I was surprised to learn that the much-revered Mediterranean Diet went back nearly 70 years to the work of American physician Ancel Keys, MD, stationed in Italy during World War II. Keys, who died in 2004 at age 100 (!), noted the very low incidence of heart disease and the excellent longevity among people living in Mediterranean countries, especially given postwar food shortages. He’d been pondering all the heart attacks in potbellied Americans back home, who, according to Keys “used their stomachs like garbage cans.”
It was Keys, among others, who first made the cholesterol-heart risk connection. Apparently well-fed Americans were eating inordinate amounts of saturated fat–the animal-based fats found mainly in high-fat dairy, beef, pork, and lamb and less so in poultry and fish. These were the days when the American Dairy Association was recommending everyone drink six glasses of whole milk daily. We were also eating endless amounts of refined carbohydrates (all bread was white bread, no one had ever heard the phrase “whole grain”), too much sugar and salt, and relatively few servings of fruits and vegetables.
The civilians seen by Keys in Italy were all extremely healthy, had a low incidence of heart disease and high blood pressure, and were living enviably long lives. He organized what became known as the Seven Countries Study and finally, in 1956, results in hand, representatives from the American Heart Association announced the findings: eating too much fat raised your cholesterol and having high cholesterol clogged your arteries.
But there was confusion
One factor that slowed the progress on healthful eating was confusion over which fats to eat and which to avoid. A major flaw in the Keys study was the idea that all fats were bad, with no recognition of the differences between the saturated (animal-based) and unsaturated (plant/fish-based). The message was to just get rid of them all and in their place substitute more protein and carbohydrates.
Unfortunately during these “all fat is bad” decades we chowed down on more refined carbs, the food companies having responded to the fat scare by adding lots of sugar to processed foods to replace the missing fat. We gained more weight and made little progress in reducing heart disease. If there was any headway being made, it occurred because we were smoking less and exercising more.
Finally, Keys made it clear that not all fats were the same, writing that the key was in the olive oil. His message was helped considerably with the publication of Fats That Kill, Fats That Heal in 1993 and Good Fats, Bad Fats a few years later. Mediterraneans (especially in Crete, which he’d always used as a standard of healthful eating) were using copious amounts of olive oil, which, along with fish, was very high in polyunsaturated omega 3s and actually protected the heart.
What exactly is the Mediterranean Diet?
We now have greater clarity on the meaning of a Mediterranean Diet and lifestyle, which includes:
- Regular physical activity (change careers from office clerk to goatherd).
- Abundant amounts of plant foods.
- Legumes such as beans and lentils.
- Fresh fruit as a daily dessert.
- Olive oil as principal fat (along with a few nuts).
- Minimal dairy (mainly Greek cheeses and yogurt).
- Fish and poultry in low-to-moderate amounts.
- Zero to four eggs weekly.
- Red meat rarely.
- Moderate amounts of red wine.
Or as Mark Bittman writes, “You eat like a Greek, or like a Greek used to eat: a piece of fish with a lentil salad, some greens and a glass of wine. It’s not onerous. In fact, it’s delicious.”
And now, 60 years after Keys’ original work, evidence continues to mount that this indeed is the healthiest way to eat and live. Earlier this year the New England Journal of Medicine reported a study from Spain that tracked the health habits of nearly 7,500 participants who had not been diagnosed with heart disease, but who were considered at risk for it. This meant having a strong family history of heart disease, being sedentary or overweight, having borderline high blood pressure, and the like. Half the participants were placed on the Mediterranean Diet and the others were allowed to eat their usual fare. The study was stopped early because of the death rate differences: those following the Mediterranean Diet had a 30% reduction in cardiovascular mortality.
That’s some serious preventive medicine.
Another study published more recently answered a question that had puzzled physicians for years. We know we should be eating more omega 3s (fish, olive oil) to protect our hearts. We also know that taking fish oil capsules (which contain the two types of omega-3–EPA and DHA) can be very helpful, especially for unenthusiastic fish eaters. But what would measuring blood levels of these essential fatty acids tell us? Do our personal fatty acid levels have any meaning?
The April 2, 2013, issue of Annals of Internal Medicine published the long-awaited Cardiovascular Health Study from the National Institutes of Health and Harvard. Tracking over a period of years 2,500 adults who had no evidence of heart or blood vessel disease, researchers measured their levels of omega-3 PUFAs (polyunsaturated fatty acids). Those with the highest baseline levels of omega-3 PUFAs had the lowest heart disease risk. And conversely, those with the lowest levels developed much more heart disease (heart attacks, strokes, fatal arrhythmias), but were able to boost their omega 3 levels by following a Mediterranean diet and taking EPA/DHA fish oil supplements.
If you come from a family with a high risk of heart problems or you’re simply concerned about your omega 3 status, you can have blood levels of your PUFAs analyzed. Unfortunately, health insurance companies regard such testing with skepticism (probably thinking a la Marie Antoinette, “Let them eat fish”). Depending on your coverage, expect to pay somewhere between $200 and $300 for this test. If you’re interested, call our office, schedule a “lab only,” and arrive having fasted since midnight the night before.
Or don’t bother with the test and put the $300 in your travel fund for a vacation to Crete. Meantime, enjoy a Mediterranean diet and quit eating junky processed foods. For added insurance, take fish oil supplements.
David Edelberg, MD