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.
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.
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)
Here is a mortality chart for 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?