Peripheral Arterial Disease, Cardiovascular Risk and Mediterranean diet


Demosthenes Panagiotakos1, DrMedSci, Christina Chrysohoou2, MD, PhD, Katherine Esposito3, MD, PhD, and Dario Giugliano3 MD, PhD


1Department of Nutrition and Dietetics, School of Health Science and Education, Harokopio University, Athens, Greece

2First Cardiology Clinic, School of Medicine, University of Athens, Greece

3Department of Experimental Medicine and Experimental Medicine, Second University of Naples, Naples, Italy

4Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging Second University of Naples, Naples, Italy


The prevalence of Peripheral arterial disease (PAD) which refers to the obstruction of large arteries of the body is estimated to be around 12-14% in the general population and increases up to 20% of those over 70 years old. It is of interest that 70-80% of affected individuals are asymptomatic and only a minority requires revascularisation or amputation. Major risk factors of PAD are smoking, physical inactivity, dyslipidemias, hypertension, diabetes, and, consequently, the metabolic syndrome (MetS). Since the early 1990s, studies revealed the association between PAD and mortality from cardiovascular disease (CVD). Diet has long been investigated in relation to cardiovascular disease (CVD) risk and its major risk factors, like dyslipidemia, hypertension, diabetes, as well as the MetS. A recent systematic search of the literature based on 15 relevant observational studies that evaluated the direct effect of diet on CVD risk reported that the attributable risk of an unhealthy dietary pattern varies from 9 - 37%.

            The Mediterranean diet is one of the most known and studied dietary patterns in relation to human health. This traditional dietary pattern is characterized by daily consumption of olive oil, fruits and vegetables, non-refined grains and dairy products, as well as weekly consumption of fish and poultry, potatoes, olives, nuts and legumes, and monthly consumption of red meat. Another major characteristic of this dietary pattern is the moderate consumption of alcohol, mainly wine (1-2 glasses/day), usually with meals. However, it should be acknowledged that although the dietary patterns that prevail in the wider Mediterranean region share many common characteristics, the macronutrient distribution varies from area to area. Nevertheless, studies from the Mediterranean region, as well as from other parts of the world strongly support the cardioprotective role of this dietary pattern, mainly through its beneficial role on cardiometabolic markers, and particularly due to its antioxidant and anti-inflammatory effects. Despite the large body of evidence regarding Mediterranean diet and CVD mortality and morbidity, the role of this traditional dietary pattern on PAD risk has rarely been studied. Very recently, Miguel Ruiz-Canela et al., in a randomized trial conducted from October 2003 and December 2010 in Spain, assessed the association between Mediterranean diet and the occurrence of symptomatic PAD, in 7,477 participants with type 2 diabetes mellitus or at least 3 cardiovascular risk factors, aged 55 to 80 years and without clinical PAD or baseline CVD. Participants were randomized to the following groups: a Mediterranean diet supplemented with extra-virgin olive oil; a Mediterranean diet supplemented with nuts; or counseling on a low-fat diet (control group). All participants received a comprehensive dietary educational program on a quarterly basis. Both Mediterranean diet intervention groups were associated with lower risk of PAD compared with the control group. A mechanistic hypothesis of the beneficial effect of Mediterranean diet on PAD may be due its pleiotropic beneficial effects on endothelial function, arterial blood pressure, lipids and glucose levels. In a recent Editorial by Chrysohoou et al., it was highlighted based on previous studies that greater adherence to the Mediterranean diet had a strong, protective role against PAD in patients with type 2 diabetes mellitus, whereas the use of saturated fat increased the risk of PAD even in those patients who were regularly consuming olive oil. Moreover, others observed that long-term effects of exercise and Mediterranean diet intervention may benefit vascular function, even in older healthy people. In another study, Rallidis et al., reported that the Mediterranean diet reduced endothelial damage and improved its regenerative capacity in individuals with abdominal obesity, both factors that may promote the development of PAD. Diabetes is a major factor for PAD development; there are findings supporting that Mediterranean diet has beneficial effects against the development of diabetes, mainly due to the overall antioxidant profile of the diet that may suspend oxidative stress accumulation, which mediates the development of insulin resistance and β-cell dysfunction, as well as the moderate alcohol consumption, that characterizes this dietary pattern, and has been associated with enhanced insulin sensitivity, possibly through changes in adiponectin or High Density Lipoprotein (HDL) cholesterol levels. Taking into account that the management of PAD should not be restricted only to the peripheral circulation, but should include measures to manage and decrease the systemic atherosclerotic burden of the people, factors that promote healthy living, like adherence to the Mediterranean diet, should accompany general recommendations for PAD prevention. However, and despite the findings from numerous studies, there is no doubt that the Mediterranean diet is being progressively lost, especially in the younger generations. To prevent the diet of our ancestors, immediate actions are needed by everyone, but especially from public health policy makers, in order to preserve the wisdom hidden in this traditional dietary pattern. 




Chen Q, Shi Y, Wang Y, Li X. Patterns of Disease Distribution of Lower Extremity Peripheral Arterial Disease. Angiology. 2014 Mar 19. [Epub ahead of print]

Chrysohoou C, Esposito K, Giugliano D, Panagiotakos DB. Peripheral Arterial Disease and Cardiovascular Risk: The Role of Mediterranean Diet. Angiology. 2014 Oct 28. pii: 0003319714556651.

Chrysohoou C, Panagiotakos DB, Pitsavos C, Das UN, Stefanadis C. Adherence to the Mediterranean diet attenuates inflammation and coagulation process in healthy adults: The ATTICA Study. J Am Coll Cardiol. 2004;44(1):152-158.

Ciccarone E, Di Castelnuovo A, Salcuni M,  et al; Gendiabe Investigators. A high-score Mediterranean dietary pattern is associated with a reduced risk of peripheral arterial disease in Italian patients with Type 2 diabetes. J Thromb Haemost. 2003;1(8):1744-1752.

Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326(6):381–386.

Esposito K, Marfella R, Ciotola M, et al. Effect of a Mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomized trial. JAMA. 2004;292(12):1440-1446.

Georgousopoulou EN, Pitsavos C, Yannakoulia M, Panagiotakos DB. The role of dietary patterns' assessment in the predictive ability of cardiovascular disease risk estimation models: a review. Int J Food Sci Nutr. 2014;65(1):3-8.

Hamalainen H, Ronnemaa T, Halonen JP, et al. Factors predicting lower extremity amputations in patients with type 1 or type 2 diabetes mellitus: a population-based 7-year follow-up study. J Intern Med. 1999;246(1):97–103.

Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol. 2011;57(11):1299-1313.

Katsiki N, Tziomalos K, Mikhailidis DP. Alcohol and the Cardiovascular System: a Double-Edged Sword. Curr Pharm Des. 2014 Jun 20. [Epub ahead of print]

Keys A, Menotti A, Karvonen MJ, et al. The diet and 15-year death rate in the seven countries study. Am J Epidemiol. 1986;124(6):903-915.

Klonizakis M, Alkhatib A, Middleton G. Long-term effects of an exercise and Mediterranean diet intervention in the vascular function of an older, healthy population. Microvasc Res. 2014;95C:103-107.

Koloverou E, Esposito K, Giugliano D, Panagiotakos D. The effect of Mediterranean diet on the development of type 2 diabetes mellitus: a meta-analysis of 10 prospective studies and 136,846 participants. Metabolism. 2014;63(7):903-911.

Maksimovic M, Vlajinac H, Marinkovic J, Kocev N, Voskresenski T, Radak D. Health-Related Quality of Life Among Patients With Peripheral Arterial Disease. Angiology. 2013;65(6):501-506.

Marín C, Yubero-Serrano EM, López-Miranda J, Pérez-Jiménez F. Endothelial aging associated with oxidative stress can be modulated by a healthy Mediterranean diet. Int J Mol Sci. 2013;14(5):8869-8889.

Panagiotakos DB, Chrysohoou C, Pitsavos C, Stefanadis C. Association between the prevalence of obesity and adherence to the Mediterranean diet: the ATTICA study. Nutrition. 2006;22(5):449-456.

Panagiotakos DB, Pitsavos C, Matalas AL, Chrysohoou C, Stefanadis C. Geographical influences on the association between adherence to the Mediterranean diet and the prevalence of acute coronary syndromes, in Greece: the CARDIO2000 study. Int J Cardiol. 2005;100(1):135-142.

Paraskevas KI, Mukherjee D, Whayne TF Jr. Peripheral arterial disease: implications beyond the peripheral circulation. Angiology. 2013;64(8):569-571.

Rallidis LS, Lekakis J, Kolomvotsou A, et al. Close adherence to a Mediterranean diet improves endothelial function in subjects with abdominal obesity. Am J Clin Nutr. 2009;90(2):263-268.

Ruiz-Canela M, Estruch R, Corella D, Salas-Salvadó J, Martínez-González MA. Association of Mediterranean Diet with Peripheral Artery Disease. JAMA. 2014;311(4):415-417.

Shammas NW. Epidemiology, classification, and modifiable risk factors of peripheral arterial disease. Vasc.. Health.. Risk Manag. 2007;3(2):229-234.

Tyrovolas S, Bountziouka V, Papairakleous N, et al. Adherence to the Mediterranean diet is associated with lower prevalence of obesity among elderly people living in Mediterranean islands: the MEDIS study. Int J Food Sci Nutr. 2009;60(Suppl 6):1-14.

UNESCO (2010). Representative List of the Intangible Cultural Heritage of Humanity. culture/ich/en/RL/00394 (accessed September 2014).

Willett WC, Sacks F, Trichopoulou A, et al. Mediterranean diet pyramid: a cultural model for healthy eating. Am J.Clin Nutr. 1995;61(6 Suppl):1402S-1406S.


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