Non capisco

Mediterranean diet is an oxymoron. I have met many an Italian or a Greek who will shudder at the word “diet”. But semantics aside, it is one of the most popular diet plans recommended for weight loss, diabetes and heart disease prevention. If you ask a random person on the street what the Mediterranean diet is, they will probably mention olive oil, fruits and vegetables and red wine. They might also remember cheeses, cured meats, salty preserves and rich yoghurts. But if you look at the Mediterranean diet food pyramid on the official MD website, you might get quite a shock.

Meat once a month? I think the Greeks and Italians might have missed that memo.

The story begins with Dr Ancel Keys, the father of lipophobia. In his famous Seven Countries Study which served as a basis for lipid hypothesis (and has since been thoroughly debunked by many experts) Keys brought attention to a tiny Greek island of Crete and the region of Southern Italy where people were beautiful, life expectancy long and heart disease almost non-existent. The survey of the Cretan diet revealed that they consumed little saturated fat. Aha! said Keys, because this confirmed his long-cherished hypothesis that saturated fat in the diet causes heart disease. The data from the Seven Countries Study was used to justify the anti-fat movement in America which was eventually sanctioned by the governments in the infamous McGovern Report in the 1977*. And we have been healthy and free of  heart disease and diabetes ever after.

Well, not quite.

 *For detailed description of the birth of the lipid hypothesis please read Gary Taubes’s ground-breaking article “Soft science of dietary fat” or, if you are brave enough, his impressive tome “GCBC”.

While the anti-fat coalition kept inventing new food substances like cardboard-tasting breakfast cereals and low-fat Snickers bars, the Mediterranean connection went unexplored for some time. It was revived in 1994 with the Lyon Diet Heart study. Heart attacks patients who followed the MD were had their risk of dying reduced as well as their risk of another heart attack, compared to patients on a usual “prudent” diet. It was very impressive, although I have a few issues with the study itself which I will address another time. After many studies trying to pinpoint the elusive magic ingredient behind the results (and you know what I think about magic ingredients), after resveratrol in red wine and antioxidants in olive oil, the vague consensus was finally reached: the protective power of the MD results from replacing saturated fats with polyunsaturated and monounsaturated ones.

This is the story so far. Let’s leave the biochemistry for later because I would like to start in the beginning.

The problem with the initial premise of the MD is that it is based on an observation. I have pretty awesome observational skills myself so here are some of my observations.

1. Anyone who has been to any of the 21 countries on the shore of the Mediterranean sea knows that there is no one Mediterranean diet. There is more in common between American and Australian diet, than between French and Greek.

2. While it is true that olive oil is used in Italy, Greece and Crete, the French preferentially use lard and butter, enjoying (wouldn’t you?) one of the highest saturated fat intake levels in the world. They also have the second lowest incidence of heart disease after Japan.

3. While fish is a popular part of the menu on the coast, salmon (the number one fish on any dieter’s menu) is not even native to the Mediterranean sea.

4. Wholegrains do not traditionally provide the bulk of the carbohydrate requirements on this diet.

Here is a description of Cretan agriculture:

The cultivation of the olive tree  is very important in Crete and excellent virgin olive oil is produced here. Other important products include oranges, grapes and vegetables from greenhouses. Honey, cheese and herbs are of excellent quality also. Finally, big numbers of sheep and goats are raised in Crete.

From Wikipedia:

As in many regions of Greece, viticulture and olive groves are significant; oranges and citrons are also cultivated. Until recently there were restrictions on the import of bananas to Greece, therefore bananas were grown on the island, predominantly in greenhouses. Dairy products are important to the local economy and there are a number of speciality cheeses such as mizithra, anthotyros, and kefalotyri.

And another one:

Another occupation for quite a few Cretans is fishing. Although the quantity of fish in Crete is limited the quality is generally very good.

Somehow I don’t see a lot of wholegrains. In case you think that they might be importing it, here is the link with the top 43 wheat importers in the world. Greece (and Crete) are not on the list. In case you are wondering, the US is at number 10.

4. High polyunsaturated/low saturated fat intake doesn’t stop Israel from having high prevalence of heart attacks and diabetes (so called Israeli paradox).

5. Italy, the Mediterranean country famous for it breads, pasta and cereals, also enjoys a dubious honour of having one of the highest rates of celiac disease in the world, closely following Ireland.

6. Fast forward to 50 years later and countries like Italy still enjoy their olive oil, fruits and vegetables, red wine and sourdough. In addition they also have higher activity levels than Australians, higher vitamin D levels (extra cardioprotection), lower stress levels and stronger family ties. All factors  which are supposed to ensure long and healthy life.

Here is a kicker.

Their life expectancy is now the same as for Australians: 79 for men and 84 for women.

OK, maybe they die at the same time, but maybe we have better treatments for infectious disease and less accidents? Actually, according to the WHO mortality figures, more Italians die of non-communicable diseases than Australians. Non-communicable diseases are the chronic diseases which kill you slowly: diabetes, cancer, heart disease.

Here is a mortality chart for Italy. (The picture quality is not great but you can follow the link above and select your country of interest in NCD profile)

Proportional mortality in males. Italy

Here is a mortality chart for Australia.

Proportional mortality in males. Australia

Yes, Europeans sure do smoke a lot. But their smoking rates have actually dropped in the last 50 years. So I doubt that it would explain their not-so-great performance in the health stakes. Could it…possibly…be…the increasing consumption of Western-style low-fat industrial garbage together with flour and sugar? No, of course not, it must be the fat.

As with any diet of any nation on Earth, there have to be protective factors and harmful factors. When you look at the Mediterranean factors how do you know which is which? Imagine a world where smoking is considered good for your health and vegetables are considered evil. If you then apply this reasoning to the Mediterranean lifestyle, it still works! All these vegetables are putting them at risk for a massive heart attack, thank goodness they smoke. Have you been naughty and had a cauliflower binge? Don’t forget to light up your Marlboros.

To demonstrate a perfect example of this backwards thinking, here is the American Heart Association view on the MD.

Mediterranean-style diets are often close to our dietary  recommendations, but they don’t follow them exactly. In general, the  diets of Mediterranean peoples contain a relatively high percentage of  calories from fat. This is thought to contribute to the increasing  obesity in these countries, which is becoming a concern.

So the traditional diets of the Mediterranean were higher in fat than in the US, the people in the region were slimmer than in the US, but their growing obesity is caused by their levels of dietary fat?

What happens when you combine the lipid hypothesis with a diet from a few carefully selected locations with cherry-picked ingredients?

Big picture, please

No science today, folks. Just a good old rant.

It’s the evening rush in a city gym. A 20-something personal trainer with biceps bulging out of his sleeves is leading a middle-aged woman into a designated PT area. This is clearly her first time here. She is wearing the world’s biggest t-shirt, nervously tugging it down to the knees, looking flushed already from going up the stairs. The PT pulls out a funny-looking half ball and gestures her to come to a push up position. She obediently kneels down on the ground, places her hands on the flat part of the ball, hikes her hips high into the air, lifts her knees off the ground and promptly starts to shake all over. Two seconds later she collapses back down and the PT kindly encourages her to come up again. The second time she works out that she can take her feet wider and this time she stays up but her whole body is shaking uncontrollably from the wrists to the pelvis. I mentally shoo away the image of her falling flat on her face and breaking her nose. Her PT enthusiastically announces that she will be doing 3 sets of 12 push ups with one leg in the air and this is “great for her shoulder stability and core muscles”.

Oh my…

It’s a no-brainer that a 40-something overweight de-conditioned woman should be first building her base strength and fitness. Maybe wall push-ups and half-squats would be a good place to start. Seems like a common sense approach. Then again common sense is not very common.

Similar approach is used in health and nutrition on a regular basis. I love berries. But if I hear of another berry which has been found to reduce inflammation/fight cancer/bring about world peace, I swear I will lose it. A quick browse through a popular bodybuilding magazine reveals that apparently honey has antibacterial properties and lycopenes in tomatoes are good for prostate health. How many times have you seen a woman (not to be a sexist or anything, but it is normally a woman) standing near the fridge with a frozen meal in each hand earnestly comparing the nutrient composition? Hmmm… This one has more antioxidants, and this one has more protein. Which one of these highly processed refined carb-loaded artificial nutrient- fortified examples of food manufacturing science is better for me?

Talking about food manufacturers, they bit down on this concept very quickly. Every commercial is quick to point out that one magic ingredient which makes their product essential for health.

Food “reductionism” has been rife in health and nutrition for a long time. It’s as if the elusive search for gold in alchemy has morphed into its modern scientific equivalent.

Spag Bol is Italian. Italy is in the Mediterranean. The Mediterranean diet is healthy. Ergo: spag bol is healthy

The Mediterranean diet is a common example. After we have successfully promoted red wine into a health food category (no objections here) with resveratrol, we found another magic component which mitigates the unhealthy saturated fat levels in the diets of the a French, Spanish, Italians and Greeks: polyunsaturated fatty acids. Actually, the studies talked about omega-3 polyunsaturated fats but omega-6 is riding along on the wave of a sudden “omega” popularity. The market reacted instantaneously. Olive oil, being holier than thou, is now used in spreads, frozen meals, tuna cans, body butter and strangely enough, perfume. I will talk about the Mediterranean diet another day but Stephan from Whole Health Source did a good analysis of the famous Lyon Diet-Heart Study which started the whole craze.

I am sorry to say it but even some well educated people in the primal/Paleo community fall into this trap. I have read many a forum where a question from a newbie turns into a heated discussion: is white potato Paleo? What about nectarines, since they are technically a new breed of fruit? What’s the best ratio of DHA/EPA in my fish oil? Am I doomed if I can’t source grass-fed beef?

There is nothing wrong with wanting perfection in your diet. And if you have that much time and energy to devote to your diet, that’s great. If you choose to count your calories, I think you are wasting precious brain power, but whatever floats your boat. However, let’s not forget that the majority of people are still buying banana bread because it contains fruit. And if you are one of them, no amount of blueberries is going to fix that damage.

I’m a visual kind of person so to make things easy I’ve designed a little pie chart representing how the majority of the community (as I know it) sees nutrition.

Food attitudes in modern society. Source: Anastasia's extensive life experience

“Disinterested Rebels” are the ones who are happily chugging away the pizzas and the burgers washed down by liters of Coke. They don’t care about heart disease, cholesterol or getting a beer gut. I nominated the 20% figure because the smoking prevalence in Australia is 19%. And if you are still smoking it’s pretty safe to say you are not terribly concerned about living.

“Endeavouring Hopefuls” are the concerned consumers, representing the majority of the population. They listen to the nutrition guidelines, buy diet magazines and are the main marketing targets for low-fat muffins and diet sodas.

Major Healthnuts” take their health and diet very seriously. They painstakingly research the nutritional benefits of every mouthful. They are the organics, the fruitarians, paleos, vegans, raw foodists…They also tend to have a firm unwavering belief that their way is the only right way and they will fight for it foaming at the mouth. If you receive this via an email subscription and follow numerous bloggers on Twitter and Facebook, congratulations, you belong to the last group. Welcome to the club.

The common term Standard American Diet can probably encompass the first 2 groups. And by the way, my American friends, you don’t have a patent on crap food, I think it’s time to change the term to SWD (Standard Western Diet). It doesn’t have the same punch as SAD but it accurately portrays that here is Australia we like our bagels and soda (aka soft drinks) too.

Bottom line: before splitting hairs about your macronutrient ratios and decanting cod liver oil by the millilitre, fix the BIG things that are wrong with your diet. Get rid of processed food. Period. Anything that comes in a box and has a Heart foundation tick should also be burned, just in case. I’m sorry, boys, protein shakes are never Paleo. If you need them, have them, just don’t lie to yourself.

Many smart people before me have identified 4 major components of the SWD which cause the most damage. Dr Kurt Harris has succinctly named them NADs (Neolithic Agents of Disease). They are wheat, fructose, industrial seed oils and soy. Until you eliminate these 4 you can stop worrying about dairy, legumes, nuts and rice. These are the only agents which truly fail the Framework of Common Sense.

And a word of advice: when your truck driver uncle Harry comes home from the doctor dejected because he was told to lose 20 kilos, don’t start a conversation about medium chain fatty acids. That would be the nutritional equivalent of one-legged BOSU ball push ups. Let’s get the “Disinterested Rebels” and “Endeavouring Hopefuls” off the NADs first.

In the world we live in, THIS is a healthy afternoon snack.