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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.

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Ensuring Food Security (FS) for all citizens is a fundamental human right and policy for all countries. Dealing with Food Insecurity (FINS) is a challenge causing stress at many levels-national, household, and individual. The conceptual framework of the Sociotype has been developed as a summary ecological construct to organize the multiple, dynamic, reciprocal inputs from the environment that interact with the genotype to determine the expression of phenotypic behaviors such as coping with stress. The Sociotype ecological framework has three domains-Individual (intra-personal), Relationships (inter-personal, family and community), and Context (environment, national)-and their interactions determine an individual's resilience across the life trajectory from birth to old age. We have applied the principles of the Sociotype to classify both the stresses of, and the coping strategies to, FINS. The stresses of FINS may occur at any place along the FS pathway-Availability, Accessibility, Utilization, and Stability. The elicited coping responses may take place in one or more of the three Sociotype domains. The two processes are inter-related linearly with re-iterative feedback loops such that stress leads to coping responses that may or may not be adequate, thereby requiring modifications in the coping strategies until FS is regained. Resilience is considered to represent long-term coping strategies. The Sociotype framework is both a determinant of, and constant input to, building and strengthening resilience. However, the people with the most problems with FINS are rarely included in these discussions. They are the marginalized members of society: unemployed, homeless, displaced persons, special needs, elderly, single parents, mentally frail, and more. Applying the Sociotype ecological framework for coping with FINS stresses can allow better strategic planning for FS at national, household and individual levels and understanding the interactions between them to reach out to and help these sectors of the population.

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BACKGROUND: There 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. METHODS: In 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. RESULTS: Thirteen 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. CONCLUSION: The 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.

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The notion of the Mediterranean diet has undergone a progressive evolution over the past 60 years, from a healthy dietary pattern to a sustainable dietary pattern, in which nutrition, food, cultures, people, environment, and sustainability all interact into a new model of a sustainable diet. An overview of the historical antecedents and recent increased interest in the Mediterranean diet is presented and challenges related to how to improve the sustainability of the Mediterranean diet are identified. Despite its increasing popularity worldwide, adherence to the Mediterranean diet model is decreasing for multifactorial influences - life styles changes, food globalization, economic, and socio-cultural factors. These changes pose serious threats to the preservation and transmission of the Mediterranean diet heritage to present and future generations. Today's challenge is to reverse such trends. A greater focus on the Mediterranean diet's potential as a sustainable dietary pattern, instead than just on its well-documented healthy benefits, can contribute to its enhancement. More cross-disciplinary studies on environmental, economic and socio-cultural, and sustainability dimensions of the Mediterranean diet are foreseen as a critical need.

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OBJECTIVE: To position the concept of sustainability within the context of food security. DESIGN: An overview of the interrelationships between food security and sustainability based on a non-systematic literature review and informed discussions based principally on a quasi-historical approach from meetings and reports. SETTING: International and global food security and nutrition. RESULTS: The Rome Declaration on World Food Security in 1996 defined its three basic dimensions as: availability, accessibility and utilization, with a focus on nutritional well-being. It also stressed the importance of sustainable management of natural resources and the elimination of unsustainable patterns of food consumption and production. In 2009, at the World Summit on Food Security, the concept of stability/vulnerability was added as the short-term time indicator of the ability of food systems to withstand shocks, whether natural or man-made, as part of the Five Rome Principles for Sustainable Global Food Security. More recently, intergovernmental processes have emphasized the importance of sustainability to preserve the environment, natural resources and agro-ecosystems (and thus the overlying social system), as well as the importance of food security as part of sustainability and vice versa. CONCLUSIONS: Sustainability should be considered as part of the long-term time dimension in the assessment of food security. From such a perspective the concept of sustainable diets can play a key role as a goal and a way of maintaining nutritional well-being and health, while ensuring the sustainability for future food security. Without integrating sustainability as an explicit (fifth?) dimension of food security, today's policies and programmes could become the very cause of increased food insecurity in the future.

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OBJECTIVE: To present the Mediterranean diet as an example of a sustainable diet, in which nutrition, biodiversity, local food production, culture and sustainability are strongly interconnected. DESIGN: Review of notions and activities contributing towards the acknowledgement of the Mediterranean diet as a sustainable diet. SETTING: The Mediterranean region and its populations. SUBJECTS: Mediterranean populations. RESULTS AND CONCLUSIONS: The acknowledgement of the Mediterranean diet as a sustainable diet needs the development of new cross-cutting intersectoral case studies to demonstrate further the synergies among nutrition, biodiversity and sustainability as expressed by the Mediterranean diet for the benefit of present and future generations.

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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.

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The Forum on Mediterranean Food Cultures has the purpose to foster an interdisciplinary dialogue to acknowledge the underestimated role of the Mediterranean diet and of the Mediterranean food cultures for an effective sustainable development in the Mediterranean. It is addressed towards the achievement of food security and a broader nutritional well-being in the entire Mediterranean area. The Forum uses a creative approach for the development of community-based programmes to manage the emerging trend of childhood overweight and obesity, as well as to reduce the increasing erosion of the Mediterranean food cultural heritage.

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OBJECTIVE: As a qualitative problem solving method, to manage the accelerating phenomenon of overweight and obesity among children and adolescents as well as to promote the Mediterranean Diet and the diversity of the Mediterranean Food Cultures heritage, it is presented a creative interdisciplinary approach through art. DESIGN: Taking into account that young generations are becoming the highest majority of the consumer population in the Southern and Eastern Mediterranean countries, it is reported the artist practice and the creative community-based interdisciplinary experience of Plexus International, a network of artists and scientists of various nationalities and disciplines. SETTING: Mediterranean Region and International. SUBJECT: Young Populations. RESULTS: Through the Ark of the Well Being project, artists and scientists have collaborate together, promoting The 2005 Rome Call for a Common Action in the Mediterranean and raising more attention on the erosion of the cognitive capacities of young generations by hunger and malnutrition. CONCLUSIONS: A creative interdisciplinary approach was developed to transmit through art Mediterranean food culture with the aim to achieve a broader nutritional well being.

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