1. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Report of he MGSD Nutrition Study B. Karamanos MD Associate Professor of Medicine 10 th Meeting of the MGSD 27 April 2007 Istambul

2. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 15 year mortality % in the 7 Country Study AreaN All cause CHD Non CHD Non Mediter ranean 2701216.614 Mediter ranean 3506162.813 Keys et al Am J Epidemiol 124:903, 1986

3. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Diet and 15 year mortality 7 – country study SAFAPositivePUFANull MUFANegativeProteinNull MUFA/SAFANegativeCHONull Keys et al Am J Epidem 124:903, 1986

4. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007

5. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007

6. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Change in Mortality after a two point increment in the Mediterranean Diet Score MortalityHRCI Total0.750.64 – 0.87 CVD0.670.47 – 0.94 Cancer0.760.59 – 0.98 NEJM 348:2599, 2003

7. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Fat intake g/day in Nicotera, Italy 19601996 Males67117 Females51119

8. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007

9. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Comparison of the Dietary Questionnaire with the 3-Day Diet Diary Questionnairep3-Day Diet Diary Energy Kcal/day 1897NS1791 CHO g/day2070.01179 Prot g/day83NS80 Fat g/day79NS81

10. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Comparison of the Dietary Questionnaire with the 3-Day Diet Diary Questionnairep3-Day Diet Diary Animal Fat35NS35 Plant Fat41NS43 Cholesterol263NS263 Fibre g/day210.0116

11. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Subjects studied 4254 MalesFemalesTotal Normals9169171833 Diabetics9139841897 Total182919013730

12. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Obesity % in males and females without and with Diabetes AlgEgyI-PavI-RomGrBulgSerb M 7.5%3.715.221.630.419.2--- F 6.1%14.716.729.935.517.1--- M 9113532122827 F 2333464241 50 norm DM

13. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Conclusions The prevalence of obesity varies greatly among Mediterranean countries In diabetics does not reach the 80% reported in the literature

14. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Energy intake and % contribution of each nutrient to it (normals) AlgEgyI-PavI-RomGrBulg Energy274824223049182425453322 Protein%17.815.715.317.413.415.6 Fat%33.926.529.428.336.537.2 CHO%47.857.746.345.545.142.4

15. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Conclusions The prevalence of obesity varies greatly among Mediterranean countries In diabetics does not reach the 80% reported in the literature Diet composition varies greatly among countries

16. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 MGSD NormalDiabetic Kcal/day2654*1897 CHO %47.9*44.0 Fat %32.8*34.6 Prot %16.0*19.3 Fiber g/d22.2NS21.9

17. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Percentage of subjects who meet the Nutritional Recommendations of the DNSG. (normal & diabetic) AlgEgyI-PavI-RomGrBulgSerb Prot, CHO and Fat N 187324271210 DM 42412102220 All above and Fibre N 3425264 DM 21731118

18. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Mediterranean Diet Comparison of data from the 7 – country and MGSD studies. Greece BreadPotatoVegetFruitMeatCheeseMilk 19613801901914643513235 1996269471683548267153 1.Kromhout D. Am J Clin Nutr 49:889, 1989 2.Karamanos B. Eur J Clin Nutr 56:983, 2002

19. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Mediterranean Diet Score Plant /Animal Fat ratio Vegetables Alcohol ConsumptionMeat Legumes Dairy products Cereals Fruits Fish Score 0-9 Good > 5 BMJ 311:1457-60, 1995

20. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 MGSD g/dNormalDiabetic Bread219 * 170 Fish3234 Fruit325 * 266 Meat115124 Vegetables185 * 252 % Recomm3225 % MedDiet5836

21. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Conclusions The prevalence of obesity varies greatly among Mediterranean countries In diabetics does not reach the 80% reported in the literature Diet composition varies greatly among countries Nutritional recommendations and MD are followed by very few subjects, especially in diabetics

22. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Fat intake and Diabetes MGSD Study Unknown DMControls Fat %34.7 *30.4 Animal Fat % 14.2 **10.6 Thanopulou A. Diabetes Care 26:302, 2003 13.0 %34.0%

23. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Conclusions The prevalence of obesity varies greatly among Mediterranean countries In diabetics does not reach the 80% reported in the literature Diet composition varies greatly among countries Nutritional recommendations and MD are followed by very few subjects, especially in diabetics Fat intake is related with the incidence of diabetes

24. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Prevalence of the Metabolic Syndrome by country and in the population as a whole

25. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Prevalence of the Metabolic Syndrome by BMI category p<0,001

26. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Prevalence of the Metabolic Syndrome in the Mediterranean countries Observed (499 subjects) Expected (441 subjects) 27.223% p=0.03 24.036% OR=1.18 (CI 1.01-1.37)

27. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Metabolic Syndrome (NCEP-ATP III) Presence  3 of the following risk factors Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. Risk factorLevel Central Obesity Waist circumference Males Females >102 cm > 88 cm Triglycerides  150 mg% HDL-C Males Females <40 mg/dL <50 mg/dL Blood Pressure  130 /  85 mm Hg Fasting Glucose  110 mg%

28. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 DM2NORp W * HDL * BP30.1%14.2%1.8<0.001 Tg * HDL* BP27.9%27.9%11.7%2.3<0.001 W * Tg * BP23.3%7.2%2.8<0.001 W * Tg * HDL21.0%7.2%5.9<0.001 W * Tg * HDL * BP 17.6%5.2%3.9<0.001

29. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007 Conclusions The prevalence of obesity varies greatly among Mediterranean countries In diabetics does not reach the 80% reported in the literature Diet composition varies greatly among countries Nutritional recommendations are followed by very few subjects, especially in diabetics Fat intake is related with the incidence of diabetes The components of MetS cluster more frequently than expected by chance Diabetes per se promotes the clustering of the other 4 components of MetS

30. Diabetes Centre Hippokration Hospital Athens, Greece B. KARAMANOS 2007