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  • Writer's pictureKenneth Civello, MD

Mediterranean Keto Diet

After researching the Keto diet over the last few weeks, I am comfortable recommending it for people looking to lose weight, or patients who have metabolic syndrome/ diabetes.

Many studies have found that ketogenic diets help to preserve muscle mass, reduce appetite, favor increased fat loss, promote a healthy cholesterol profile, lower blood pressure and show an improvement in blood levels of glucose and insulin (1).

Despite this, as a cardiologist, I still struggle with abandoning the Mediterranean diet since it is well known to be one of the healthiest diets we have studied. Longer lifespan, lower rates of coronary heart disease and certain cancers, improved cholesterol, reduced blood pressure, lower rates of diabetes, and obesity are all of the proven benefits of the Mediterranean diet.

I also have some reservations about recommending a Ketogenic diet when the primary fat is processed meats, such as bacon. Processed meats and red meat have been shown to promote coronary artery disease. I know this topic has zealots on both sides of the argument, but I think the mechanism of red meat contributing to coronary and peripheral artery disease is gaining some stronger evidence (2-4).

Recently, I came across an interesting study which I feel is a compromise between both dietary arguments. I use the word argument because it indeed can become an argument when you try to discuss a diet with someone who is a firm believer in a particular diet.

The study was called the A Spanish Ketogenic Mediterranean diet: a healthy cardiovascular diet for weight loss by Pérez-Guisado J, Muñoz-Serrano A, Alonso-Moraga published in Nutrition Journal (5).

It takes a page from both the Mediterranean diet and ketogenic diet.

The objective of the study was to determine the dietary effects of a Spanish Ketogenic Mediterranean Diet (SKMD) diet which was rich in olive oil, salad, fish and red wine. It looks at its impact on weight loss, glycemic control, blood pressure and lipid profile.

Overall Description of SKMD Diet

1. Virgin olive oil as the principal source of fat (a minimum of 30 ml of virgin olive oil)

2. Moderate red wine intake (Around 1-2 glasses of red wine)

3. Green vegetables, salads and low-carbohydrate vegetables as the primary source of carbohydrates (a maximum of 30 g of carbs)

4. Fish as the primary source of proteins (no limit).

If you want specifics participants were permitted to eat:

  1. Three portions of vegetables daily. Two portions of salad vegetables and one portion of low-carbohydrate vegetables (such as broccoli, cauliflower, cabbage, artichoke, eggplant, squash, tomato, and onion).

  2. Salad dressings allowed were: garlic, olive oil, vinegar, lemon juice, salt, herbs, and spices.

  3. The principal meal (breakfast, lunch, and dinner) had a minimum of 30 ml of olive oil distributed in 10 ml per meal.

  4. Red wine accompanied lunch and dinner (1-2 glasses a day).

  5. At least four days of the week all the types of fish (except swordfish and shark) were consumed. The other three days included meat, fowl, eggs, shellfish, and cheese.

  6. Trans fats (margarine and their derivatives) and processed meats with added sugar were not allowed.

  7. No more than two cups of coffee or tea and at least 3 liters of water were intake each day.

  8. Infusions and artificial sweeteners were allowed (saccharin, cyclamate, acesulfame, aspartame and sucralose).

Effects on Weight loss

The results of this study confirmed that the Spanish Ketogenic Mediterranean diet is an effective therapy for obesity without caloric restriction. There was an extremely significant (p < 0.0001) reduction in body weight (239 lb→ 208 lb), BMI (36.46 kg/m2→31.76 kg/m2)

Effects of the on cardiovascular parameters

The data presented in this study showed that the SKMD significantly decreases the total cholesterol, LDL (bad) cholesterol, triglycerides, Systolic Blood Pressure, Diastolic Blood Pressure and increases the level of HDL (Good) Cholesterol.

  • Systolic Blood Pressure (125.71 mmHg→109.05 mmHg)

  • Diastolic Blood Pressure (84.52 mmHg→ 75.24 mmHg)

  • Glucose (109.81 mg/dl→ 93.33 mg/dl)

  • Total cholesterol (208.24 mg/dl→186.62 mg/dl)

  • LDLc (114.52 mg/dl→105.95 mg/dl)

  • HDLc (50.10 mg/dl→54.57 mg/dl)

The benefits of this diet were very favorable for cardiovascular endpoints, and I feel it is a well-rounded diet which is keto-friendly but still provides healthy proteins, vegetables, red wine, and greens. It is important to remember that different diets can work on different people so when you start on a new diet keep in mind the number on the scale is not always what matters.

What matters is not just your weight. It is your cardiovascular health, so be sure you see a cardiologist or primary care doctor to measure your cholesterol and blood pressure to make sure things are trending in the right direction.


1. Pérez-Guisado J. Arguments In Favor Of Ketogenic Diets. Internet J Nutr Wellness. 2007;4:2.

2. Wang Z, Klipfell E, Bennett BJ, Koeth R, Levison BS, Dugar B, Feldstein AE, Britt EB, Fu X, Chung YM, Wu Y, Schauer P, Smith JD, Allayee H, Tang WH, DiDonato JA, Lusis AJ, Hazen SL. Gut flora metabolism of phosphatidylcholine promotes cardiovascular disease. Nature. 2011;472:57–63.

3. Koeth RA, Wang Z, Levison BS, Buffa JA, Org E, Sheehy BT, Britt EB, Fu X, Wu Y, Li L, Smith JD, DiDonato JA, Chen J, Li H, Wu GD, Lewis JD, Warrier M, Brown JM, Krauss RM, Tang WH, Bushman FD, Lusis AJ, Hazen SL. Intestinal microbiota metabolism of l‐carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med. 2013;19:576–585.

4. Tang WH, Wang Z, Levison BS, Koeth RA, Britt EB, Fu X, Wu Y, Hazen SL. Intestinal microbial metabolism of phosphatidylcholine and cardiovascular risk. N Engl J Med. 2013;368:1575–1584.

5.Pérez-Guisado J, Muñoz-Serrano A, Alonso-Moraga Á. Spanish Ketogenic Mediterranean diet: a healthy cardiovascular diet for weight loss. Nutrition Journal. 2008;7:30. doi:10.1186/1475-2891-7-30.

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