Does a Mediterranean Diet Reduce the Risk of Heart Disease in Women?

Key Points

• The Mediterranean diet could help reduce the chance of developing cardiovascular disease (CVD) in women.
• Many factors can contribute to developing heart disease.
• A large-scale, multi-year study suggested a link between a reduced rate of CVD and the Mediterranean diet.

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The Mediterranean diet may reduce the risk of cardiovascular disease (CVD) in women, suggests a first-of-its-kind study. Among the many risk factors that contribute to the development of CVD, diet is one of the most prominent and modifiable, according to experts.

What is cardiovascular disease?

Heart disease is a leading cause of death worldwide, according to the World Health Organization (WHO). It far outpaces other causes of death. Ischemic heart disease was responsible for 16 percent of global deaths.

It's the primary cause of death for 1 in 5 women in the United States, per the Centers for Disease Control and Prevention (CDC).

Cardiovascular disease is an umbrella term that refers to diseases of the heart and blood vessels, according to the WHO. The most common is coronary heart disease, a treatable but incurable condition often caused by plaque accumulation in the coronary arteries, according to the National Heart, Lung and Blood Institute.

The buildup can wholly or partially inhibit blood flow into the heart. Another type of heart disease, coronary microvascular disease (MVD), or small vessel disease, is most common in women and occurs when the heart's small blood vessels don't work as they should.

"The main factors for heart disease are diabetes, high blood pressure, high cholesterol and smoking," said Alexandra Kharazi, M.D., a cardiothoracic surgeon at Southern California Surgical in Chula Vista, California.

Other risk factors include but aren't limited to the following, according to the CDC:

• Excess weight
• Unhealthy diet
• Stress and depression
• Early age of the first period
• Early onset of menopause
• Polycystic ovary syndrome (PCOS)
• Pregnancy complications, including high blood pressure during pregnancy, gestational diabetes or preterm labor
• Race, as Black women are 60 percent more likely than white women to have high blood pressure

Women are 20 percent more likely than men to develop heart failure or die within five years of their first severe heart attack, indicated a 2020 study published in Circulation, the flagship publication of the American Heart Association (AHA).

Black women are even more likely to die of a heart attack at younger ages compared to white women, per the AHA.

There are multiple reasons why, said Mary Greene, M.D., a cardiologist with Manhattan Cardiology in New York City.

Women often have different symptoms than men, such as shortness of breath, exhaustion, nausea, or back or jaw pain. In part because most initial studies on heart disease exclusively involved men, doctors may dismiss or misdiagnose these symptoms, a 2018 report suggested.

Although heart disease affects women of all ages, it's particularly prevalent after menopause due to the protective effects of estrogen, Greene said. An older age of CVD onset can further raise the likelihood of an incorrect or delayed diagnosis, leading to more severe disease.

"When coronary artery blockages are caught early, the heart function is still preserved. We can intervene with a bypass and maintain the heart function," Kharazi said. "However, if the diagnosis is delayed, the decrease in blood flow downstream from the blockage often causes damaged heart muscle and decreased heart function, which may not be recoverable. At this point, the patient has heart failure, which could have been avoided."

What is the link between a lowered risk of heart disease and the Mediterranean diet?

Women who followed a Mediterranean diet had up to a 24 percent reduced risk of heart disease and a 23 percent reduced risk of death, a large-scale study suggested.

The meta-analysis, published in March 2023 in the journal Heart, examined 16 previous studies and separated data based on sex. Ample evidence has already established the diet's health benefits, but few studies have examined the effects on women.

By comparison, researchers found that men who followed the eating plan had a 22 percent lower risk of heart disease and a 23 percent lower risk of death.

"Diet plays a large role in preventing the development of heart disease," said Terry Simpson, M.D,, a Camarillo, California-based Mediterranean diet expert and advisor to ModifyHealth.

"In the original studies with the Mediterranean diet, they found people who ate a standard American diet had twice the rate of deaths from heart disease as those who ate the Mediterranean diet," Simpson said.

Previous research from France found that the Mediterranean diet was roughly 70 percent more effective at reducing heart disease risk than the French Prudent diet that is similar to the American Cardiac Diet, Simpson said.

People who have heart disease and adopt a Mediterranean-style diet have less risk of a second heart attack, according to a 2020 study published in PLOS One.

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How does the Mediterranean diet help keep your heart healthy?

All facets of the Mediterranean diet work together to promote heart health.

"Overall, the Mediterranean diet has a beneficial effect on heart health because it combines nutrient-dense plant-based foods, healthy fats, lean proteins and less processed food," Greene said.

The diet is low in saturated fat and high in monounsaturated healthy fats found in foods such as olive oil, sunflower oil, avocadoes, soy products, pumpkin seeds, fatty fish and many nuts, Simpson said.

These healthy fats are good for your heart and promote an increase in "good" HDL cholesterol and a decrease in "bad" LDL cholesterol, Kharazi said. The diet minimizes or eliminates red and processed meats that can raise LDL cholesterol.

Healthy fats, including omega-3 fatty acids, can benefit the heart due to many factors, according to the National Library of Medicine. They can:

• Reduce triglycerides, a type of fat in the blood
• Reduce the risk of developing an irregular heartbeat
• Slow the buildup of plaque, which can block the arteries
• Support blood vessel function
• Lower blood pressure slightly
• Reduce inflammation

"In addition, the diet is rich in legumes, fruits, whole grains and vegetables—all high in fiber," Simpson said. "Higher fiber makes blood sugar easier to control and decreases cholesterol."

Fresh produce provides abundant vitamins, minerals and antioxidants such as potassium and vitamin C, Greene said. These support heart health by lowering blood pressure, reducing inflammation and enhancing blood vessel function, among other benefits.

Lean proteins, including low-fat dairy products, beans and legumes, provide the vital amino acids that red meat lacks without excessive saturated fats, Greene said, noting that protein is essential for maintaining and repairing body tissues, including the heart.

What are the potential benefits of the Mediterranean diet?

"It is well-known for its health advantages and has been linked to a lower risk of developing a variety of chronic conditions," said Kayleen Eslinger, R.D.N., M.S., a dietician based in New York City.

Pregnant people who follow the nutrition plan may have a reduced risk of adverse pregnancy outcomes (APOs) such as preeclampsia and gestational diabetes, according to a large 2022 study.

Other research indicates that the plan can also benefit people with chronic diabetes. This is due to a number of factors, Eslinger said. One is the plan's high fiber content, which can help manage blood sugar levels. Another is its emphasis on healthy fats that can help control blood sugar while increasing insulin sensitivity.

This diet can help support weight loss and management, which may help people with diabetes and conditions such as polycystic ovary syndrome (PCOS), Eslinger said.

Research indicates the eating plan can support sexual and reproductive health, too. Omega-3 fatty acids may help with hormone regulation and alleviate menstrual symptoms.

One 2017 study suggested that women with metabolic syndrome and sexual dysfunction who adopted the diet experienced improved desire, arousal, lubrication, orgasm and satisfaction, and less pain, Simpson said.

What foods are allowed on the Mediterranean diet?

The Mediterranean diet is based on the typical dietary patterns of people who live on or near the Mediterranean Sea, Eslinger said. Diets native to places such as India, the Philippines and Norway have the same fundamental characteristics, according to Simpson.

These experts said plant-based foods comprise most of the Mediterranean diet food pyramid, followed by moderate amounts of natural dairy products and fish and poultry. The diet includes few or no highly processed foods or red meat.

Herbs and spices are typically used for seasoning, while salt is used sparingly, Eslinger said.

Examples of key foods in the Mediterranean diet include the following:

• Fruits
• Vegetables
• Whole grains
• Nuts
• Seeds
• Legumes
• Olive oil (ideally extra virgin)
• Herbs and spices

Other optional foods to be consumed in moderation include:

• Seafood, such as salmon, sardines and mackerel
• Poultry and eggs
• Dairy products
• Red wine

Mediterranean diet snacks may include the following items:

• Fruits, such as apples, oranges, grapes and berries
• Nuts and seeds, such as almonds, pistachios, sunflower seeds and walnuts
• Greek yogurt
• Hummus
• Olives
• Whole-grain crackers
• Tzatziki dip
• Hard-boiled eggs
• Roasted chickpeas

"These snacks adhere to the tenets of the Mediterranean diet and provide a variety of critical nutrients, such as fiber, healthy fats and protein," Eslinger said.

What foods are not allowed on the Mediterranean diet?

Nothing is forbidden, but Eslinger said the following are foods to limit or avoid in the Mediterranean diet:

• Red meat
• Highly processed and refined foods
• Added sugars (including high fructose corn syrup)
• Foods with saturated and trans fats, such as cheese, butter, bacon, frozen pizzas, commercial baked goods and margarine
• Sodium
• Sweetened beverages, such as soda and fruit juices with added sugar

Is the Mediterranean diet difficult to follow?

Most people find the Mediterranean diet fairly easy to stick to, Eslinger said. The following are some reasons why the diet is moderately simple to follow for many people:

• It prioritizes a wide range of delicious, nutrient-dense foods, making it easy to enjoy a variety of different cuisines and foods.
• There are no rigid guidelines or restrictions. It doesn't forbid any entire food categories but emphasizes consuming not-so-healthy foods in moderation.
• Foods are accessible and familiar. Most of the ingredients and foods can be found at local markets and grocery stores.
• It's flexible. Folks can customize their diet to suit their tastes and cultural contexts.

Adopting a new way of eating may be challenging for some people, especially if they are transitioning from a typical Western diet. In that case, try adding foods from one of the diet's main categories—vegetables, fruits and nuts, legumes, or whole grains—at a time, Simpson said.

Adding foods instead of taking things away is a different mindset that can make the plan easier to follow. For example, cooking a Mediterranean diet breakfast might mean adding asparagus and spinach to your omelet and using olive oil instead of butter in the pan.

The bottom line

The Mediterranean diet isn't a cure-all, but research indicates it can improve heart health and add other benefits, such as supporting your blood pressure and a healthy body weight.

"A Mediterranean diet or any comparable healthy eating pattern can improve health in a period of weeks to months when compared to the conventional Western diet," Eslinger said.

Consistency is important. So, too, are healthy habits such as regular exercise, stress management and keeping up with routine healthcare, including high blood pressure, heart disease and diabetes screenings.

"The most important thing is to stay involved in your health," Kharazi said.