Is the Mediterranean Diet the New Ambiguous Diet?

ravello-2

The “calorie is a calorie” crowd has strongly pushed the “eat less, exercise more” message to millions of Americans over the last 30 years. Not surprisingly, intangible psychological and physical failure followed, often coupled with angst and even self-loathing. Perhaps summed up best by Dr. Richard Feinman in The World Turned Upside Down, this same crowd often also preaches against fat. If all calories are the same and we need to eat less, why should we care if it is fat? Such inconsistencies define these groups as they love pushing intangible and esoteric messages that few can follow. More recently, the dietary world and media have been praising the merits of the Mediterranean Diet.

The issues of calories and low-fat aside, one common pattern within the dietary world is its ability to often make recommendations as confusing and unable to follow as possible. This leaves the blame on those helpless individuals who are unable to decipher the banter that often ultimately leads to their nutritional demise. Counting elusive calories is nearly impossible (read more for a humorous and spot-on discussion by Adele Hite). Simply eating less and exercising more is difficult, if not impossible as many watch their metabolism and energy levels dwindle making weight loss difficult.1 Other esoteric dietary mantra is the en vogue “plant-based” diet, which may be a vegetarian diet masquerading as common dietary advice or perhaps something else – patients rarely even know what this recommendation means and nor do I.

The Mediterranean diet seems to be fitting in quite nicely with the esoteric dietary recommendations masquerading as part of the low-fat, eat less, and exercise more dogma. The Mediterranean diet varies largely based on which region you encounter, who is describing it, and with what time period. As mostly Southern Italian, I find a fondness with my ancestors’ homeland and travel there often to rest, relax, and write. Perhaps most enjoyable, I also find myself surrounded with a Mediterranean diet that actual Mediterranean people are eating (and not one a scientist conceptualized). Three years ago I wrote an article on the so called Mediterranean diet that I encountered during my time in Italy along the Mediterranean. I am annoyed with myself for not including this as a chapter in the Second Edition of Misguided Medicine, but have decided to update this article to make up for this oversight.

According to the Mayo Clinic, the Mediterranean diet:

“incorporates the basics of healthy eating — plus a splash of flavorful olive oil and perhaps a glass of red wine — among other components characterizing the traditional cooking style of countries bordering the Mediterranean Sea.

Most healthy diets include fruits, vegetables, fish and whole grains, and limit unhealthy fats. While these parts of a healthy diet are tried-and-true, subtle variations or differences in proportions of certain foods may make a difference in your risk of heart disease.

  • Eating primarily plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts
  • Replacing butter with healthy fats such as olive oil and canola oil
  • Using herbs and spices instead of salt to flavor foods
  • Limiting red meat to no more than a few times a month
  • Eating fish and poultry at least twice a week
  • Enjoying meals with family and friends
  • Drinking red wine in moderation (optional)
  • Getting plenty of exercise”

This description sounds eerily familiar to the typical low-fat mantra, which they describe as “tried-and-true” (data missing…). While it echoes common descriptions of the Mediterranean diet, issues immediately jump out of this list – like the fact that vegetables are extremely (and annoyingly) rare within the Mediterranean compared to what I eat in the US, nuts are quite rare, and in all of my travels to various parts of Italy, I have never ever seen Canola oil. Also, there goes the esoteric “plant-based” reference again, signaling more vagueness and confusion. Let’s dig a little deeper into the up-close and personal Mediterranean diet.

Is the Mediterranean Diet that Good or are We that Bad?

Three years ago I spent some time traveling through Southern Italy, with stops in Sorrento, Capri, and Positano. I have since returned several times to vacation, research, and write, traveling along the Mediterranean coast of Italy tracking upward into France. Years back, I was also fortunate enough to work in a hospital in Kosice, Slovakia and made my way down the coast of Croatia along the Adriatic Sea. For those that remember, it was the hottest summer recorded in Europe since the 1500s. I did get to hang out with Matt Damon and Heath Ledger, so it was all worth it.

me_damon_ledger_smaller

The Author with Heath Ledger and Matt Damon. He swears his shirt was in style at the time of the photo – you can make your own conclusions.

My trip three years ago was originally set in motion to put all work aside, relax, and enjoy the beautiful sights and sounds of the Mediterranean Coast of Southern Italy – while washing it down with some unforgettable Campania wine, of course. The latter was easy to accomplish, and as expected, I failed miserably with the former. An exploration of the culture, food, and wine of Italy constantly and uncontrollably stimulates much thought regarding health and nutrition.

Countless times throughout my trip I heard the following:

“When in Italy, you have to have pasta.”

“When in Italy, you have to have gelato.”

“When in Italy, you have to have bread.”

“When in Italy, you have to have pizza.”

First and foremost, let’s get this straight – gelato and ice cream are the same thing. Many readers will scoff at this comment, but it amazes me how we go crazy over gelato as if it is this rare treasure of the world when, in reality, it tastes pretty darn close to good ice cream.

But back to the main point: it seemed like any time I encountered a food that was clearly less than ideal in terms of health (like gelato), I was told I had to eat it. There was no mention of the cultural significance of bronzino fish, Florentine Steak, or bufala mozzarella. It is interesting how the human mind works as we rationalize excuses for poor eating choices, especially when they are cultural as this is generally sacred and untouchable territory. Of my friends and patients who are trying to influence their family members to make healthy lifestyle changes, one of the most difficult tasks to overcome convincing a loved one to avoid unhealthy foods that are part of his or her culture, with bread traversing dozens of cultures.

Rarely did I hear that a certain healthy food should be consumed as it is part of Italian culture. I personally love the cultural differences of foods that lead to different flavors, spices, and methods of preparation – preparation, that is, of foods that are healthy. Meanwhile, ubiquitous bread often serves as a vehicle for other foods (butter, jam, olive oil, or basically anything).

We had salmon with pesto sauce with one meal – an odd combination that was delicious and a healthy method of using cultural seasoning and preparation techniques to dress a healthy food. To give credit to my sister, she did at one point say “When in Italy, you have to have local grown tomatoes.”  She also helps edit some of my articles, so I am kissing up.

The Mediterranean Diet – Food Observations

With all the recent notoriety of the Mediterranean diet, what better way to explore the diet than to be in the country nearly surrounded by the Mediterranean sea? A newish popular study revealed that randomizing individuals to a “Mediterranean diet” with a liter of extra virgin olive oil per week and 30g of nuts per day could lower their cardiovascular risk.2 This is nothing new, as many studies have shown that replacing carbohydrates with fat improves health,3,4 and the fact that increasing fat in this study improved outcomes – something that flies in the face of conventional medical wisdom – was lost on many.

Study participants cooked with the olive oil and even drank it. This diet also pushed plenty of pesce (fish) and avoided red meat and dairy fat. The results revealed that it lowered blood pressure and reduced stroke risk. Shortly after this study was published, I left for Italy to see the diet firsthand to marvel at its health-promoting power.

However, upon taking a closer look, I witnessed a diet much different than the one in this study and described in most media outlets. In fact, the only nuts I saw the entire trip were the almonds and macadamia nuts in my travel bag.

So, what did the Mediterranean diet really look like?

The Mediterranean Diet – Bread, Pizza, Pasta, Meat, and Fish?

Per the Mayo’s description above, I expected to see whole grains and legumes pouring from the facets. In actuality, legumes were quite rare and nonexistent at many places, besides a rare small plate of green beans and fava beans in Capri. The amount of bread was also very minimal as compared to what I expected and compared to what I see in the US. A bread basket was brought out at each meal, and I did notice many of the US tourists consuming the entire basket as their appetizer. The locals, on the other hand, seemed to use a single piece to mop up the fat and oil on their plate after finishing their meal. I expected much more bread consumption.

Perhaps even more interesting was the fact that the bread was mostly white bread, not whole grains as defined in the study above and as often included in descriptions of the Mediterranean diet. Pizza was similar to bread – it seemed more to signal a large density of US tourists as opposed to native Italian restaurants. It was present on some menus, but was less commonly seen at the traditional restaurants.

Pasta, which I figured would be raining from the skies, was consumed at a much smaller amount than I ever expected. The locals would have a small portion in the beginning of their dinner, but rarely did I see it consumed as a large meal, except in the case of tourists, who were often seen with large plates of pasta as their main meal.

Perhaps our views on pasta merely parallel our incorrect view of the Italian and Mediterranean diet?

Corresponding to this was the proportion of dishes on the menu.  Often there was a page or two of meat, including beef, lamb, chicken, and a rare pork dish, with a page or two of fish, and a page or two of appetizers, which consisted of carpaccio, tuna, prosciutto (cured ham) and bufala mozzarella (buffalo mozzarella) which is extremely common in southern Italy.

It is largely made in Paestum, from the milk of grass-fed water buffalo, also known as “the queen of the Mediterranean cuisine”, “white gold” or “the pearl of the table.” The milk of these behemoths is significantly higher in fat and nutrition. Traveling to Paestum, is a trip well worth it as you get to see incredibly preserved Greek ruins while eating the world’s best mozzarella cheese. I promise you will enjoy some of the best cheese you have ever had, while peering out into amazing Greek ruins.

Mediterranean diet

Greek ruins and the word’s best bufala mozzarella at Paestum.

Mediterranean diet

Bufala mozzarella at Paestum. Put it on your bucket list.

Even the traditional sauces often contained meat and when we ordered the appetizer listed as a traditional local appetizer, it contained a dozen or so cured meats, cheeses, and a couple tomato slices. “Traditional” sure does not sound like the low in fat or saturated fat “Mediterranean diet.” We also noticed that when we started a meal with heavy amounts of fats, as was traditionally done, we found ourselves less hungry and consuming less food, consistent with plenty of studies showing a high-fat diet to satiate. We even let “nonna” order for us at a traditional “trattoria” in the quaint village of Ravello. She did bring out a small plate of pasta, along with her homemade wine, salsiccia (sausage) with cheese, meatballs, and aged meat and cheese platter.

Mediterranean diet

Nonna’s pick: lots of meat, cheese, fat, and flavor. She must have missed the memo on the Mediterranean diet being low-fat.

The amount of cured meats consumed at meals was much greater than I expected and far too much for me to eat. While I am no expert on the matter, this was likely from ease of preserving meat and doing so with much less cost or risk of spoil.

Finally, the further north we got, the more organ meats entered the picture, including liver, lungs, and tripe (stomach). However, the food that dominated the menus and plates of most local restaurants along the southern coast was the calamari and octopus, soaked in olive oil and lemon.

Mediterranean diet

Octopus in lemon juice while looking out into the sea in Capri: One of the best and most experiential meals of my life.

The Mediterranean Diet – Olive Oil with Minimal Vegetables and Water

The amount of olive oil consumed was somewhat as expected; food was cooked in olive oil and bottles were set out at each table upon being seated for meals. While people were not drinking it as in the above study, or showering with it as you would expect (though our hotel did have olive oil soap), certainly more is consumed with each meal than in the US.

What was more shocking to me was the scarcity of vegetables. I eat more vegetables than the average American, but how did I hold up against the “plant-based” Mediterranean diet? I found myself constantly begging for more vegetables at restaurants. Menus often contained meat or fish dishes with a couple leaves of lettuce, spinach, or arugula. A few potatoes would be served with some dishes, but rarely did they include veggies, except for a couple tomato slices. Oddly enough, when I saw broccoli on the menu and ordered it, the waiter came back empty handed. If a restaurant did have vegetable options, I would load up as I did not know when my next dose of these fibrous vitamins to fuel my bowel bacteria would come.

Finally, as a side note, the amount of water consumed was unbearably small. Little water was served with meals, and often a small bottle of water was brought out for four people to share. I found myself dehydrated on a daily basis and was forced to supplement my meals with bottled water, a large pet peeve of mine. The mineral and tap water was salty and food was generally cooked with liberal amounts of salt, so perhaps this helps offset the low amounts of water.

Overall, the Mediterranean diet that I observed was markedly different from the diet in the above study and the one portrayed by most US sources. It instead consisted of drastically larger amounts of cured meats and cheeses, much less bread, and even lesser amounts of grains. Meat was consumed several times per week in the sauces or as a main dish, and this was not including the plentiful amount of cured meats.

The Mediterranean Diet: Fasting and Food Consumption

The Italians certainly eat less than us. They also eat much less appetite-stimulating low-fat foods found throughout America. It remains unknown if this is the primary difference and driver of our larger caloric consumption. McDonalds, biggie-sized meals, and other unhealthy food chains with constant unavoidable advertisements are not present in Italy. Also, the major mode of transportation often is our feet. As you will read below, this includes miles of walking on steep inclines. Such steady and often intense activity scattered throughout the day does not allow snacking or overeating, as it would leave a 45 degree climb up the side of a hill rather miserable, if not impossible.

Along these lines, there is less snacking and longer periods between meals, and many have pointed out that this may be a large part of the benefit seen in the initial studies assessing the Greek population. The constituents of the original Mediterranean diet study fasted for up to 103 days per year. This was astutely pointed out by Katerina Sarri and her group in Crete. Fasting provides a plethora of health benefits, including cardiovascular benefits,5–7 improved brain health,9 and potential anticancer effects.8

Her group found significant consumption differences between the fasting versus non-fasting Greek Orthodox Christians living in Crete for over a year. Greek Orthodox Christians often fast multiple times over the year: 40 days during Christmas, 48 days during Lent, and 15 days during the Assumption.10 The initial study published the year before made no assessment of the effect of fasting, nor did they even mention fasting.11


The Mediterranean Diet – A Few Words on Organ Meats and Food Variety

Prior to a trip to Italy late last year, I received the typical banter from my friends and family questioning what in the world I would eat (I generally follow a lower carbohydrate diet and do not eat any bread or pasta). Most Americans think that Italian cuisine is made up solely of bread, pizza, and pasta, and the endless bread sticks at Olive Garden represent a traditional Italian dish. An insult to true Italian cuisine, it could not be further from the truth. Most restaurants do provide a small basket of bread with meals and the menus contain pasta dishes, but these are overshadowed by the meats, cheeses, fish, and wine. Pizza is rarely on traditional Italian menus, except for pizzerias. Even there, it is underrepresented in comparison to the variety of other foods. In fact, it is fairly obvious that the Americanized restaurants in the popular areas of Rome serve these foods to cater to Americans.

As I generally follow a modified paleo-esque diet, I love the cuisine in Italy as it always leaves me with new ideas to incorporate into my own cooking. This trip was no different.

Traditional Italian Variety – Senza Bread and Pasta

Upon arriving at Fiumicino Airport in Rome, we took an immediate train to Florence. I had not eaten a meal for almost a day, and after dropping our bags off at the hotel, we headed for a local trattoria. We ordered the Caprese salad with vegetables. This included the typical tomatoes, basil, bufalo mozzarella, olive oil, and balsamic vinegar. The vegetables on the side included tomatoes and eggplant and were covered with a ground, paste-like substance. I immediately knew what it was, but watched my travel companion unknowingly scarf down the delicious chicken liver. My main course was tripe, a delicious noodle-like food comprised of stomach lining full of nutrients and minerals. Our first meal in Italy, and we already had two different types of organ meat – quite a variety from the start. A small bread basket accompanied the meal, but neither of us ate any of this – the actual meal was too good in itself to ruin with any dull bread.

Mediterranean Diet

Starting the trip off with some healthy and delicious tripe. So much for lack of variety…

Over the ensuing week, my meals ranged from Florentine steak and lamb to a plethora of vegetables. My travel companion ordered one pasta dish throughout the entire trip, and the highlight of this pappardelle dish was the wild boar that accompanied it. The pasta, if anything, took away from the delicious wild boar and sage. We enjoyed the tripe so much that we ordered it again and again. My favorite meal was lamb liver, lung, and heart cooked in olive and truffle oil. The cheap Barolos and Brunellos that accompanied all of our meals did not hurt, either.

Misguided Medicine

Lamb liver, lung, and heart – and more variety

After one of my recent trips to Italy, I traveled to Germany to give a presentation on the effect of diet on cancer treatment and prevention. I was lucky enough to stay with a colleague and friend who follows quite a healthy lifestyle, Rainer Klement. He even set up a traditional Frankonian dinner that was served off of slabs of wood. The meal consisted of horseradish and sauerkraut with several courses of cuts of a butchered pasture-raised pig that were served to us by the butcher as he prepared them. The first meal was pork belly, followed by pork shoulder, with the final including the kidneys, jowl (cheek), heart and snout. I enjoyed the entire meal, but was intimidated by the snout so avoided this.

Mediterranean Diet

For those who truly value variety, perhaps they should participate in a traditional Frankonian meal.

As we move more towards traditional food in most cultures, it often resembles those that rarely exist in modern meals. These nutrient-dense and healthy foods are not only delicious and flavorful (unlike bread and pasta), but add immense variety to our dinner table.

The Standard American Diet has Little Variety

The irony with my “limited” and “restricted” diet is that in actuality I eat a large amount of foods that most people have never even considered including in their diet. Many consider a healthy diet limited if it eliminates bread and pasta, yet, most standard American diets rely on these bland foods as the backbone of their meals. If we eliminate them and favor real, whole foods, and we immediately must be more creative with our cooking and preparation. No more bread leads to no more unhealthy sandwiches for lunch and requires us to instead eat real foods that take some preparation and knowledge of cooking. This is often best exemplified with typical American breakfasts.

The standard breakfast for many (most?) people includes:
  1. Cereal
  2. Muffins
  3. Coffee
My standard “limited” breakfast:
  1. Fasting
  2. Coffee with cream (or rarely MCT oil)
  3. One of the many varieties of bone broth
  4. Eggs or omelet (with a variety of vegetables, kimchi, avocado, or cheese)
  5. Sometimes kefir (fermented dairy product)

Most people that I encounter on the SAD diet (Standard American Diet) eat nearly the same foods every day. Dinner seems to vary the most while breakfast and lunch are nearly identical. If variety was that important to most Americans, they should welcome the addition of healthy green leafy vegetables and animal sources along with the cooking and preparation required for these meals.


A Variety of Nutrient and Flavors and a Lack of Excuses

What this trip made me realize is that we often use “lack of variety” as an excuse to avoid a healthy diet that eliminates or avoids breads and pasta – a diet that is often low in carbohydrates. People often have trouble coming out of their comfort zone, and unfortunately many carbs have literally been spoon-fed to us as children to provide comfort (if you are sick, you get toast with sugar and cinnamon!). If our goal was truly a diet with both food and flavor variety, mundane bread and pasta would play little part.

Perhaps the best part of eating a diet that focuses on nutrient-dense variety is that it involves intense flavors that most people miss out on with their SAD. The next time you are looking to change up a meal, think about ways to make the experience more than a meal. Cook some delicious and nutritious organ meat to add some actual variety. You may find that you like it.

This works for the Italians, and they seem to know a thing or two about good food.

The Mediterranean Diet – Why Organ Meat?

Now, for a moment, let’s travel a bit southwest to Africa, which is actually not too far from Southern Italy. When I give presentations on diet and cancer, I often reference my friends’ encounter with the Masaai during a trip to Africa. They spent a day at a Masaai village to soak in their culture and observe a day in the life of a modern hunter-gatherer. As expected, they enjoyed the experience and to thank the tribesman for their hospitality, presented them with the gift of a live goat. The following description may be tough for many of us to see, but further illustrates just how far we have departed from our ancestors when it comes to food.

The Masaai thanked them for their gift, and then slit the goat’s throat to drain its blood into a basin. Several quickly drank the blood. It sounds crazy to us Americans, but blood is extremely nutrient-dense with valuable proteins and lipids. If we are truly eating for nutrition, blood is actually a valuable meal that we should think twice about disposing. In actuality, the Italians have their blood pudding, the English have their black pudding, the Swedes have their blodplättar, and the Finns have their veriohukainen – all illustrating the value of blood, and also that it is multicultural and not just for the vampires and Masaai.

Masaai

The Masaai love their raw blood. Sometimes they even mix a little raw milk with it as well.

The other Masaai tribesmen made a vertical incision along the abdomen of the goat with surgical precision, removed most of the organs, and then immediately ate them raw. The “scraps” were returned to my friends in case they wanted them. The scraps were essentially the muscular cuts of meat – the same cuts that we, as Americans, seem to favor.

Masaai

A Masaai man eating the kidneys seconds after removing them.

Vitamins and Nutrients – The Meat of the Issue

The main point from the story above is that a somewhat nomadic group of hunter-gatherers who spend much of their day attempting to find food to avoid starvation threw away the muscular parts of a free gift of food while devouring the parts that we often scoff at. These scraps are the same parts that we find at every grocery store. Add on the fact that they ate the organs raw, and this hardly compares to char-grilled muscle meat that most Americans consume during several meals per week.

Why eat the organs and throw out the rest?

The Masaai aim to optimize their diet by consuming the most nutritious foods possible containing the largest amounts of vitamins and calories. Our ancestors did the same over the past million years or so (as did mine – the Pesce’s and Ciampetti’s from Southern Italy), as would any sensible person who had a limited amount of available food. This type of diet supplies 2-10 times the recommended daily allowance of vitamins and nutrients for Americans.12 This diet is high in vitamins, minerals, and omega-3 fatty acids.13 Compare and contrast this with a typical western dietary recommendations, and over half the US population is failing to meet the recommended dietary allowance (RDA) for vitamin A, vitamin, B-6, magnesium, calcium, and zinc.14  Even worse, a third of our population is under the RDA for folate.

We have some of the best scientists, researchers, and physicians in the world, yet we have recommended a diet that leaves its citizens with a paucity of vitamins and minerals. Meanwhile, hunter-gatherers in Africa and paisanos living in the mountains of southern Italy are knowledgeable enough about the human body to know what it needs to consume, including the most nutrient dense foods and parts of the animal available, while we focus on their scraps.

To assess the diet of the Masaai – and organ meat in general – versus those cuts that we typically eat and are recommended, I compared some nutrition facts from nutritiondata.com. They have a nice way of comparing macronutrients as well as showing the nutrient-density of a food. I compared kidney with the fan favorite recommendation of our health leaders: skinless chicken breast. The picture below is just a small example, but it holds over many different organ meats.

 

organ meat

As we move from lean muscular meats to organ meats, the nutrient “completeness” score, which measures vital nutrients like magnesium and zinc, rises significantly.

I also did this while eating some grass-fed lamb heart, which is saturated with vitamins and minerals like zinc, phosphorous, and selenium along with significantly higher amounts of elastin and collagen than other muscular cuts. Most importantly, it has a massive amount of coenzyme Q10 (CoQ10), which, by no coincidence, is necessary for a healthy heart.

I also graphed out some of the important nutrients to assess how much of the daily value of vitamins and minerals each provides. The differences are striking:

Organ Meat

The percent daily value of vitamins and minerals found in chicken breast and sirloin pale in comparison to beef kidneys.

Organ Meats – More than Liver

When I was joining the healthy world of organ meat eaters, I naturally started with liver; this was my biggest mistake. While organs like the heart or tongue taste like tender meat, the liver is a pasty, odd-textured organ with a particular metallic taste that has to be masked with large amounts of onions and bacon. While bacon can make nearly anything taste good, the texture of liver is still a turnoff for many (including me). In fact, the texture of liver was such a turnoff that it forced me to cut organ meats entirely out of my diet for some time. Once I realized that liver is clearly not the bridge to enjoying organ meat, I began enjoying delicious organs like bone marrow, tripe, tongue, and the heart.

In my opinion, organ meats are most easily introduced into the diet in this order:

Muscle cuts -> bone marrow -> heart -> tripe -> liver -> kidney -> everything else

After decades of recommending nutrient-sparse foods like skinless chicken breasts and claiming they are healthier than fattier cuts, it is no wonder that we are left with a population of hungry over-eaters who are simultaneously nutrient and vitamin deprived and malnourished.15 For the calorie counters out there, this may not make sense. But for those of us attempting to eat the most nutritious foods available, we may want to turn to organ meat more often.

Maybe we can learn a thing or two from the Masaai and the Italians.


 

The Mediterranean Diet Versus Mediterranean Fitness:

Rounding out my assessment of Italy and the Mediterranean would not be complete without a discussion of the fitness level. The continual confusion between fitness and health has always been a pet peeve of mine. Fitness is being fit to do a task, i.e. fit to reproduce, fit to run a marathon, or fit to climb a set of stairs. Fitness does not define health and some tasks that one is fit for may lead to worse health; for example, ultra-marathon running can damage the heart and joints and being fit at basketball destroyed my knees. However, after observing the complete and utter lack of general fitness within the American tourists, I think it may be time to unite the two.

The amount that Europeans walk on a daily basis is no secret and is often felt to be a major reason they stay so slim. However, in Southern Italy, one realizes this has little to do with walking, but rather extreme fitness. Walking up 300 stairs at an incline of what feels like 90 degrees in Positano is not just walking, it is the equivalent of doing a 30-minute leg session in the gym including squats, lunges, and whatever other quad and calf-annihilating exercise you can ponder. This is fitness at its finest and surely gets the mitochondria and muscles pumping to promote greater health. Walking five flat miles is not even comparable to walking from the beach in Positano to the top of the city.

When we were checking in to our hotel in Positano, they kept trying to take our luggage to the room. We explained to them that we liked to take our own luggage up the steps as a form of exercise. The woman at the hotel responded:

“This is Positano. You do not have to try to exercise. After simply walking around the city, you will have done plenty of exercise.”

She was right.

Countering this was the utter and complete lack of fitness in the American tourists, and this was not due to injuries or handicaps inhibiting fitness. This was clearly the product of poor diet and sedentary lifestyle. It becomes difficult as a physician to turn off your brain when you are sitting at a cafe enjoying your coffee while watching American tourists pay a fortune for taxis (cabs in Southern Italy are a complete rip-off – i.e. upwards of 30 Euro for a half mile ride), since they are unable to escalate a simple hill or set of stairs. The cab drivers know what they are doing.

Worse-off is the fact that many of these tourists were relatively young. This point really hit home when I was sitting on the coastline in Sorrento. An artificial lagoon was created and you could dive in and swim.  The water was freezing and I was hesitant to go in, but after my good friend Cesar jumped in and swam across, I followed. However, like most things in Southern Italy, this “pool” was not user friendly. To get out of the water, there was a makeshift set of steps etched into the rocks – or the rocks themselves could be used. Most of the travelers sunbathing were unable to swim across because they would be unable to get out. Many tourists were in their thirties or younger. This struck a chord with me; while fitness and health are not synonymous, clearly the complete lack of fitness is a strong marker for a lack of health. Along these lines, a simple study assessing whether people are able to get up off of the ground without help tells us just this, as it predicts a greater risk of dying prematurely in males.16

The Mediterranean Diet Versus the American Habitus

While the climbing rates of obesity in the US are apparent to those of us who are even somewhat observant, when our population is juxtaposed to that of Southern Italy it becomes rather shocking. Do not get me wrong, you will encounter some overweight Italians while venturing through the cities. As an academic exercise, I assessed the first 30 Italians I encountered while walking through Pompeii. I considered 5 overweight and 2 were borderline obese (and I am a harsh critic). The average US tourist group, on the other hand, was usually about 50-70% overweight, with about a 30% obesity rate. This was obviously not the case with all groups, but these types of numbers do not even exist in Southern Italy, partially because it would be nearly impossible to live there as it requires extreme fitness and mobility.

Such findings further illustrate how much work is needed to improve health and fitness in the US.

The Real Mediterranean Diet Benefit? Freedom from Stress, Anxiety, and Channeling Everyday Worries

Part of the greatest challenge of this trip was to stop all work and just enjoy life. This included no blog, no work on the book, and no papers or manuscripts. I did allow myself to work on one manuscript on the flight to Italy and I tweeted a couple times, but otherwise my time was to be spent with as little thought as possible. Instead, I was to enjoy nature and the beauty of Southern Italy and the Mediterranean Sea, Aglianico, and other Italian wines. In doing this, I literally had to force myself to turn off my concerns regarding trivial matters and also those less trivial involving my job as a physician. The trivial matters were easy to forget. Work, my latest book release, and this blog were nearly impossible to get off of my mind, especially for all the reasons listed above. However, when I hit Capri and Ravello during the tail end of my trip, my mind was at ease. With all due respect to American tourists, sitting along the coast in Positano and watching people unable to climb stairs, the same people who likely obsess over things like Facebook and worry about what was in the recent US Weekly, made me realize how backwards we (and I) can be a times. Observing the locals loving life with clearly as little stress as possible only further emphasizes this. Flicking off that mental switch and just observing life and allowing self-reflection really makes you realize that not only is stopping and observing life important, it is vital.

Mediterranean diet

Anxious about taxes, Facebook, Twitter, and other stressors? Go to Ravello and watch them melt away.

Mediterranean diet

If you still find yourself stressed, take a boat over to Capri for a couple days.

The Mediterranean Diet – In Conclusion

The Mediterranean Diet – at least according to Italy, the country ensconced by the Mediterranean Sea – is certainly anything but low-fat. Delicious nutrient-dense foods, full-fat cheeses, meats, organ meats, and fish dominate. Bread, pasta, and pizza is present, but pale in comparison to the Olive Garden and other pathetic American attempts to categorize what Italians really eat. If you can muster the time and money, go to Southern Italy. The people are friendly, the food and wine is delicious, and the blend of culture, nature, and incredible views are life-changing.

However, when you go, make sure to remember these sayings:

“When in Italy, you have to have calamari and octopus.”

“When in Italy, you have to have organ meat.”

“When in Italy, you have to walk the steepest steps of your life.”

“When in Italy, you have to walk several miles per day.”

“When in Italy, you have to be at total peace with yourself as you observe the most beautiful place on earth.”

Oh and to accomplish these, you may want to pass or limit the pizza, pasta, bread, and gelato.

 

References:

  1. Phinney, S. D., LaGrange, B. M., O’Connell, M. & Danforth Jr, E. Effects of aerobic exercise on energy expenditure and nitrogen balance during very low calorie dieting. Metabolism 37, 758–765 (1988).
  2. Estruch, R. et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. N. Engl. J. Med. 368, 1279–1290 (2013).
  3. Volek, J. et al. Carbohydrate Restriction has a More Favorable Impact on the Metabolic Syndrome than a Low Fat Diet. Lipids 44, 297–309 (2009).
  4. Forsythe, C. et al. Limited Effect of Dietary Saturated Fat on Plasma Saturated Fat in the Context of a Low Carbohydrate Diet. Lipids 45, 947–962 (2010).
  5. Horne, B. D. et al. Usefulness of Routine Periodic Fasting to Lower Risk of Coronary Artery Disease in Patients Undergoing Coronary Angiography. Am. J. Cardiol. 102, 814–819.e1 (2008).
  6. Varady, K. A. & Hellerstein, M. K. Alternate-day fasting and chronic disease prevention: a review of human and animal trials. Am J Clin Nutr 86, 7–13 (2007).
  7. Mattson, M. P. & Wan, R. Beneficial effects of intermittent fasting and caloric restriction on the cardiovascular and cerebrovascular systems. J Nutr Biochem 16, 129–137 (2005).
  8. Harvie, M. & Howell, A. Energy restriction and the prevention of breast cancer. Proc Nutr Soc 71, 263–275 (2012).
  9. Safdie, F. et al. Fasting enhances the response of glioma to chemo- and radiotherapy. PLoS One 7, e44603 (2012).
  10. Sarri, K. O., Linardakis, M. K., Bervanaki, F. N., Tzanakis, N. E. & Kafatos, A. G. Greek Orthodox fasting rituals: a hidden characteristic of the Mediterranean diet of Crete. Br. J. Nutr. 92, 277–84 (2004).
  11. Trichopoulou, A., Costacou, T., Bamia, C. & Trichopoulos, D. Adherence to a Mediterranean diet and survival in a Greek population. N. Engl. J. Med. 348, 2599–608 (2003).
  12. O’Keefe, J. H. & Cordain, L. Cardiovascular disease resulting from a diet and lifestyle at odds with our Paleolithic genome: how to become a 21st-century hunter-gatherer. Mayo Clin. Proc. 79, 101–8 (2004).
  13. Eaton, S. B. & Konner, M. J. Review Paleolithic nutrition revisited: A twelve-year retrospective on its nature and implications. Eur. J. Clin. Nutr. 51, 207–216 (1997).
  14. Cordain, L. et al. Origins and evolution of the Western diet: health implications for the 21st century. Am. J. Clin. Nutr. 81, 341–354 (2005).
  15. Grotto, D. & Zied, E. The Standard American Diet and Its Relationship to the Health Status of Americans. Nutr. Clin. Pract. 25, 603–612 (2010).
  16. de Brito, L. B. B. et al. Ability to sit and rise from the floor as a predictor of all-cause mortality. Eur. J. Prev. Cardiol. (2012). doi:10.1177/2047487312471759

 

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17 Comments

  1. Gearóid Ó Laoi

    I loved this Colin. It echoed my own knowledge of Spain which I’ve toured extensively by bicycle and where I have had an apartment (in Andalucía) for the last 10 years. The Spanish eat a high fat diet with lots of cheese, jamon, processed meat, fish, olive oil, butter etc. The eat little vegetables in restaurants, though quite a lot at home. I’ve never seen wholegrains here. They eat white bread but not huge quantities. They eat rice, potatoes, but again not in large quantities. They are undoubtedly getting fatter due to the adoption of abominations like French fries, but still lag a good bit behind Americans.

    Reply
    1. colinchamp (Post author)

      Thanks Gearóid! I couldn’t agree more. They certainly eat a wide range of different foods, but those that dominate are markedly different than what we are told here in the States. It’s a shame our bad habits are spreading there!

      Reply
  2. Alessio

    Hi Colin, I’m Alessio from Italy.
    I find your article really interesting.
    I want to give my opinion since I’m italian.
    Though Italy is a relatively small country, it is a mixture of different cultures and it’s still a wonder how they managed to create a unique state from such variety.
    The southern part of the country is still more “traditional” while the northern part is more “americanized”.
    I have to say that what you find at the restaurant is not always a reliable indicator of what italians regularly eat in their home.
    I think it’s apparently true that we eat far less than americans, and while they include some amount of grains at every meal, they also have some meat or fish.
    At least, so far in the southern part and until some years ago in the north.
    I live near Milan and I can swear that we are exactly brainwashed like americans toward a low fat diet rich in grains.
    My collegues every day show how they are committed to eat whole grains (crackers misura with added fibers!!), skimmed yogurt, they substitute butter with seeds oil in their homemade cakes, they try to eat as less red meat as possible, since it is carcinogenic, they ate organ meats, they blame dietary colesterol, etc…
    I spent hours and hours to tell them that it’s a fake and they would be far better off to go back with fat, but they frown at me like I was mad.
    Thus, if you go in a traditional Tuscany restaurant, you can be happy to find plenty of the mentioned stuff, but the reality is that they are disappearing from the average italian table.
    Here in the north we have the strong influence of Barilla SPA (do you know?), with Mulino Bianco snacks, Ferrero, etc…
    I can tell you what my friends and my collegues eat in a typical day (note:who wants to eat healthy..):

    Breakfast: brioches (now with wholewheat and honey to eat “healthy”) and cappuccino with skimmed milk.
    Snack: soy yogurt with chia or flax seeds and fibre supplements (you know, fibers are good…)
    Lunch: a tiny plate of pasta with tomatoes or pesto, a flimsy laser cut slice of chicken breast or canned tuna, some lettuce
    Dinner: grain fed red meat once a week, otherwise some farmed fish, maybe “light” cheese, some wholewheat bread, some vegetables

    The “others’ diet (health “unconscious”):
    Breakfast: brioches or biscuits with milk and coffee
    Snack: focaccia
    Lunch: pasta, bread, a slice of cake
    Snack: merendine from Mulino Bianco
    Dinner: junk fed pork ham, maybe a grainfed steak, once or twice a week pizza, once a week McDonald’s, some vegetables

    When they go to a traditional restaurant, they think to do the “cheating meal”, eating plenty of harmful fats and colesterol, and the day after they come at work feeling guilty, totally unaware they they probably did the healthiest meal of the week.

    This, for me, is why a tourist may be led to think that we have a healthy lifestyle, while we have been quickly americanized.
    We certainly eat far less than americans, we still have few ultraprocessed foods, we are certainly thinner than the average Joe, but we are far from being healthy and fit. Probably in the southern part there is still some kind of tradition, but I can swear that in Milan we are certainly lost.
    We are still not like Americans, but are still far from the ideal diet and lifestyle and we are quickly steering away from any trace of it.
    I’m sincerely worried…

    Reply
    1. Alessio

      Sorry, I was meaning “hate” organ meats, that have been confined to a niche food.
      We also have famous epidemiologists who daily warn about the dangers of red meat, and when I talk about my diet, almost everyone claim: you don’t eat carbs, meat is carcinogenic.
      You can spend hours to explain that carbs are not =pasta, focaccia or pizza.
      Amusingly, when you make them note that they think to eat a variety of foods while they are actually eating grains at every meal, they say that they don’t eat grains, because cereal grains in their minds are the kellogs cornflakes at breakfast (in italians indeed cereali is mostly use to talk about them).
      Some awareness is on a raise, but we are still too brainwashed and here people believe at 50 years old american myths, at least here in the northern part.

      Reply
      1. colinchamp (Post author)

        Alessio,

        Thanks for the interesting comments. What a shame that these unhealthy recommendations are spreading throughout Italy as well! Hopefully the awareness you speak of continues and the Italians can return to some of their traditional foods!

        Keep fighting the good fight,
        Colin

        Reply
  3. karen motlow

    my breakfast: i poach an egg in bone broth. first, heat the broth with roasted garlic, ginger and/or turmeric root, then add the egg, heat until desired yolk doneness (i like a soft yolk). then add scallions, cilantro, slivered jalapeños or whatever else you desire. all good. if you use my recipe, please give me credit. thanks Colin Champ.

    Reply
    1. colinchamp (Post author)

      Sounds delicious! Thanks!

      Reply
  4. Gearóid Ó Laoi

    I’m off to Spain next week. When I’m there I go on jaunts with the retired men of the small town where we have an apartment. I’m the only non-Spaniard. Lunch is supplied with these and you have some choices.
    This is the last lunch we had.

    Salmorejo. A delicious cold-soup with tomatoes etc.
    Callos: Tripe cooked in a spicy tomato sauce. Totally delicious. I’d never actually liked tripe until this. Had second helpings.
    Salad. Tomatoes, a little tuna etc.
    Cold plate: Jamon (Airdried full fat Spanish ham), Chorizo (spicy sausage), Salami, Sheeps milk cheese. Lots of this. White bread. (I avoid). Olive oil if you want it.
    Stewed pork with small amounts of rice. Very little vegetable material.
    Fish:
    Dessert: A sweet concoction (I don’t eat it).
    Lots of wine.

    The Spanish apparently eat a lot of vegetables at home, but they are scarce in restaurants. Their diet is high fat and satfat also. They do use a lot of Olive Oil, on bread, salads and for frying.
    Unfortunately their diet is slowly becoming Americanised with fries making inroads and fear of fat being preached at the same time.
    When I first started coming to Spain 26y ago, boiled potatoes were the norm with your meal (2 small ones usually). Fries are the usual now.

    Reply
    1. colinchamp (Post author)

      This is great – thanks for the description! Unfortunately the prepackaged processed food diet seems to be spreading like a virus…

      Reply
  5. puddleg58

    Thanks for this great report. Some thoughts are, that restaurant food can be different from everyday food, and that food can vary in times of plenty from what was available to the bulk of the population in the pre-modern times when Keys drew up the idea of the Mediterranean diet.
    There is an excellent short description of various Italian peasant diets at the start of the 20th Century in Bertha M Wood’s Foods of the Foreign Born from 1921.
    Heavy dark bread, beans in great variety (it takes time to prepare beans, perhaps the reason they have fallen from favour), and macaroni were the main carbohydrate foods, but corn and potatoes were also eaten. Red meat was scarce but cured pork and pork sausage were more common, as was seafood in the South. Eggs and (whole) milk were major sources of protein. Cheese was common, of course, but no-one mentions yoghurt. Fat was more likely to be added to food at the end of cooking than at the start; lard, olive oil and butter if available. And green etc veges and tomatoes were everywhere, as was wine.
    So no sugar, no refined starches (except durum wheat in the macaroni), no lean or low-fat proteins, no limit on saturated fat, no oils or foods high in PUFAs.
    https://archive.org/details/foodsforeignbor00woodgoog

    Reply
    1. colinchamp (Post author)

      Thank you for the reference – very interesting! I need to start a collection of books like these as I got a couple emails with some other good reads. No oils and PUFAs and mention of yogurt – interesting as these are often cited as staples of the Med diet…

      Reply
  6. Colin MacDonald

    I expect the Italians were also smoking a fair bit, I’m not claiming this is healthy(!), however there does seem to be a mentality in the “Anglosphere” that in order to live a virtuous healthy life we need to ban anything that’s actually enjoyable. This of course has obvious benefits with tobacco, however banning salt, sunbathing, saturated fat (I could go on and on) seems to outweigh these benefits big time. Just sayin’. I don’t think the Italians are any wiser than us but do benefit from an absence of puritanism. And I speak as a Scottish presbyterian here!

    Reply
    1. Karina

      I think our reductionist way of evaluating things scientifically strips a lot of variables out of its whole context & we tend to try to adopt the conclusions of nutritional studies without its cultural & social settings. The southern european cultures from Spain, Italy, Portugal & Greece have a very laid back approach to life, work, making money, and success. Family and social interactions are warmer, more supportive, caring, integrated, and centered around cooking and dining together as a family or with close friends. They have drawn out meals with wine, music, relaxed conversation & laughter not hurried meals in front of the TV with everyone disconnected from each other. Having worked with a number of visiting Italian scientists I’ve heard of their habits… some of them most contrary to prescribed ways of living in sensibly healthy countries like the US but they don’t seem to kill them there e.g they smoke, drink, eat very late dinners & drink espresso sometimes past midnight, have an entirely obscure circadian rhythm and go to bed in the wee hours of the morning instead of getting 8 hours of regular sleep. Similar to other nationalities that immigrate to the US, their descendants however exhibit many of the same health problems as the general population after a couple of generations here. I do not think you can remove the warm climate, sunshine, social context. family closeness, relaxed setting with wine, music & laughter out of the equation and focus solely on the fat content, high carb Vs high fat Vs protein proportions in their diet. Even if their dishes are loaded with EVOO or natural animal fats people do not eat as much as Americans, the fat satisfies their appetites earlier & they don’t consume processed food that is nutritionally deficient & full of food additives that would be detrimental to their digestive systems. Of course life there has become as busy & demanding as life here & adoption of processed food in those cultures has probably been detrimental to their health as it has here in the US.

      Reply
      1. Alessio

        Exactly Karina, the laid back attitude is gone, at least here in the northern part of Italy. Come here to visit Milan and you’ll feel like you were in the US. Frenetic people in hurry…

        Reply
        1. Karina

          Milan is probably one of the most expensive cities to live in and life there must be as competitive to be successful as any other major international metropolitan city even if it has gorgeous architecture & other features of Italian life. If I ever come to Italy I would love to get away from the touristy locations in the bustling cities and experience the beauty, simplicity and serenity of life in the rural areas where I believe people are closer to their Italian roots than in the cities. But then that would be a vacation & life can not always be like one long vacation depending on the career you choose, the needs you have to satisfy materially, etc. I grew up in Bombay (now “Mumbai”) one of the most crowded, bustling metropolitan cities but my parents had their roots in Goa, a small predominantly catholic coastal state that was a Portuguese colony for 450 years. It’s like Rio. Life slows down there, the people, the food & even water are better there. Unlike the rest of India which was ruled by the British, Goa still shuts down for their daily afternoon “Siesta” & Goans enjoy life according to laid back, “Susegad” manner thanks to the Portuguese influence. Check it out – it’s even made it into Wikipedia!! https://en.wikipedia.org/wiki/Susegad. My belief is that no matter where we are instead of dissecting the constituents of food we need to slow down, embrace simplicity, live mindfully, engage in the process of selecting and preparing food and enjoying it in good company. The body responds differently, digests & absorbs better, and doesn’t react as if constantly in a stressful situation even at meal times. Americans are all over the board – high fat/ low fat/ high carb/ low carb/ high protein/ low protein/ only cabbage/Paleo/ Atkins/ etc etc etc till finally they’re all eating lettuce leaves like rabbits in a land of plenty filled with self-loathing and not enjoying any of the abundant blessings bestowed by God & nature. Michael Polan has boiled it down to 3 common sense recommendations: “Eat food, eat real food, not too much”. Bringing out the cornucopia once a year at Thanksgiving and indulging in the bounty of good food is not the way to enjoy life. The southern european cultures in Italy, Spain, Portugal and Greece were right about this – being “susegad” is a healthy way to live no matter where you are!

          Reply
    2. colinchamp (Post author)

      Amen! Check out this talk, is it along the same lines: https://www.youtube.com/watch?v=UWxYQMoUJzU

      Reply
  7. Karina

    Enjoyed reading this blogpost about the Mediterranean diet versus the commercialized restaurant chain influenced “Italian food”. It read like a travel account that transported me to places I dream of visiting along with some honest-to-goodness medically based evaluation of the nutritional value of the food you encountered in Italy. I think bread, pasta and thick pizza became staples of italian dishes in US restaurants because it’s cheaper than meats, easier to make/bake in bulk, & provides quantity to fill customers up. I often wonder what american italians prepare in their homes especially the ones who still have grandparents/family ties with their italian homeland/ancestry. I can relate somewhat to what the italian & spanish commentors have said – I hail originally from Goa, a small coastal Indian state that was under Portuguese rule for 450 years. Thanks to the Portuguese influence & St. Francis Xavier’s efforts Goa was predominantly Catholic & non-vegetarian unlike most of predominantly Hindu & vegetarian India. Goan “non-vegetarian” includes entire body parts of cows (not eaten by Hindus who consider it sacred), pigs (avoided by muslims who consider it unclean), goats, lamb, chicken and all kids of fish especially mackerel, sardines, small shark, prawns/shrimp, mussles, crabs & clams. Several of our specialities include goat brain, cow tongue, roast pigling (a must at all weddings & feasts), tripe, pigs feet, a spicy pork chorizo. Meals would always start with a marrow-bone broth based soup followed by a small serving of curried beef/pork/chicken & boiled/sauteed veggies or salad (shredded carrot, sliced cucumber, tomato, beets, & onion with cilantro, vinegar/lime juice). ie we ate anything before it ate us, organ meats, fat, skin and all included. And the last course was a small serving of rice with fish curry and fried mackeral/sardines…and being coastal it was all cooked in coconut-based curry or fried in coconut oil.

    Reply

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