Monday, 6 May 2013

The Mediterranean Diet: a food fad or a recipe for healthy living?

Eating less, living longer ... a table for one in the mountain village of Koutouloufari in Crete (Photograph: Patrick Comerford)

Patrick Comerford

I am not the best person to recommend a diet to anyone – and there are some good reasons for saying that: I’m not a good cook, I’ve never followed a diet, I’m a picky eater because of my vegetarianism, my GP thinks I’m a little overweight and do not exercise enough, and forty years of a strict vegetarian diet have caused a severe B12 deficiency and damaged my joints.

But, despite all this, I enjoy eating out, especially on holidays, and most especially on holidays in Mediterranean countries such as Greece, Cyprus, Italy and Turkey. In fact, truth to tell, I enjoy eating out in this part of Europe too – in particular in Greek, Italian, Turkish and Lebanese restaurants.

So, despite my reluctance to even hint at sharing my food idiosyncrasies, you can imagine my smug feelings when I came across a report a few weeks ago that claims eating a Mediterranean Diet rich in either extra-virgin olive oil or nuts cuts by 30% the risk of death from heart attacks and strokes.

The findings, published online by the New England Journal of Medicine, offer hope to people who are in danger of a heart attack or stroke because they smoke, who have type-2 diabetes or who exhibit other unhealthy characteristics.

The study also confirms that the diet common in southern European countries such as Greece, Spain and Italy, which involves consuming a lot of fruit, vegetables, fish and wine, and only small amounts of red meat or dairy products, offers protection against heart problems.

The trial results

Real food is not fast food ... the boast of restaurant in Aghios Nikolaos in Crete (Photograph: Patrick Comerford)

“The results of our trial might explain, in part, the lower cardiovascular mortality in Mediterranean countries than in northern Europe or the United States,” the authors conclude. The risk of those on the diet having a stroke was significantly reduced, they found.

Spanish researchers, led by Professor Ramon Estruch if Barcelona University, studied 7,447 men aged 55 to 88 and women aged 60 to 80 between 2003 and 2009.

Eating out in the sunshine in Tuscany (Photograph: Patrick Comerford)

None of the men in the study had any cardiovascular disease when they enrolled, but all were at risk of it because they had type-2 diabetes or had at least three risk factors from a list that includes:

● smoking;
● high blood pressure;
● high levels of bad cholesterol in their blood;
● low levels of healthy cholesterol;
● being overweight;
● a family history of coronary heart disease.

The participants either followed a Mediterranean Diet in which they had to eat four tablespoons of extra-virgin olive oil each day or another version of the diet in which they had to eat about an ounce a day of walnuts, almonds and hazelnuts.

These two groups were also told to eat fruit three times a day, vegetables twice daily, fish as well as beans, peas and lentils at least three times a week, and have seven glasses of wine a week with their meals. The third group followed a low-fat diet.

When the participants were examined an average of 4.8 years later, 228 had suffered a heart attack or stroke or died of heart problems – 96 occurred in the group with the diet that was heavy in olive oil (3.4% of participants), 83 among those eating a lot of nuts (3.4%), and 109 in the low-fat group (4.4%).

These results correspond to a drop in risk of 30% for those on the Mediterranean Diets compared with the low fat diet.

The key components of those diets that improve the risk of survival include moderate consumption of ethanol, from the wine, low consumption of meat and meat products, and a high intake of vegetables, fruit, nuts, legumes, fish and olive oil, they said.

Dining in a shady, quiet corner of Athens (Photograph: Patrick Comerford)

The researchers were so impressed with the Mediterranean Diet’s benefits that they all began following it.

“This large long-term study shows that eating a Mediterranean diet is associated with heart health benefits, including reductions in heart attack, stroke and deaths from cardiovascular disease,” Dr Mike Knapton, associate medical director of the British Heart Foundation, told the Guardian.
It seems that in the daily barrage of conflicting health advice, one theme stands out – eat a Mediterranean Diet, and you will live a longer, healthier life. Other studies claim the Mediterranean Diet reduces childhood asthma, hay fever and Alzheimer’s or that it can halve the risk of serious lung disease.

What part of the Med?

A Greek salad and a glass of wine (Photograph: Patrick Comerford)

It is worth asking why people who live in the Mediterranean have low rates of skin cancer, which is widely believed to be caused by over-exposure to solar UV radiation. For example, the incidence of melanomas in Mediterranean countries may be lower than in Northern Europe and significantly lower than in other hot countries such as Australia and New Zealand. Is it possible that some elements of the Mediterranean diet provide protection against skin cancer?

A study published in the Archives of General Psychiatry also claims that people who follow the Mediterranean Diet are less likely to develop depression.

A table for two in Crete (Photograph: Patrick Comerford)

But there are 21 different countries on the shores of the Mediterranean. So where is this Mediterranean Diet to be found? Spain? Southern France? Italy? The Greek islands? Turkey? Lebanon?

In 2010, UNESCO recognised the Mediterranean Diet pattern as an “Intangible Cultural Heritage” of Italy, Greece, Spain and Morocco.

But, despite its name, this diet is not typical of all Mediterranean countries. In Northern Italy, for example, lard and butter are commonly used in cooking, while olive oil is reserved for dressing salads and cooked vegetables. Muslims in North Africa traditionally avoid wine.

Of course, our images of the Mediterranean Diet are not based on a shared reality. Matthew Fort, author of Eating Up Italy: Voyages on a Vespa, says that in southern Italy, southern Spain and Sicily pig fat is used in cooking, while mutton fat is used in North Africa.

Nor does the Mediterranean Diet come from some fashionable food fad. At one time, poverty forced people in Mediterranean countries to rely on vegetables, pulses and cheap fish. Now there is more money, there is more meat, more fat and more obesity.

Ready for dinner .at Lychnos in Piskopiano, Crete (Photograph: Patrick Comerford)

Perhaps what we call the “Mediterranean Diet” is merely a short-hand for an ideal. But all food writers agree that the Mediterranean Diet is a lighter type of eating. More food is grilled rather than fried, there are plenty of vegetables, especially tomatoes, fish that is low in fat and, of course, olive oil – and this latest study recommends four spoonfuls of olive oil a day.

Olive oil is an essential ingredient in the Mediterranean Diet (Photograph: Patrick Comerford)

The Mediterranean Diet also emphasises plenty of exercise and recognises the importance of enjoying meals with family and friends. Although bread is an important part of the diet, throughout the Mediterranean bread is eaten plain or dipped in olive oil, and not with butter or margarines.

Discovering the Mediterranean Diet

Making fresh pasta in Chania in Crete (Photograph: Patrick Comerford)

Although the Mediterranean Diet failed to gain widespread recognition until the 1990s, a forerunner was first promoted in England by Giacomo Castelverto in A Brief Account of the Fruits, Herbs, and Vegetables of Italy (1614), when he tried but failed to convince the English to eat more fruits and vegetables.

It was only in 1945 that the Mediterranean Diet it was first publicised by Dr Ancel Keys from the University of Minnesota, who was then stationed in Salerno, Italy.

A Greek olive grove in the mountains of Crete (Photograph: Patrick Comerford)

Objective data about the benefits of the Mediterranean Diet first emerged in 1970 in the Seven Counties Study. It was carried out in the US, Finland, the Netherlands, Italy, Yugoslavia, Greece and Japan, and found that men in Crete had exceptionally low death rates from heart disease, despite their moderate-to-high intake of fat.

The most commonly understood version of the Mediterranean Diet was presented, among others, by Dr Walter Willett of Harvard University’s School of Public Health from the mid-1990s on.

Olives growing on a tree in a street in Thessaloniki (Photograph: Patrick Comerford)

According to a paper from the Mayo Clinic, the Mediterranean Diet incorporates the basics of healthy eating, along with “a splash of flavourful olive oil and perhaps a glass of red wine.” They said the Mediterranean diet reduces the risk of heart disease, reduces the incidence of cancer and cancer mortality, and reduces the incidence of Parkinson’s and Alzheimer’s diseases.

The Lyon Diet Heart Study set out to mimic the Cretan diet, consisting mostly of olive oil, bread, abundant fruit and vegetables, fish, and a moderate amount of dairy foods and wine. On this diet, mortality from all causes was reduced by 70%.

Fresh grapes on a market stall in Rethymnon in Crete (Photograph: Patrick Comerford)

A study in the British Medical Journal in 2008, found that the Mediterranean Diet provides substantial protection against Type-2 diabetes, and reduces the risk of cancer of cardiovascular disease and Parkinson’s and Alzheimer’s.

Now, a trial published in the New England Journal of Medicine has found that people on the Mediterranean Diet, supplemented with mixed nuts and olive oil, have a 30 per cent reduction in the risk of having a major cardiovascular event compared to people on just a low fat diet.

Starting on the Mediterranean Diet

Bread in a Greek baker’s window in Thessaloniki (Photograph: Patrick Comerford)

For all it’s worth, here are some steps to start on the Mediterranean Diet:

1, Eat your vegetables and fruits, and switch to whole grains. An abundance and variety of plant foods should make up the majority of your meals. They should be minimally processed and bought in season. Try to eat seven to ten servings a day of vegetables and fruits. Carrots, apples and bananas are handy for quick snacks, and fruit salads are a creative way to eat more fruit.

2, Switch to wholegrain bread and cereal, and begin to eat more wholegrain rice and pasta products.

3, Eat more nuts. Keep almonds, cashews, pistachios and walnuts on hand for quick snacks.

4, Cut out or reduce your use of butter, replacing it with olive oil. Use olive oil for cooking. After cooking pasta, add a touch of olive oil, some garlic and green onions for flavouring. Dip your bread in flavoured olive oil or lightly spread it on wholegrain bread for a tasty alternative to butter. Tahini, made from blended sesame seeds, is a good dip and spread too.

Melons on a market stall in Rethymnon in Crete (Photograph: Patrick Comerford)

5, Use herbs and spices instead of salt to flavour your food – they are also rich in health-promoting substances.

Fish on a market stall in Thessaloniki (Photograph: Patrick Comerford)

6, Eat fish once or twice a week, but avoid fried fish.

7, Cut back on red meat, and substitute it with fish or poultry. When you eat red meat, make sure it is lean and in small portions, and avoid sausage, bacon and other high-fat meats.

8, Choose low-fat dairy, and limit your use of higher fat dairy products such as whole milk, cheese and ice cream. Instead, try skim milk, fat-free yoghurt and low-fat cheese.

9, Raise a glass to healthy eating. If your doctor approves, have a glass of wine at dinner.

Nikos the Fisherman in Koutouloufari ... the Mediterranean Diet includes fish that is low in fat (Photograph: Patrick Comerford)

Canon Patrick Comerford is Lecturer in Anglicanism and Liturgy, the Church of Ireland Theological Institute, and an Adjunct Assistant Professor, Trinity College Dublin. This essay was first published in May 2013 in the Church Review (Dublin and Glendalough) and the Diocesan Magazine (Cashel and Ossory).

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