title: Challenges to the Mediterranean diet at a time of economic crisis.
abstract: The traditional Mediterranean diet (MD) is reportedly associated with lower risk of major chronic diseases and long considered to contribute to the reduced rates of cardiovascular and cerebrovascular events and to the highest life expectancy in adults who lived near the Mediterranean Sea. But despite its widely documented health benefits, adherence to this dietary pattern has been rapidly declining over the last decades due to a clear socioeconomic influence. The present review provides an overview of the evidence on the current major determinants of adherence to the Mediterranean diet, with a particular emphasis on Mediterranean Countries at a time of economic crisis; second it explores emerging socioeconomic inequalities in other domains of healthy dietary behaviours such as dietary variety, access to organic foods and food purchasing behaviour.
  
  
  
  According to ecological evidence, the Mediterranean Countries that used to have the highest adherence to the Mediterranean pattern in the Sixties, more recently experienced the greatest decrease, while Countries in Northern Europe and some other Countries around the world are currently embracing a Mediterranean-like dietary pattern. A potential cause of this downward trend could be the increasing prices of some food items of the Mediterranean diet pyramid. Recent evidence has shown a possible involvement of the economic crisis, material resources becoming strong determinants of the adherence to the MD just after the recession started in 2007-2008. Beyond intake, the MD also encourages increasing dietary diversity, while international dietary recommendations suggest replacing regular foods with healthier ones.
  
  
  
  Socioeconomic factors appear to be major determinants of the adherence to MD and disparities also hold for other indices of diet quality closely related to this dietary pattern.
authors.affiliation: Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli (IS), Italy.
authors.forename: M
authors.initials: M
authors.lastname: Bonaccio
authors.affiliation: Dept. Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain; CIBERobn, Instituto de Salud Carlos III, Madrid, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Bes-Rastrollo
authors.affiliation: Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli (IS), Italy.
authors.forename: G
authors.initials: G
authors.lastname: de Gaetano
authors.affiliation: Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli (IS), Italy. Electronic address: licia.iacoviello@neuromed.it.
authors.forename: L
authors.initials: L
authors.lastname: Iacoviello
mesh_terms: D000368:Aged; D000072001:Diet, Healthy / Q000191:economics* / Q000639:trends; D038441:Diet, Mediterranean / Q000191:economics*; D004435:Eating; D057172:Economic Recession / Q000639:trends; D005247:Feeding Behavior; D005260:Female; D005502:Food / Q000191:economics*; D058870:Food, Organic / Q000191:economics; D054624:Health Status Disparities; D006801:Humans; D007250:Inflation, Economic / Q000639:trends; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D064167:Recommended Dietary Allowances / Q000191:economics; D012959:Socioeconomic Factors; D013997:Time Factors
keywords: Cardiovascular and cerebrovascular diseases; Dietary diversity; Economic crisis; Food cost; Health disparities; Mediterranean diet; Organic foods; Socioeconomic status