Mediterranean Diet protective against cardiovascular and neurodegenerative diseases

Mediterranean Diet protective against cardiovascular and neurodegenerative diseases

Protective diet HTN-NDD

Nutritionnal

• Early reduction of the risk of cardiovascular events in patients suffering from arterial hypertension (HTN).
• ICD 11 : BA00

The antihypertensive benefit of the Mediterranean diet observed and demonstrated by clinical studies (Gay 2016; Toledo 2013; Estruch 2018; Cowell 2021; Filippou 2021) is mainly explained by the improvement of endothelial function, the reduction of inflammation and oxidative stress, better electrolyte balance, and metabolic effects (Filippou 2021; Młynarska 2025). There is a dose-response relationship, in other words, the better the diet is followed, the greater its benefits on cardiovascular health (Yan 2025).

Measurement of resting blood pressure with a manual or electronic blood pressure monitor.

Blood pressure equal to or greater than 140/90 mmHg confirmed after several measurements.

Reduction of systolic blood pressure greater than or equal to 4 mmHg. If possible, blood pressure below 140/90 mmHg.

• Reduction of obesity (Franquesa 2019).
• Decrease in the risk of cardiovascular diseases (Sánchez-Taínta 2008; Estruch 2018; Martínez-González 2024; Barbería-Latasa 2025).
• Reduction in the risk of cardiac arrhythmia (Qin 2025).
• Decrease in the risk of metabolic syndrome and type 2 diabetes (Kesse-Guyot 2013; Kargin 2019; Dayi 2022).
• Reduction in the risk of cancer (Leone 2020).
• Reduction in the risk of neurodegenerative disease such as Alzheimer’s (Walker 2021; Li 2024; Youn 2025; Hajji-Louati 2026).

• Nutritional deficiency if the diet is too restrictive, particularly in calcium, vitamin D, and protein.
• Decompensation in case of excessive restriction of salt or fluids.
• Eating behavior disorders if the goals are inappropriate or if the expectations are unrealistic.
• About 30% dropout induced by financial constraints (Heneghan 2025) or organizational constraints in access to necessary food products.

• Diuretic medications: risk of hypokalemia if potassium intake is insufficient; risk of dehydration if fluid intake is overly restricted.
• Antihypertensive medications: risk of hyperkalemia if on a potassium-rich diet (legumes, dried fruits, bananas, etc.).
• Beta-blockers and calcium channel inhibitors: limited food interactions, but caution with alcohol (enhancement of the hypotensive effect).

Endothelial function and nitric oxide production
The Mediterranean diet improves endothelial vasodilation through an increase in nitric oxide bioavailability (Jennings 2019; Shannon 2020).

Anti-inflammatory and antioxidant effects
The richness in polyphenols (olive oil, fruits, vegetables, nuts) reduces systemic inflammation (CRP, cytokines) and oxidative stress, limiting vascular dysfunction and chronic vasoconstriction (De Pergola 2018).

Electrolyte and renal balance
A high intake of potassium (fruits, vegetables, legumes) and a lower relative sodium density contribute to lowering blood pressure through natriuretic effects and better renal regulation of extracellular volume (He 2013; Filippou 2023).

Weight, insulin resistance, and metabolic profile
NPI promotes moderate weight loss, improves insulin sensitivity, and reduces sympathetic activation, which lowers blood pressure in subjects with metabolic disturbances (Cowel 2021).

Arterial stiffness and vascular remodeling
In the medium term, the combined anti-inflammatory and antioxidant action reduces arterial stiffness and remodeling (Shannon 2020).

Weight reduction in case of overweight
Weight loss, particularly of fat mass in favor of lean mass, lowers blood pressure (Dayi 2022).

Food regulation
Better food autonomy and better management of eating behaviors under stress limit the intake of risky industrial foods and alcohol that increase hypertension (Dayi 2022).

Microbiota
The Mediterranean diet, rich in fiber in particular, promotes the growth of bacteria associated with weight regulation and reduction of inflammation (Carvalho 2025).

• Adult with mild to moderate hypertension.
• Adult presenting a cardiovascular risk factor (overweight, dyslipidemia, family history, etc.).
• Patient with hypertension for secondary prevention of cardiovascular disease in combination with drug treatment (Haber 2025).

Patient with unstable heart failure, severe uncontrolled renal insufficiency, or major eating behavior disorders.

Individual

5 months

1 session per month

Feasible and acceptable intervention (Storniolo 2017; Alvarez-Alvarez 2020) in Europe as in Asia (Yang 2025), in Africa (Liweleya 2025) or in the Middle East (Altawili 2023). It can be called the "Mediterranean-Dietary Approaches to Stop Hypertension Intervention" or the "Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay" (MIND) (Li 2024).

• Collect medical, personal, nutritional, and educational data (psycho-affective, bioclinical, socio-professional).
• Define a nutritional and educational diagnosis shared with the patient.
• Agree on realistic objectives according to the 6 essential components determined in the card.
• Establish a care plan translating the general objectives into specific and incremental objectives allowing the patient's progress on the 6 axes.
• Include in each session a time for nutritional education of 10 to 15 minutes and negotiation of incremental specific objectives to promote patient autonomy and participation in their nutritional care pathway.
• Wait for the achievement of the specific objective before moving to a higher cognitive level.
• Wait for the achievement of one or more objectives ensuring a minimal threshold of coverage of nutritional recommendations before moving to another area.
• Organize regular follow-up: in-person or video conference meetings at least once a month for 30 to 50 minutes.
• Provide a means of contact between appointments to answer any questions the patient may have.
• Offer a reinforcement session after any disruptive health event (hospitalization, decompensation episode, treatment change).
• Inform the primary care physician and the specialist doctor about the implementation and progress of the nutritional program.
• Record and quantify the degree of achievement of each general objective.
• Record and quantify the degree of application of each specific objective set and the degree of delivery of each education session provided.
• Note the main markers for monitoring nutritional status at each session: weight changes, collection of dietary habits by food groups, food frequency.
• Involve family members whenever possible and relevant (particularly those responsible for shopping or food preparation).

Components to observe associated with therapeutic education:
Reduction of sodium intake
- General consumption goal: Sodium intake < 5 g/day (table salt + processed foods), goal to be adjusted if there is a different medical prescription. This recommendation is important for the success of the intervention (Filippou 2023).
- Breakdown into a clinical objective: Reduction of systolic blood pressure by 5–10 mmHg in 3 months.
- Examples of breakdown into specific monthly objectives: replace consumption of industrial soup with a frozen soup containing less salt or a homemade soup; for cooking starchy foods, limit the use of bouillon cubes to 1 per cooking session; do not add extra salt to lunch and dinner dishes; use spices, herbs, or seasonings instead of salt.

Increase in fiber and antioxidants
- General consumption goal: Intake of fruits and vegetables ≥ 400 g/day or 5 servings per day; increase consumption of so-called whole foods or foods made from wholemeal flour to 1 serving per day; increase consumption of legumes to 2 servings per week.
- Breakdown into clinical goals: Reduction of systolic blood pressure by 5 to 10 mmHg with a decrease in associated physical symptoms and cardiovascular risk; improvement of glycemic profile with a reduction in associated cardiovascular and metabolic risks.
- Examples of breakdown into specific monthly goals: Have one serving (minimum 100 g or the equivalent of a closed fist) of raw vegetables or fruit per day; consume a handful of nuts (almonds, walnuts, hazelnuts), roasted or unroasted; consume 100 g of berries at your breakfast 3 times per week.

Lipid balance (less saturated fatty acids, more polyunsaturated fatty acids and omega-3s)
- General consumption goal (formulation to be adapted according to the patient): Reduce the proportion of saturated fatty acids in the diet so that they represent less than 12% of total energy intake OR limit the consumption of foods high in saturated fatty acids (cold cuts, cheeses, pastries, fried products) to a frequency of 1 to 2 times per week or lower than previous habits; increase the proportion of unsaturated fatty acids in the diet so that they represent more than 4% of total energy intake for omega-6, more than 1% of total energy intake and 500 mg for EPA + DHA.
- Breakdown into clinical objectives: Improvement of lipid and glycemic profile and reduction of metabolic and cardiovascular risks.
- Examples of breakdown into specific monthly objectives: Make salad dressing with olive oil and rapeseed oil; consume fatty fish at least once a week (salmon, tuna, sardines); favor a starter based on raw vegetables combined with a source of protein (eggs) and good fats (nuts), replacing cold cuts to limit their consumption to a maximum of once a week.

Increase in calcium and potassium intake
- General consumption goal: Increase the consumption of dairy products to 2 per day; increase hydration with water rich in calcium to at least 1L per day; increase the consumption of vegetables and raw fruits to at least one serving per day; increase the consumption of legumes to 2 servings per day.
- Breakdown into clinical objectives: Lower blood pressure to improve vascular function and reduce cardiovascular risk.
- Examples of breakdown into specific monthly objectives: Drink 0.5 to 1L of water per day; add a fromage blanc (sweetened with 1 teaspoon of jam) to breakfast; integrate 2 to 3 dried apricots or about ten raisins into a plain yogurt for the evening meal; consume 1 kiwi or 1 banana at breakfast.

Establishing a General Dietary Balance
- General consumption goal: Increase hydration to reach the minimum intake of 1.5L to 2L of water per day; improve meal distribution with 3 meals per day + 1 to 2 snacks; improve the balance of the lunch and dinner plate by combining a source of protein, a source of complex carbohydrates, and a source of fiber.
- Breakdown into clinical objectives: Lower blood pressure; initiate weight loss; improve lipid and glycemic profiles and reduce metabolic and cardiovascular risks.
- Examples of breakdown into specific monthly objectives: Include at each lunch and dinner a portion of cooked starchy foods (semi-whole pasta, rice, potatoes, quinoa, lentils, or chickpeas), this portion should represent ¼ of your plate; have an afternoon snack combining a dairy product and a portion of raw fruit; in addition to the usual hydrationDrink a large glass of water in the morning and a large glass of water at 4 p.m. (possibility of flavoring it with lemon or mint leaves, for example).

Educational / Behavioral Dimension 
- General Objective: Reduce food-related guilt and implement self-assessment exercises and monitoring of eating behavior.
- Breakdown into clinical objectives: Improve the relationship with food and better manage snacking or overeating episodes; adjust portions and dietary balance according to different situations.
- Examples of breakdown into specific monthly objectives: Write the first 3 columns of Beck (description of the situation, emotions felt during this situation, and thoughts that arise during the situation) during a moment of food-related guilt to discuss at the next session; assess your appetite before the meal on a scale from 0 (no hunger) to 5 (extreme hunger), then record eating behavior during the meal (meal duration, overall balance of the plate, quantity consumed, satiety).

Nutritional education time to be utilized during sessions
- Understanding high blood pressure (definition, mechanisms, risk factors) and its relationship to cardiovascular health (general advice, role of diet and physical activity).
- Role of salt, hidden sodium, and ultra-processed foods in hypertension (explanations and reduction strategies).
- Importance of potassium, magnesium, and calcium intake for blood pressure (food sources and recommendations).
- Choices of fats and proteins (Mediterranean diet, omega-3s, limiting saturated fats and red meats).
- Stress, sleep, and emotion management (direct impact on blood pressure and eating behaviors).
- Practical strategies to adapt daily eating (meal planning, choosing healthy foods, adaptation to socio-professional context).

• Software to assist with nutritional consultation with consultation form.
• Educational sheets in PDF and printed versions for postal mailing if necessary.
• Document from the High Authority of Health (HAS,2016) and from Health Insurance (2025).
• Consultation report with summary of important information from data collection, nutritional diagnosis, general care objectives, and specific therapeutic objectives.
• Videoconferencing system.

Dietary office.
Video conference.

• Clearly explain the role of diet in hypertension.
• Use simple educational materials.
• Encourage the implementation of a balanced diet in the long term, adapted to lifestyle habits.
• Explain that the benefit of care lies in adopting new eating habits over the long term and that these changes occur gradually.
• Check understanding and adherence at each session.
• Adapt advice to the sociocultural and professional context and to the person's lifestyle.
• Promote step-by-step progression.
• Encourage regular physical activity.

• Emphasize maintaining a balanced diet in the long term.
• Offer concrete strategies (batch cooking, shopping lists, reading labels).
• Provide appropriate documentary resources.

• Check for interactions with antihypertensive treatments (diuretics, supplements).
• Avoid a diet that is too restrictive and radical (risk of deficiencies, loss of lean mass).
• Adapt management in case of comorbidities (diabetes, renal insufficiency, digestive disorders).
• Take into account age, comorbidities, and dietary preferences to personalize the intervention and maintain it over time.
• Respect the gradual implementation of dietary changes to promote adherence and limit digestive issues.
• Inform the attending physician when implementing the intervention, especially if the patient is on antihypertensive treatment or another medication.

On medical prescription.
The practitioner must systematically cite the intervention and its code.
Supervision by a dietitian qualified and trained at the NPI.

This program on the Mediterranean diet against hypertension and neurodegenerative diseases is the result of cumulative and collaborative work by nutrition researchers since the 1950s.

Dietitian or nutritionist doctor.
Training in the care approach and in the good interprofessional practices of NPIs.
Specific training at the NPI.

Prototype study
De Lorgeril M et al. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999 Feb 16;99(6):779-85. https://doi.org/10.1161/01.cir.99.6.779

Mechanistic study
Ros E et al. Mediterranean diet and cardiovascular health: Teachings of the PREDIMED study. Adv Nutr. 2014 May 14;5(3):330S-6S. https://doi.org/10.3945/an.113.005389

Interventional studies
Toledo E et al. Effect of the Mediterranean diet on blood pressure in the PREDIMED trial: results from a randomized controlled trial. BMC Med. 2013 Sep 19;11:207. https://doi.org/10.1186/1741-7015-11-207
Jennings A et al. Mediterranean-Style Diet Improves Systolic Blood Pressure and Arterial Stiffness in Older Adults. Hypertension. 2019 Mar;73(3):578-586. https://doi.org/10.1161/HYPERTENSIONAHA.118.12259

Risk assessment studies
Filippou CD et al. Mediterranean diet and blood pressure reduction in adults with and without hypertension: A systematic review and meta-analysis of randomized controlled trials. Clin Nutr. 2021 May;40(5):3191-3200. https://doi.org/10.1016/j.clnu.2021.01.030
Cowell OR et al. Effects of a Mediterranean diet on blood pressure: a systematic review and meta-analysis of randomized controlled trials and observational studies. J Hypertens. 2021 Apr 1;39(4):729-739. https://doi.org/10.1097/HJH.0000000000002667

Implementation study in Europe
Alvarez-Alvarez I et al. Adherence to a priori dietary indexes and baseline prevalence of cardiovascular risk factors in the PREDIMED-Plus randomised trial. Eur J Nutr. 2020 Apr;59(3):1219-1232. https://doi.org/10.1007/s00394-019-01982-x

Other publications
Altawili AA et al. An Exploration of Dietary Strategies for Hypertension Management: A Narrative Review. Cureus. 2023 Dec 7;15(12):e50130. https://doi.org/10.7759/cureus.50130
Assurance Maladie. Quelle alimentation en cas d'hypertension artérielle? CNAM, Paris, 2025. https://www.ameli.fr/assure/sante/themes/hypertension-arterielle-hta/alimentation-et-hta Barbería-
Latasa M et al. The Mediterranean diet and cardiovascular disease. Cardiovasc Res. 2025 Dec 18;121(16):2465-2475. https://doi.org/10.1093/cvr/cvaf218 Carvalho LM et al. Precision nutrition for obesity management: A gut microbiota-centered weight-loss approach. Nutrition. 2025 Dec;140:112892. https://doi.org/10.1016/j.nut.2025.112892
Cowell OR et al. Effects of a Mediterranean diet on blood pressure: a systematic review and meta-analysis of randomized controlled trials and observational studies. J Hypertens. 2021 Apr 1;39(4):729-739. https://doi.org/10.1097/HJH.0000000000002667
Dayi T et al. Effects of the Mediterranean diet on the components of metabolic syndrome. J Prev Med Hyg. 2022 Oct 17;63(2 Suppl 3):E56-E64. https://doi.org/10.15167/2421-4248/jpmh2022.63.2S3.2747
De Pergola G et al. Influence of Mediterranean Diet on Blood Pressure. Nutrients. 2018 Nov 7;10(11):1700. https://doi.org/10.3390/nu10111700
Filippou C et al. DASH vs. Mediterranean diet on a salt restriction background in adults with high normal blood pressure or grade 1 hypertension: A randomized controlled trial. Clin Nutr. 2023 Oct;42(10):1807-1816. https://doi.org/10.1016/j.clnu.2023.08.011
Franquesa M et al. Mediterranean Diet and Cardiodiabesity: A Systematic Review through Evidence-Based Answers to Key Clinical Questions. Nutrients. 2019 Mar 18;11(3):655. https://doi.org/10.3390/nu11030655
Gay HC et al. Effects of Different Dietary Interventions on Blood Pressure: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Hypertension. 2016 Apr;67(4):733-9. https://doi.org/10.1161/HYPERTENSIONAHA.115.06853
Haber M et al. Preventing premature cardiovascular mortality: the role of lifestyle interventions and pharmacotherapy-a narrative review. Front Cardiovasc Med. 2025 Dec 8;12:1664802. https://doi.org/10.3389/fcvm.2025.1664802
Hajji-Louati M et al. Adherence to the Mediterranean and Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) Diets and Parkinson's Disease Incidence in Women: Results from the Prospective E3N Cohort. Ann Neurol. 2026 Jan 6. https://doi.org/10.1002/ana.78115
Haute Autorité de Santé. Prise en charge de l’hypertension artérielle de l’adulte. HAS, Saint-Denis la Plaine, 2016. https://www.has-sante.fr/jcms/c_2059286/fr/prise-en-charge-de-l-hypertension-arterielle-de-l-adulte
He FJ et al. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ. 2013 Apr 3;346:f1325. https://doi.org/10.1136/bmj.f1325
Heneghan JL et al. Adherence to the combined Mediterranean-dietary approaches to stop hypertension diet is shaped by neighborhood socio-economics and food environments. Health Place. 2025 Nov 30;97:103575. https://doi.org/10.1016/j.healthplace.2025.103575 
Kargin D et al. Experimental Outcomes of the Mediterranean Diet: Lessons Learned from the Predimed Randomized Controlled Trial. Nutrients. 2019 Dec 6;11(12):2991. https://doi.org/10.3390/nu11122991 Kesse-Guyot E et al.
Adherence to Mediterranean diet reduces the risk of metabolic syndrome: a 6-year prospective study. Nutr Metab Cardiovasc Dis. 2013 Jul;23(7):677-83. https://doi.org/10.1016/j.numecd.2012.02.005
Leone A et al. Mediterranean diet, Dietary Approaches to Stop Hypertension, and Pro-vegetarian dietary pattern in relation to the risk of basal cell carcinoma: a nested case-control study within the Seguimiento Universidad de Navarra (SUN) cohort. Am J Clin Nutr. 2020 Aug 1;112(2):364-372. https://doi.org/10.1093/ajcn/nqaa127
Li J et al. The MIND diet, brain transcriptomic alterations, and dementia. Alzheimers Dement. 2024 Sep;20(9):5996-6007. doi: 10.1002/alz.14062 Liweleya S et al. Mediterranean Diet as a Therapeutic Strategy for Hypertension and Cardiovascular Health. Int J Hypertens. 2025 Dec 3;2025:2369674. https://doi.org/10.1155/ijhy/2369674
Martínez-González MÁ et al. Effect of the Mediterranean diet in cardiovascular prevention. Rev Esp Cardiol (Engl Ed). 2024 Jul;77(7):574-582. https://doi.org/10.1016/j.rec.2024.01.006
Młynarska E et al. The Mediterranean Diet in Primary and Secondary Prevention of Coronary Heart Disease: Evidence and Mechanisms. Nutrients. 2025 Nov 20;17(22):3617. https://doi.org/10.3390/nu17223617
Qin P et al. Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) diet and cardiovascular disease and arrhythmias. BMC Med. 2025 Dec 2;24(1):13. https://doi.org/10.1186/s12916-025-04546-5
Sánchez-Taínta A et al. Adherence to a Mediterranean-type diet and reduced prevalence of clustered cardiovascular risk factors in a cohort of 3,204 high-risk patients. Eur J Cardiovasc Prev Rehabil. 2008 Oct;15(5):589-93. https://doi.org/10.1097/HJR.0b013e328308ba61
Shannon OM et al. Mediterranean Diet Increases Endothelial Function in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Nutr. 2020 May 1;150(5):1151-1159. https://doi.org/10.1093/jn/nxaa002
Storniolo CE et al. A Mediterranean diet supplemented with extra virgin olive oil or nuts improves endothelial markers involved in blood pressure control in hypertensive women. Eur J Nutr. 2017 Feb;56(1):89-97. https://doi.org/10.1007/s00394-015-1060-5
Walker ME et al. Associations of the Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay diet with cardiac remodelling in the community: the Framingham Heart Study. Br J Nutr. 2021 Dec 28;126(12):1888-1896. https://doi.org/10.1017/S0007114521000660
Yan F et al. Dose‒response relationships of DASH, Mediterranean, and AHEI dietary patterns with heart failure incidence: a systematic review and meta-analysis of cohort studies. Eur J Clin Nutr. 2025 Dec 19. https://doi.org/10.1038/s41430-025-01697-9
Yang L et al. Association between cMIND diet adherence and frailty among Chinese older adults: A 10-year longitudinal study. J Nutr Health Aging. 2025 Dec;29(12):100709. https://doi.org/10.1016/j.jnha.2025.100709
Youn JE et al. Association of Mediterranean, high-quality, and anti-inflammatory diet with dementia in UK Biobank cohort. J Nutr Health Aging. 2025 Jul;29(7):100564. https://doi.org/10.1016/j.jnha.2025.100564