Objective: To present the Mediterranean diet (MD) pyramid: a lifestyle for today. Design: A new graphic representation has been conceived as a simplified main frame to be adapted to the different nutritional and socio-economic contexts of the Mediterranean region. This review gathers updated recommendations considering the lifestyle, dietary, sociocultural, environmental and health challenges that the current Mediterranean populations are facing. Setting and Subjects: Mediterranean region and its populations. Results: Many innovations have arisen since previous graphical representations of the MD. First, the concept of composition of the 'main meals' is introduced to reinforce the plant-based core of the dietary pattern. Second, frugality and moderation is emphasised because of the major public health challenge of obesity. Third, qualitative cultural and lifestyle elements are taken into account, such as conviviality, culinary activities, physical activity and adequate rest, along with proportion and frequency recommendations of food consumption. These innovations are made without omitting other items associated with the production, selection, processing and consumption of foods, such as seasonality, biodiversity, and traditional, local and eco-friendly products. Conclusions: Adopting a healthy lifestyle and preserving cultural elements should be considered in order to acquire all the benefits from the MD and preserve this cultural heritage. Considering the acknowledgment of the MD as an Intangible Cultural Heritage of Humanity by UNESCO (2010), and taking into account its contribution to health and general well-being, we hope to contribute to a much better adherence to this healthy dietary pattern and its way of life with this new graphic representation.

Background: Nowadays the food production, supply and consumption chain represent a major cause of ecological pressure on the natural environment, and diet links worldwide human health with environmental sustainability. Food policy, dietary guidelines and food security strategies need to evolve from the limited historical approach, mainly focused on nutrients and health, to a new one considering the environmental, socio-economic and cultural impact—and thus the sustainability—of diets. Objective: To present an updated version of the Mediterranean Diet Pyramid (MDP) to reflect multiple environmental concerns. Methods: We performed a revision and restructuring of the MDP to incorporate more recent findings on the sustainability and environmental impact of the Mediterranean Diet pattern, as well as its associations with nutrition and health. For each level of the MDP we provided a third dimension featuring the corresponding environmental aspects related to it. Conclusions: The new environmental dimension of the MDP enhances food intake recommendations addressing both health and environmental issues. Compared to the previous 2011 version, it emphasizes more strongly a lower consumption of red meat and bovine dairy products, and a higher consumption of legumes and locally grown eco-friendly plant foods as much as possible.

Objective: To characterize the multiple dimensions and benefits of the Mediterranean diet as a sustainable diet, in order to revitalize this intangible food heritage at the country level; and to develop a multidimensional framework -the Med Diet 4.0 -in which four sustainability benefits of the Mediterranean diet are presented in parallel: major health and nutrition benefits, low environmental impacts and richness in biodiversity, high sociocultural food values, and positive local economic returns. Design: A narrative review was applied at the country level to highlight the multiple sustainable benefits of the Mediterranean diet into a single multidimensional framework: the Med Diet 4.0. Setting/subjects: We included studies published in English in peer-reviewed journals that contained data on the characterization of sustainable diets and of the Mediterranean diet. The methodological framework approach was finalized through a series of meetings, workshops and conferences where the framework was presented, discussed and ultimately refined. Results: The Med Diet 4.0 provides a conceptual multidimensional framework to characterize the Mediterranean diet as a sustainable diet model, by applying principles of sustainability to the Mediterranean diet. Conclusions: By providing a broader understanding of the many sustainable benefits of the Mediterranean diet, the Med Diet 4.0 can contribute to the revitalization of the Mediterranean diet by improving its current perception not only as a healthy diet but also a sustainable lifestyle model, with country-specific and culturally appropriate variations. It also takes into account the identity and diversity of food cultures and systems, expressed within the notion of the Mediterranean diet, across the Mediterranean region and in other parts of the world. Further multidisciplinary studies are needed for the assessment of the sustainability of the Mediterranean diet to include these new dimensions. Keywords Mediterranean dietSustainable diets Sustainable food systems Public health nutrition Food security and nutrition Sustainability

BackgroundThere is increasing evidence of the multiple effects of diets on public health nutrition, society, and environment. Sustainability and food security are closely interrelated. The traditional Mediterranean Diet (MD) is recognized as a healthier dietary pattern with a lower environmental impact. As a case study, the MD may guide innovative inter-sectorial efforts to counteract the degradation of ecosystems, loss of biodiversity, and homogeneity of diets due to globalization through the improvement of sustainable healthy dietary patterns. This consensus position paper defines a suite of the most appropriate nutrition and health indicators for assessing the sustainability of diets based on the MD.MethodsIn 2011, an informal International Working Group from different national and international institutions was convened. Through online and face-to-face brainstorming meetings over 4 years, a set of nutrition and health indicators for sustainability was identified and refined.ResultsThirteen nutrition indicators of sustainability relating were identified in five areas. Biochemical characteristics of food (A1. Vegetable/animal protein consumption ratios; A2. Average dietary energy adequacy; A3. Dietary Energy Density Score; A4. Nutrient density of diet), Food Quality (A5. Fruit and vegetable consumption/intakes; A6. Dietary Diversity Score), Environment (A7. Food biodiversity composition and consumption; A8. Rate of Local/regional foods and seasonality; A9. Rate of eco-friendly food production and/or consumption), Lifestyle (A10. Physical activity/physical inactivity prevalence; A11. Adherence to the Mediterranean dietary pattern), Clinical Aspects (A12. Diet-related morbidity/mortality statistics; A13. Nutritional Anthropometry). A standardized set of information was provided for each indicator: definition, methodology, background, data sources, limitations of the indicator, and references.ConclusionThe selection and analysis of these indicators has been performed (where possible) with specific reference to the MD. Sustainability of food systems is an urgent priority for governments and international organizations to address the serious socioeconomic and environmental implications of short-sighted and short-term practices for agricultural land and rural communities. These proposed nutrition indicators will be a useful methodological framework for designing health, education, and agricultural policies in order, not only to conserve the traditional diets of the Mediterranean area as a common cultural heritage and lifestyle but also to enhance the sustainability of diets in general.