The effect of green Mediterranean diet on cardiometabolic risk; A randomised controlled trial

Gal Tsaban, Anat Yaskolka Meir, Ehud Rinott, Hila Zelicha, Alon Kaplan, Aryeh Shalev, Amos Katz, Assaf Rudich, Amir Tirosh, Ilan Shelef, Ilan Youngster, Sharon Lebovitz, Noa Israeli, May Shabat, Dov Brikner, Efrat Pupkin, Michael Stumvoll, Joachim Thiery, Uta Ceglarek, John T. HeikerAntje Körner, Kathrin Landgraf, Martin Von Bergen, Matthias Blüher, Meir J. Stampfer, Iris Shai

Research output: Contribution to journalArticlepeer-review

37 Scopus citations


Background A Mediterranean diet is favourable for cardiometabolic risk. Objective To examine the residual effect of a green Mediterranean diet, further enriched with green plant-based foods and lower meat intake, on cardiometabolic risk. Methods For the DIRECT-PLUS parallel, randomised clinical trial we assigned individuals with abdominal obesity/dyslipidaemia 1:1:1 into three diet groups: healthy dietary guidance (HDG), Mediterranean and green Mediterranean diet, all combined with physical activity. The Mediterranean diets were equally energy restricted and included 28 g/day walnuts. The green Mediterranean diet further included green tea (3-4 cups/day) and a Wolffia globosa (Mankai strain; 100 g/day frozen cubes) plant-based protein shake, which partially substituted animal protein. We examined the effect of the 6-month dietary induction weight loss phase on cardiometabolic state. Results Participants (n=294; age 51 years; body mass index 31.3 kg/m 2; waist circumference 109.7 cm; 88% men; 10 year Framingham risk score 4.7%) had a 6-month retention rate of 98.3%. Both Mediterranean diets achieved similar weight loss ((green Mediterranean -6.2 kg; Mediterranean -5.4 kg) vs the HDG group -1.5 kg; p<0.001), but the green Mediterranean group had a greater reduction in waist circumference (-8.6 cm) than the Mediterranean (-6.8 cm; p=0.033) and HDG (-4.3 cm; p<0.001) groups. Stratification by gender showed that these differences were significant only among men. Within 6 months the green Mediterranean group achieved greater decrease in low-density lipoprotein cholesterol (LDL-C; green Mediterranean -6.1 mg/dL (-3.7%), -2.3 (-0.8%), HDG -0.2 mg/dL (+1.8%); p=0.012 between extreme groups), diastolic blood pressure (green Mediterranean -7.2 mm Hg, Mediterranean -5.2 mm Hg, HDG -3.4 mm Hg; p=0.005 between extreme groups), and homeostatic model assessment for insulin resistance (green Mediterranean -0.77, Mediterranean -0.46, HDG -0.27; p=0.020 between extreme groups). The LDL-C/high-density lipoprotein cholesterol (HDL-C) ratio decline was greater in the green Mediterranean group (-0.38) than in the Mediterranean (-0.21; p=0.021) and HDG (-0.14; p<0.001) groups. High-sensitivity C-reactive protein reduction was greater in the green Mediterranean group (-0.52 mg/L) than in the Mediterranean (-0.24 mg/L; p=0.023) and HDG (-0.15 mg/L; p=0.044) groups. The green Mediterranean group achieved a better improvement (-3.7% absolute risk reduction) in the 10-year Framingham Risk Score (Mediterranean-2.3%; p=0.073, HDG-1.4%; p<0.001). Conclusions The green MED diet, supplemented with walnuts, green tea and Mankai and lower in meat/poultry, may amplify the beneficial cardiometabolic effects of Mediterranean diet. Trial registration number This study is registered under Identifier no NCT03020186.

Original languageEnglish
Pages (from-to)1054-1061
Number of pages8
Issue number13
StatePublished - 1 Jul 2021


  • cardiac risk factors and prevention
  • metabolic syndrome
  • obesity

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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