Mediterranean Diet Revisited

By Paul E. Lemanski, MD, MS, FACP

Medicines are a mainstay of American life and the healthcare system not only because they are perceived to work by the individuals taking them, but also because their benefit may be shown by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of heart attacks, strokes and cardiovascular death while others may reduce certain types of cancer.

In the first 78 installments of the Non-Medicated Life, informed diet and lifestyle have been shown to accomplish naturally for the majority of individuals, many, if not most of the benefits of medications in the prevention and treatment of chronic medical conditions. Moreover, as a medical intervention they may accomplish such benefits with fewer side effects, may reduce the number and amount of medication, and may allow in some individuals actual discontinuation of medication.

One example of such an informed diet is the eating pattern practiced in Mediterranean countries. This way of eating has been shown in both population-based studies and clinical trials to reduce all-cause mortality, cardiovascular death, non-fatal heart attack, and the development of certain cancers. Moreover, this way of eating is particularly attractive from a health perspective because it is sustainable: it offers a variety of flavors, textures, and aromas satisfying to most individuals over years. What constitutes a Mediterranean eating pattern and how one may start to implement it is discussed below.

The basis of the Mediterranean pattern of eating and cuisine was determined not by design, but by happenstance: by the climate, and in turn, the flora and the fauna of the countries which surround the Mediterranean Sea. This is a region rich in grain, vegetables, fruits, legumes, and fish and, of course, olive trees. Cattle needed for red meat, while available, are not as easily supported perhaps because of a relative dearth of large expanses of grazing pasture.

The dietary composition of Mediterranean cuisine developed from what were the available food sources. Humans require proteins, carbohydrates and fats to survive. The Mediterranean pattern of eating, which is predominantly plant based, supplies protein from grains, legumes and vegetables, as well as fish and meat when available.

Carbohydrates from grains in Mediterranean cuisine are relatively unrefined. Such carbohydrates keep some of the germ or plant fat, and its presence helps slow the absorption of starch into the blood as glucose. The rate of absorption and rise of blood glucose is referred to as glycemic index. Although carbohydrates make a large part of the Mediterranean diet, the blunting of the rise in blood glucose – or lowering of glycemic index – helps prevent metabolic derangement such as the development of diabetes. Additionally, the soluble fibers in legumes will lower the glycemic index of a meal, as does the use of olive oil when consumed with grains and starchy vegetables. Lastly, the consumption of fruit in its whole form provides soluble fiber and membranes to further slow absorption and lower glycemic index.

The main fat in Mediterranean cuisine is olive oil. Olive oil is an omega-9 oil which contains only a small amount of saturated fat and in moderation has no known detrimental effects in the body. The low level of saturated fat may help reduce the amount of LDL or bad cholesterol, especially when olive oil takes the place of the saturated fats in meats. Olive oil also contains natural antioxidants that may also decrease oxidation of LDL cholesterol. Such oxidation of LDL sets up an inflammatory reaction in existing cholesterol plaques, which increases the risk of plaque rupture, the primary mechanism of heart attacks and strokes.

Finally, Mediterranean cuisine also incorporates an increased amount of omega-3 fats. Omega-3 fat may be plant-based, such as short chain alpha-linolenic fats found in certain leaf vegetables like purslane, or it may be long chain EPA or DHA fats found in fish. Omega-3 fats are anti-inflammatory in the body and also may help to both stabilize cholesterol plaque and decrease heart arrhythmias.

Although the composition of the Mediterranean diet described above is important to its health benefit, equally important is how such foods are consumed. Mediterranean cuisine emphasizes social interaction with the sharing of food. Social interaction slows the eating process. Satiety in humans requires a communication between stomach and brain, and it is known that it takes about 20 minutes for the stomach to tell the brain that food has been consumed. Therefore, the slower the eating, the fewer calories are consumed before that communication takes place. Equally important, Mediterranean cuisine relies on a lower caloric density of food to help achieve satiety. By eating foods like leafy vegetables that have volume but few calories, stretch receptors in the stomach wall are activated early, with satiety achieved with fewer calories consumed. Early satiety is most important because it helps control body weight without hunger. Reductions in body weight reduce blood pressure and blood sugar and improve heart health.

If you understand these essential aspects of a Mediterranean diet, conscious implementation of this way of eating becomes easier. For most Americans the first priority is to reduce frequency of red meat consumption to once a week and to reduce the portion to no more than about four to six ounces. Searching for recipes that substitute fish for red meat is one way to start.

Without learning any new cooking skills, the incorporation of legumes and vegetables can be increased by consuming a large salad for lunch and one with dinner as well. Arugula, kale, purslane, spinach, mixed greens, tomatoes, cucumbers, onions, red and green peppers, pimentos, chick peas, and a salad dressing using balsamic vinegar and olive oil can be simple, easy and satisfying. Additionally, the low calories of a salad for its volume will help to achieve satiety and control body weight.

Soups are a mainstay of Mediterranean cuisine, are easy to prepare, and have relatively low calories for the volume consumed. Moreover, they allow for a variety of vegetables and legumes to be more easily incorporated into ones diet and when a large amount is prepared they freeze well for future use. Start with a minestrone to get into Mediterranean soups. Gazpacho is also great in warmer weather.

While pasta and bread are certainly part of Mediterranean cuisine, reducing the amount consumed may be helped by eating a large salad beforehand and substituting whole wheat pasta and whole wheat bread for those made with white flour. Dipping bread in olive oil instead of using butter is much healthier as long as moderation is exercised. Mediterranean alternatives to wheat pasta that can be explored include couscous, bulgar, faro and risotto.

Searching for recipes for entrees should emphasize increasing vegetables and legumes and minimizing the portion size of red meat, chicken, and fish. This will be both less expensive and healthier.

In summary, a Mediterranean diet reduces the risk of heart disease, diabetes, and certain cancers. Implementation of a Mediterranean diet is helped by understanding the principles described above and beginning with a reduction in the frequency and amount of red meat consumed, and emphasizing vegetables and legumes. Mediterranean salads and soups are an easy way to begin and will help achieve satiety at lower total calories consumed. By naturally improving health a Mediterranean diet may help us to lead a more non-medicated life.

Paul E. Lemanski (plemanski@capcare.com) is a board certified internist at the Center for Preventive Medicine, CapitalCare Medical Group in Albany. He is medical director of the Department of Community Medicine and Population Health at CapitalCare Medical Group. Paul has a master’s degree in human nutrition. He is an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.