The Mediterranean Ketogenic Lifestyle

colinchamp November 20, 2018 3 Comments

Many of us have been promoting a ketogenic diet for years – and that includes both strict and continual ketosis, or the often-preferable low carb diet that fluctuates through intermittent states of ketosis. Initially people like Jeff Volek were laughed at and criticized. Then, he and others produced dozens of high-level randomized studies which exhibited the ability of the ketogenic diet to aid in weight loss, and others followed suit.^1–5 The potential of ketogenic and low-carbohydrate diets for improving health blossomed even further as the benefits expanded to include metabolic improvement, combating diabetes, and neurocognitive enhancement.^6–9 Our attempts were to assess strict ketosis during cancer treatment,^10–12 but the potential applications of the diet seem endless and we are now amidst a ketogenic diet craze. Halle Barre, Lebron James, you name them and it seems like everyone is on a self-described ketogenic diet these days. (And, obviously, as is always the case, a million scientific studies are less powerful than one celebrity’s endorsement). Yet, few follow what could be considered a Mediterranean Ketogenic Lifestyle.

Ok, ok, enough stroking of the ketogenic diet’s ego, which is getting rather large these days after decades of neglect and abuse. First and foremost, most people that I know “on the ketogenic diet” are merely following a low-carb diet (and often a high-protein one to boot). In the words of Jerry Seinfeld, not that there is anything wrong with that, but by the book it is often not a ketogenic diet. Many people (including myself) are probably on the cusp of ketosis and visit it periodically either based on the seasons, what’s going on that week, or happenstance.

Yet, with the addition of cheaper ketone blood strips, somewhere along the line, those aiming for ketosis began to push harder to achieve and stay in ketosis. We began checking with urine strips for the initial 2-3 weeks, then switched over to finger sticks without mortgaging our house. (When preparing for my study I stuck myself hundreds of times, turning my fingers into pin cushions and spending a fortune in the meantime). There are even breathalyzers coming out now with more accurate values. As a result, many diet followers are chasing ketone levels, with less concern for the quality of their foods.

For many, a ketogenic diet looks like this:

• Breakfast: Coffee, MCT oil, heavy cream, and butter (followed by several trips to the bathroom and subsequent lowering of MCT oil).
• Lunch: Some meat or fish source doused with oil, in a bed of lettuce.
• Dinner: Bacon and some heavy oil used to cook broccoli, and macadamia nuts
• Snack: Some keto baked goods made of coconut flour, doused with so much sugar alcohol that their teeth ache afterwards (and for those very sensitive, a couple more trips back to the bathroom).

For many of us, when we were hoping that a ketogenic diet could be used to help everything from weight loss to enhancing cancer prevention,¹³ we did not envision an oil-heavy diet accompanied by many trips to the bathroom. Ok, maybe the trips to the bathroom are a little rarer than I am making it sound like here, but you get the point about dietary quality – it is not as if we can attain ketosis and expect all our ailments to magically resolve and our risk of cancer to disappear. An array of nutrient-dense foods with adequate vitamins and minerals is still required, and a reliance on oils and hacks like medium chain triglycerides are unlikely to lead us down the best path to optimal health. We need to continue to focus on quality, especially when it comes to high-fat, nutrient dense animal sources of food, like meat, cheese, and eggs.¹⁴ The quality of the meat and how the animals raised counts) when it comes to how our body responds, how it integrates anti-inflammatory fats like conjugated linoleic acid and omega 3 fatty acids into our cell membranes and other fatty tissues, and how harmful states like inflammation are effected by different fatty sources.

Ushering in the Mediterranean Diet

In many non-food ways, the ketogenic diet is starting to resemble the Mediterranean Diet, and my love-hate relationship with it. As the Keyser Söze of the dietary world, the Shangri La, the “member berries” from South Park, the Mediterranean Diet more often than naught is some fictitious diet built on the hopes and dreams of dietitians and physicians used as soil to help bury their decade-long mistake of promoting a low-fat diet (See, we have been promoting the right diet all along – just like all those Italians living so long!). The greatest trick the devil has ever pulled was convincing you he doesn’t exist, according to Söze, and ushering in the promotion of a diet that is “rich in fish, grains, fruits, and vegetables” from an area where they eat a plethora of cured meats, full-fat cheese, pork, and large amounts of wine seems to be a trick that only Keyser Söze himself could come up with.

The commonly quoted Mediterranean Diets that never have and never will exist is basically whatever you want it to be based on your preference: Just mix what you consider a healthy diet, or where exactly your views coincide with the ethnically diverse area known as the Mediterranean area, surrounding the 965,300 square miles of sea water. The ketogenic diet is obviously more grounded than this, as we have a strict definition: measurable ketone levels within our blood. However, where the Mediterranean and ketogenic diet cross is where the lines begin to blur. Nowadays, a ketogenic diet can range from a strict heavy oil-based diet producing tangible ketone levels over 1mmol/L, to a well-structured and diverse meal plan that produces ketosis, to a well-structured and diverse meal plan that produces periodic ketosis, to a simply low-carbohydrate diet that never produces ketones (many people on a so-called ketogenic diet are simply on a low-carb diet, which is also fine, just not actually a ketogenic diet). The sweet spot in the middle is where I would like to see the bulk of the population – a well-balanced low-carbohydrate/ketogenic diet. This is starting to sound like a Mediterranean Ketogenic Diet, and that is exactly what I am endorsing.

The Mediterranean Ketogenic Diet:

As the diet wars continue to wage on, taking millions of lives with diabetes, myocardial infarctions, cognitive decline, obesity, and other collateral damage, it seems as though there is little to agree on. Yet, what happens when we take the mystical Mediterranean Diet and blend it with a well-constructed ketogenic diet?

The thought first came to me when I wrote about the Spanish Ketogenic Diet years ago.¹⁵ Back in 2008, researchers from Spain, acknowledging the potential of the ketogenic diet, merged, in their words, the “4 important healthy components of the Mediterranean diet in Spain: olive oil, salad, fish and red wine.” Their version of the ketogenic diet, following some of our discussion above, included an array of keto friendly and keto-borderline foods. They did include some of the high-notes of a well-constructed ketogenic diet. These included:

1. Unlimited calories: like nearly all high-fat diets and dietary regimens that humans consumed for over 99.9999% of their existence, they did not count calories. When we eat satiating and satisfying foods rich in fat, hunger naturally subsides. These diets generally do not consist of the annoying and ineffective calorie counting or the painful starvation diets that many would have you believe are necessary to lose weight.
2. The major source of fat came from the monounsaturated-heavy olive oil, with over 30ml consumed per day.
3. Green vegetables and salads were the major form of carbohydrates.
4. Fish was the major source of protein.
5. Participants drank a moderate amount of daily wine.*

*By a moderate amount, they mean 200-400ml per day. To put that in context, a standard wine bottle is 750ml in size. This amount would usually begin to knock me out of ketosis.

[stextbox id=’custom’ color=’fcfcfc’ ccolor=’000000′ bgcolor=’000000′ cbgcolor=’000000′ bgcolorto=’000000′ cbgcolorto=’000000′ image=’http://colinchamp.com/wp-content/uploads/2016/03/CC-Icon.jpg’]
As a Side Note

When I was reading this study, I easily pictured the scientists and physicians as they discussed this study:

Physician 1: This study layout sounds good, but are we sure that the subjects will follow and enjoy the diet?

Physician 2: Yes, good point. My colleagues in the United States give patients protein shakes full of vegetable oils and polyunsaturated fats and even high-fructose corn syrup to get them to follow meal plans. While I would never in a million years do that myself, what if we took that approach?

Physician 3: That sounds terrible. What if we don’t do either of those things, but just tell the participants that they can drink up to a half-bottle of wine per day?

Physicians 1, 2, 3 and the entire room: Buono! Fantastico! What were we thinking! Red wine it is!
[/stextbox]

Sometimes the Europeans just do things better…

Note: I am not advocating drinking a half bottle of wine a day (though a glass of red is fine and has some established health benefits,¹⁶ but I think you get the point).

The Study Participants – The Mediterannean Ketogenic Lifestyle

Regardless, the study was a massive success, as it allowed 40 overweight individuals with an average BMI of 37 to switch from their diabetes-provoking diet containing over 50% carbohydrates for 12 weeks. Ketosis was apparently confirmed via ketone strips in the morning. This concerns me, because if they were urine strips, after 2-3 weeks they would have been inaccurate. Once again, we must question whether it was a ketogenic diet or simply a very low-carbohydrate diet. Yet, the proof is it the pudding as the Spanish Ketogenic dieters experienced an average reduction in bodyweight from 240 to 208 lbs. Most importantly, there was a clear loss of fat over muscle. Blood pressure dropped, blood lipids improved, triglycerides divebombed as they were cut in half, blood sugar dropped by almost 20 mg/dl, and HDL cholesterol – a difficult number to budge – rose significantly. Take note, as expected, the largest reduction overall was the massive drop in triglycerides, which is especially important as elevated triglycerides are strongly associated with an increased risk of stroke, heart disease, and cancer.^17–19

Globally, all of these changes are desired. The question I pose, is can we take this a step further to encourage a full-blown Mediterranean Ketogenic Diet? I have been following what I consider a Mediterranean Ketogenic Diet for years by combining the cultural and social aspects of my Southern Italian heritage along with the scientific approach of the ketogenic diet. Sounds complicated? It’s not. In fact, it is so simple, that I have distilled it down to seven steps that are so simple, your great-grandfather likely followed most of them (mine certainly did).

The Seven Pillars of the Mediterranean Ketogenic Lifestyle

1. Keep carbohydrates low

Any low-carb, ketogenic, or diet that aims to avoid the blood sugar and insulin roller coaster while enacting our body’s cellular mechanisms to recycle their faulty parts and get rid of cellular garbage should include general restriction of carbohydrates. The golden number varies, but nutritional ketosis requires it to be less than 20-50 grams per day, while a very-low and low-carbohydrate diet can range from 0-150 grams per day. Somewhere in this range should work for most people in terms of weight loss/maintenance and activating the cellular benefits that accompany this lifestyle.

When considering carbohydrates, much like with bitter vegetables and other berries full of healthy chemicals like raspberries, blackberries, and blueberries are key. Others will turn to sweet potatoes, yucca, and similar starchy sources, but this will likely boot most people from ketosis. I personally enjoy these foods, but generally consume them after a workout when I am most insulin sensitive (i.e. my body needs less insulin to reduce my blood sugar). I also will eat them most often if I am losing too much weight on the ketogenic diet (yes, this happens).

2. Green, leafy, and colorful vegetables

Eating plenty of leafy greens, colorful vegetables, and cruciferous vegetables is a must, with the goal of having them at every meal. These fibrous vegetables contain a plethora of healthy immune system-stimulating and anticancer chemicals, along with soluble fiber to feed our bowel bacteria. Most of these contain such a low amount of non-fibrous carbohydrates that they can be considered a free pass when it comes to dipping into ketosis. Those that desire to stay deeply in ketosis may have to consider how many colorful vegetables they are consuming, but it depends on the individual.

3. Fat, fat, and more fat

A true ketogenic diet, or even a periodic ketogenic diet relies on plenty of fat. Take a couple hints from the Mediterranean area and eat plenty of high monounsaturated olive oil (make sure it is real and not laced with harmful oxidized vegetable oils), fatty fish with high omega-3 fatty acids, high quality meats, some nuts, and full-fat cheese (the kind that would hang from the ceiling in my great-grandfather’s meat and cheese shop). Heavy cream from grass-fed cows and macadamia, coconut, avocado, and palm oil are great for garnishing and cooking, but if we are turning for them as our main source of fat, we need to turn back towards wholesome, nutrient-dense foods.

4. Replace sweet foods with bitter ones

Bitter foods, like many green and cruciferous veggies, contain chemicals that increase our defense system. Furthermore, they train our taste preferences to shy away from unhealthy sweet foods. Bitter foods are like exercise for your palate, to train it to avoid unhealthy and addictive uber sweet foods. For instance, infants exposed to bitter foods early in life tend to favor them throughout adulthood.²⁰ While the effect is less studied in adults, I have experienced this sensitization myself and so have many of my patients, friends and family members.

Bitter vegetables, garlic, onions, herbs, and bitter red wine all contain a plethora of chemicals that act as an empty threat to increase our cellular defense systems and to activate our antioxidant defense system. Furthermore, they activate our detoxification system to rid our body of potentially harmful and cancerous chemicals, (the same chemicals researchers use to cause cancer in mice).

5. Get plenty of daily activity with periods of intermixed intense activity, resistance training, and lifting heavy things

Any discussion of the benefits of the Mediterranean diet without considering the frequent amount of activity that individuals in the traditional longevity-dense areas of Southern Italy, Greece, and Sardinia experience is missing a major component of their health. There are no elevators and escalators in these hilly communities, and simply walking around provides a muscle-pumping leg work out that becomes exponentially harder when carrying something. Lifting heavy things and contracting your muscles prompts them to release anti-inflammatory and anti-cancer chemicals and hormones and should be part of everyone’s repertoire.

6. Go plenty of periods without food – eat dense foods then no foods

The above-mentioned foods will provide us with plenty of nutrients to function optimally while remaining a healthy weight, but that does not mean we should be eating them all day long. Avoid snacking and aim for longer stretches between meals. This is very prevalent in the real Mediterranean diet, as the Greeks and other groups fast for up to 103 days per year, providing a handful of benefits like improved heart health,^21–23 improved brain health,²⁴ and potential anticancer effects²⁵ (initial Mediterranean diet studies left out all discussion of fasting²⁶). Increasing periods without any food will lower blood glucose and insulin, while activating autophagy, which signals our cells to get rid of any clutter or junk.

7. Triple R’s: Rest, Relaxation, and Recovery

In modern society’s go, go, go atmosphere, we forget that following a healthy lifestyle is more than just our food and activity. The times when we are not eating or exercising refuel our body to recover from exercise and replenish our muscles, while high quality and adequate sleep help promote a healthy metabolism to deal with the foods we eat, maintain a low/normal blood sugar level, and keep our mitochondria functioning optimally to help fight disease. Furthermore, socializing, reading, and other hobbies allow your body to relax while exercising your mind, providing even more benefits than simply refueling. Other activities, like tending a garden, allow us to turn our minds off. Just as the body needs recuperation times, so does the mind (and no this does not include watching television).

The above seven pillars of the Mediterranean Ketogenic Lifestyle have worked well for me to maintain a healthy weight and lifestyle, while keeping my body and mind replenished. I recently spent some time in San Lorenzo Bellizzi, after my wife and I crossed the entirety of Southern Italy in a week to gather some documents from my family villages etched high in the mountain in Italy. The physically exhausting trip provided an up close and personal view of how these principles were unintentionally followed in the past by my family and how, with a little modification, can be used to attain a healthy lifestyle, that is both easy and fun to follow. With the steep cliffs, sheep, vineyards, and olive groves in sight, it was easy to imagine Leonardo Pesce, my great-grandfather, scaling the cliffs as he walked with his flock of sheep, helping to feed his family and the town with his full fat cheese. While parts of his diet would certainly violate the pillars of a Mediterranean Ketogenic Lifestyle, the large proportion of similarities are uncanny. Furthermore, by continuing many of his traditions when it comes to meat and cheese preparation, I think he would be proud that his true Mediterranean culture is being endorsed to promote a healthy lifestyle a century later.

The Mediterranean Ketogenic Lifestyle References:

1. Forsythe C, Phinney S, Fernandez M, et al. Comparison of Low Fat and Low Carbohydrate Diets on Circulating Fatty Acid Composition and Markers of Inflammation. Lipids. 2008;43(1):65-77. doi:10.1007/s11745-007-3132-7.
2. Volek J, Phinney S, Forsythe C, et al. Carbohydrate Restriction has a More Favorable Impact on the Metabolic Syndrome than a Low Fat Diet. Lipids. 2009;44(4):297-309. doi:10.1007/s11745-008-3274-2.
3. Shai I, Schwarzfuchs D, Henkin Y, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008;359(3):229-241. doi:10.1056/NEJMoa0708681.
4. Westman EC, Yancy Jr. WS, Mavropoulos JC, Marquart M, McDuffie JR, Yancy Jr. WS. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutr Metab. 2008;5:36. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19099589.
5. Yancy Jr. WS, Olsen MK, Guyton JR, Bakst RP, Westman EC, Yancy Jr. WS. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern Med. 2004;140(10):769-777. http://www.ncbi.nlm.nih.gov/pubmed/15148063.
6. Maalouf M, Rho JM, Mattson MP. The neuroprotective properties of calorie restriction, the ketogenic diet, and ketone bodies. Brain Res Rev. 2009;59(2):293-315. doi:10.1016/j.brainresrev.2008.09.002.
7. Abbasi J. Interest in the Ketogenic Diet Grows for Weight Loss and Type 2 Diabetes. JAMA. 2018;319(3):215. doi:10.1001/jama.2017.20639.
8. Klement RJ, Champ CE. Calories, carbohydrates, and cancer therapy with radiation: Exploiting the five R’s through dietary manipulation. Cancer Metastasis Rev. 2014;33(1). doi:10.1007/s10555-014-9495-3.
9. Ludwig D. Genetic Study Supports Carbohydrate-Insulin Model of Obesity. Medium. https://medium.com/@davidludwigmd/genetic-study-supports-carbohydrate-insulin-model-of-obesity-327d84be6d2b. Published 2018. Accessed January 3, 2018.
10. Champ CE, Palmer JD, Volek JS, et al. Targeting metabolism with a ketogenic diet during the treatment of glioblastoma multiforme. J Neurooncol. 2014;117(1):125-131. doi:10.1007/s11060-014-1362-0.
11. Klement RJ, Champ CE, Otto C, Kämmerer U. Anti-Tumor Effects of Ketogenic Diets in Mice: A Meta-Analysis. PLoS One. 2016;11(5):e0155050. doi:10.1371/journal.pone.0155050.
12. Klement RJ, Champ CE. Calories, carbohydrates, and cancer therapy with radiation: exploiting the five R’s through dietary manipulation. Cancer Metastasis Rev. January 2014:1-13. doi:10.1007/s10555-014-9495-3.
13. Fine EJ, Champ CE, Feinman RD, Márquez S, Klement RJ. An Evolutionary and Mechanistic Perspective on Dietary Carbohydrate Restriction in Cancer Prevention. J Evol Heal. 2016;1(1). doi:10.15310/2334-3591.1036.
14. Haskins CP, Henderson G, Champ CE. Meat, eggs, full-fat dairy, and nutritional boogeymen: Does the way in which animals are raised affect health differently in humans? Crit Rev Food Sci Nutr. April 2018:1-11. doi:10.1080/10408398.2018.1465888.
15. Pérez-Guisado J, Muñoz-Serrano A, Alonso-Moraga A. Spanish Ketogenic Mediterranean Diet: a healthy cardiovascular diet for weight loss. Nutr J. 2008;7(1):30. doi:10.1186/1475-2891-7-30.
16. Corder R, Mullen W, Khan NQ, et al. Oenology: red wine procyanidins and vascular health. Nature. 2006;444(7119):566. doi:10.1038/444566a.
17. Goodwin PJ, Boyd NF, Hanna W, et al. Elevated levels of plasma triglycerides are associated with histologically defined premenopausal breast cancer risk. Nutr Cancer. 1997;27(3):284-292. doi:10.1080/01635589709514539.
18. Hokanson JE, Austin MA. Plasma triglyceride level is a risk factor for cardiovascular disease independent of high-density lipoprotein cholesterol level: a meta-analysis of population-based prospective studies. J Cardiovasc Risk. 1996;3(2):213-219. http://www.ncbi.nlm.nih.gov/pubmed/8836866.
19. Freiberg JJ, Tybjærg-Hansen A, Jensen JS, Nordestgaard BG. Nonfasting Triglycerides and Risk of Ischemic Stroke in the General Population. JAMA J Am Med Assoc. 2008;300(18):2142-2152. doi:10.1001/jama.2008.621.
20. Mennella JA, Lukasewycz LD, Castor SM, Beauchamp GK. The timing and duration of a sensitive period in human flavor learning: a randomized trial. Am J Clin Nutr. 2011;93(5):1019-1024. doi:10.3945/ajcn.110.003541.
21. Horne BD, May HT, Anderson JL, et al. Usefulness of Routine Periodic Fasting to Lower Risk of Coronary Artery Disease in Patients Undergoing Coronary Angiography. Am J Cardiol. 2008;102(7):814-819.e1. doi:10.1016/j.amjcard.2008.05.021.
22. Varady KA, Hellerstein MK. Alternate-day fasting and chronic disease prevention: a review of human and animal trials. Am J Clin Nutr. 2007;86(1):7-13. http://ajcn.nutrition.org/content/86/1/7.long. Accessed November 23, 2014.
23. Mattson MP, Wan R. Beneficial effects of intermittent fasting and caloric restriction on the cardiovascular and cerebrovascular systems. J Nutr Biochem. 2005;16(3):129-137. doi:10.1016/j.jnutbio.2004.12.007.
24. Safdie F, Brandhorst S, Wei M, et al. Fasting enhances the response of glioma to chemo- and radiotherapy. PLoS One. 2012;7(9):e44603. doi:10.1371/journal.pone.0044603.
25. Harvie M, Howell A. Energy restriction and the prevention of breast cancer. Proc Nutr Soc. 2012;71(2):263-275. doi:10.1017/S0029665112000195.
26. Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med. 2003;348(26):2599-2608. doi:10.1056/NEJMoa025039.

© 2018 CDR Health and Nutrition, LLC. All Rights Reserved.