls. At the first session, participants establish dietary goals and receive exchange booklets that list the various foods in each food category and describe serving sizes. Additionally, they receive materials on buying fruits and vegetables, estimating portion sizes, and reading food labels, as well as a week's worth of recipes and sample menus. To ensure each participant's comprehension and ability to meet diet goals, participants keep food diaries until the dietician approves their use of a checklist format for tracking food intake. At each follow-up session, the dietician and participant review dietary intake for the 5-7 days prior to each counseling session and discuss short-term goals. The dietician also reviews vitamin and mineral levels and gives participants a list of foods to correct deficiencies if the levels are less than 67% of the recommended dietary allowance. Bimonthly newsletters are sent to participants to provide news on the program, information on seasonal foods, and sample recipes.
 

-- Approximately 1-2 hours to train registered dieticians
-- Approximately 1 hour to conduct the first counseling session
-- 20 minutes to conduct each of 15 remaining follow-up counseling sessions
 

The Mediterranean Eating Plan targets adults aged 21 years and older who are at increased risk of developing colorectal cancer.

This intervention is intended to be implemented in community settings.

Required resources to implement the program include the following:
-- Exchange Guidelines
-- Sample Menus
-- Fast Track Food Goals Record
-- Food Diary
-- Handout on How to Estimate Food Amounts
-- Mediterranean Eating Newsletters for January 2011 to April 2011
-- Mediterranean Eating Newsletter for May 2010 to August 2010
-- Mediterranean Eating Newsletters for September 2009 to December 2009
-- Phone Counseling Form
-- Mediterranean Eating Plan Exchange booklet
-- Exchange List
-- Recipes

For costs associated with this program, please contact the developer, Zora Djuric. (See products page on the EBCCP website for developer contact information.)

A randomized controlled trial compared use of the Mediterranean diet with that of an alternative diet intervention, the Healthy Eating diet, among adults at increased risk for developing colon cancer. Increased risk was defined as having one first-degree or two second-degree relatives with colon cancer or having a personal history of adenomatous polyps or early-stage colon cancer with cancer treatment ending at least 2 years ago. Other criteria included being in good general health, being at least 21 years old, and having a body mass index (BMI) between 18.5 and 35 kg/m2. The study excluded participants who were currently following a Mediterranean diet, a low-fat diet, or a medically prescribed diet.

Participants were randomized to either the Mediterranean diet group (n=59) or the Healthy Eating diet group (n=61). The groups received an equal amount of counseling, and both groups followed diets using exchange lists. Unlike the Mediterranean diet group, in which participants mastered the use of food diaries before graduating to the checklist format, the Healthy Eating diet group received a checklist at the beginning of the intervention. The Healthy Eating diet, based on Healthy People 2010, recommends low fat consumption (less than 10% of calories from saturated fat and less than 30% of calories from total fat), two daily servings of fruits, three daily servings of vegetables, one daily serving of dark and green or orange vegetables, and at least three daily servings of whole grains. Participants had to complete self-monitoring booklets to count daily servings of fruits, vegetables, and whole grains and grams of saturated fat.

The demographics of the participants were as follows: They had an age range of 22-82 years with a mean age of 53 years, they had a BMI range of 19-35 kg/m2, 88% were Caucasian, 72% were female, 63% were married or in a committed relationship, 28% had a personal history of adenomas, 64% had a family history of colon cancer, and 77% had graduated college.

The main outcomes- intake of monounsaturated fats, trans fats, and fruits and vegetables were assessed at baseline and 3 and 6 months after baseline. At each time point, these outcomes were measured using two methods: (1) Study staff made unannounced telephone calls to participants to obtain recall data on the participants' intake over the past 24 hours (two calls at baseline, two calls at 6 months, and one call at 3 months) and (2) participants tracked 2 days (Sunday and Monday) of food record data. All dietary intake data were entered into a nutrient analysis program. Secondary outcomes were body weight, C-reactive proteins, and additional anthropometric measures and food variables (e.g., PUFA, glycemic load, sodium, energy [calories], total fat, total protein, saturated fat, long chain n-3 fats, total carotenoids, variety of fruits and vegetables, whole grains, fiber, red meat, legumes, calcium). Body weight was measured at baseline and 3 and 6 months after baseline with a model 5005 Stand On Scale (Scale-Tronix, White Plains, NY, USA) when participants were in light clothing and without shoes, and weight was rounded to the nearest quarter pound. Blood samples were obtained at baseline and 6 months after baseline following an overnight fast. Laboratory analyses were done by the Michigan Diabetes Research and Training Center Core Chemistry Laboratory.

• Over the 6-month study period, participants in the Mediterranean diet group had greater MUFA intake than those in the Healthy Eating diet group (p<.05).

• Over the 6-month study period, participants in the Mediterranean diet group had lower intake of trans fats than those in the Healthy Eating diet group (p<.05).

• Over the 6-month study period, participants in the Mediterranean diet group had greater fruit and vegetable intake than those in the Healthy Eating diet group (p<.05).

Additional Findings

• From baseline to 6 months, among overweight and obese participants, those in the Mediterranean diet group had a significant weight loss and decreased C-reactive protein concentrations (p<.05).
• Over the 6-month study period, the Mediterranean diet group performed better than the Healthy Eating diet group on the following intake measures: n-6 PUFA (p<.05), n-3 PUFA (p<.05), glycemic load (p<.05), and sodium (p<.05).
• Over the 6-month study period, the Healthy Eating diet group decreased on energy (calorie) intake (p<.05) and total fat intake (p<.05) in comparison with the Mediterranean diet group.
• Over the 6-month study period, there were no significant differences between groups for the following intake measures: total protein, saturated fat, long chain n-3 fats, total carotenoids, variety of fruits and vegetables intake per day, whole grains, fiber, red meat, legumes, and calcium.