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?

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23 thoughts on “Non capisco

  1. Wonderful expose of the so called Mediterranean Diet! Interesting about Italians and Celiac disease. I had not heard that, but it makes sense. I love it when the “experts” label anything that doesn’t fit their ideas as a paradox, as in the French Paradox and Israeli Paradox. There are no paradoxes in science, just data that disproves your hypothesis, but you clearly know that. Too bad the “experts” refuse to admit that.
    Too bad Ancel Keys didn’t look at the association between sugar consumption and heart disease in his 7 (6?) country study. He could have used all the other 15 countries and still found an association! How different might life be now?

    • Peggy, I think what he “discovered” was advantageous to many people. In the words of Tom Naughton: Follow the money.

  2. I asked a co-worker his thoughts on the high level of heart disease in Israel (I’m taking your word for it). His wife is a dietitian and he had just come from a vacation to Israel, so I was interested in his response. He said “probably stress”. Made sense to me. Could be a confounding variable.

    • Drew, I am sure that stress plays a role. At the same time there is evidence that too much of a good thing (polyunsaturated fat) is not good at all. My example merely exposes the pitfalls of observational evidence.

  3. What’s up with Japan being the highest importer of wheat?

    I didn’t think that the Japenese had a big tradition of eating wheat but I guess that’s changing.

    • Bizzare, isn’t it? I think you are right, Sarah, their eating patterns are also changing. And since they don’t grow wheat they have to import all of it.

  4. I love your sarcasm heaven help Port Macquarie I say…………..xxxxxx

  5. Anastasia I recall reading a study of some many years ago comparing the high fat consumption of Greeks and the low fat of the Japanese and yet both had low heart disease issues. Being of Med background and having travelleed there and even lived there for a some periods I did do my own assessment and comparison of diets.
    Greeks do consume fish 2-3 times a week. Most foods in the house are prpepared at home – therefore little by way of processed foods, and ready to TV dinners. Food consumption is often made up of several items – however you don’t eat too much of anything. The combination of foods provices a great variety of nutrition. Greeks eat little red meat due to costs of this type opf food – however they do consume pork and chicken regularly. They do regularly eat beans, and vegetables cooked and presented in many vaired ways. Extra virgin olive is a must in any Greek household.
    Greeks do not finish a meal with a dessert – they finish with fruit. Usually apple or orange. I read somewhere that fibre from these frutis often soaks up many fats before they enter the bodys system. This may not be correct. When Greeks snack they do so with dry roasted chickpeas, pumpkin and sunflower seeds. Not chocolates and lollies. There are sevearl issues to the Med diet that are not being discussed – variaties of foods, quantities, qualities, eating habits etc etc. The Olive oil issue is overdone although I believe there are huge benefits (many which we still don’t fully underdstand). I have a personal theory that the olive oil is treated down differently by the body than many other fats – just my theory, hopefully someone will come up with the science.
    Having watched Greeks avoid McDonalds etc for years – I now see they too have adopted the Western diet – in particular in the major cities. Both parents working etc etc has changed the dynamics of the house hold, and the eating habits – I suspect the changes to heart disease can be attributed somewhat to this. One important factor which seems to have been overlooked is stress. Greeks in the main maintain a rather relaxed lifestyle – making time for coffee with friends in the town squares. Everyday you will see goups of young and old walking around the squares or along foreshores of the local villages. These daily rituals I believe contribute greatly issue of heart diseas and healthy lifestyle. Sadly this is changing too – but for me the key to Med diet is about med lifestyle.
    Finally kids in Greece go to school for 5 hours and then have lunch at home, so they eat home cooked meals. As a 10 year old I was placed in an all day private school (rare in Greece) – our school did not have a tuck shop – no school did. Each child had to bring a metal container (similar to army canteen) with our food in it (always something home cooked). It was placed in a bainmarie and given to each of us at lunch time. Everyday it was a warm home cooked meal of your choice. Compare that to what is found in most lunch boxes and I believe you will find the answer to where bad eating in western countries start from.

    • Thank you Theo. Great insight into the Greek homelife. Your description varies markedly from the “official Mediterranean diet”. Clearly theirs is the inferior version. You’ve made me want to visit Greece.

  6. I lived in Israel for a few years, and one of the interesting things – while the fruits, vegetables, and meats are incredibly fresh, the Israelis LOVE synthetic snack foods and pitas. In fact, many of the “wheat party snacks” and other pre-packaged foods all have the warning of, “do not expose bag to sunlight.” Seriously.

    That may just have something to do with it…

    • Hi Robbie, I’ve never been to Israel, thanks for the insight. Out of interest: what happens when expose the bags to sunlight? A little worrying…

  7. The high incidence of celiacs in Italy is due to a higher awareness of the real incidence of the genetic predisposition in the population. In fact, research from Italy is beginning to change the perception of celiac disease and gluten intolerance in the U.S. and elsewhere. People in Italy with celiacs are diagnosed within a few days. In the U.S., it typically takes 10-15 years! It is an issue of physician awareness!

    • Hi Ann. I saw this awareness first hand when I was in Italy. Ordering a gluten free meal in a restaurant was a piece of cake (pun unintended) and while pizza and pasta are widely considered the staples of their diet, in fact it is a lot easier to find food that doesn’t contain wheat than it is in Australia or the US. I am not sure though we can blame all the incidence on higher diagnosis rates. It’s a chicken or the egg issue: more celiacs drive the awareness or the awareness identifies more celiacs?

  8. I just discovered your blog via Emily Dean’s. This is fantastic and I am so excited to know you’re here. Another voice of sanity — and a fun-to-read one too! Sending all my family and friends your way. All the best, Florence

    • I came to say the exact same thing. Also, as an Australian, it’s great to get an Australian perspective on these things. So keep up the good work. btw, are you familiar with David Gillespie’s work (another Australian). He argues it’s all about the sugar, and he might be right. I’ve heard others argue it’s all about the grains. They might be right, too. I don’t take chances, I’ve eliminated both. Cheers, Wozza.

  9. I found your blog today via Emily Deans. Also, as an Australian, it’s great to get an Australian perspective on these things. So keep up the good work. Btw, are you familiar with David Gillespie’s work (another Australian)? He argues it’s all about the sugar, and he might be right. I’ve heard others argue it’s all about the grains. They might be right, too. I don’t take chances, I’ve eliminated both. Cheers, Wozza

    • I knew you were an Aussie the second I saw your nickname :). Not familiar with David Gillespie, will look him up. I follow similar logic. As far as I’m concerned, grains and sugar are guilty until proven innocent. Welcome to the blog, good to have more Aussie followers.

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