There's something ironic about the Mediterranean diet used in the Lyon diet heart study, the one that dramatically reduced participants' risk of heart attack and all-cause mortality relative to the prudent diet control group: it wasn't actually a Mediterranean diet.
The concept of the Mediterranean diet as protective against heart disease may have originated in Dr. Ancel Keys' Seven Countries study, in which he compared the food habits and cardiovascular mortality statistics both between and within seven European countries. Countries surrounding the Mediterranean, and in particular the Greek island of Crete, had the lowest cardiovascular death rates. The Cretan diet is high in monounsaturated fat, relatively low in saturated fat, low in omega-6, and high in omega-3 fatty acids, including fat from seafood and the plant omega-3 alpha-linolenic acid. It also includes abundant green vegetables. This became the inspiration for the modern American concept of the "Mediterranean diet". The part about low omega-6 tends to be omitted.
Of course, if you look at modern heart attack mortality statistics by country, France is the lowest in Europe. France is a Mediterranean country, yet happens to have a very high intake of saturated fat per capita. So the cardiologist-approved version of the Mediterranean diet isn't exactly accurate.
The Lyon study departs even further from the traditional Mediterranean diet. Neither the Cretan nor the French diet are low in fat, yet participants were encouraged to reduce their fat intake. The Cretan diet includes some animal fat and eggs, while Lyon participants were encouraged to avoid these. And finally, the margarine. You could be guillotined for using margarine instead of butter in France, and I'm sure the Cretans aren't too fond of it either. Yet the margarine used in the Lyon study was rich in omega-3 alpha-linolenic acid, a critical factor.
Previous intervention trials such as MRFIT, the Women's Health Initiative (WHI) dietary modification trial, and others, exhaustively tested the hypothesis that reducing total fat intake reduces cardiovascular mortality. It doesn't. A dozen trials have also tested the idea that reducing saturated fat reduces cardiovascular mortality. It doesn't. Increasing fiber doesn't, according to the DART trial. Increasing fruit and vegetables modestly doesn't, according to WHI.
So what's left that's unique about the Lyon trial? It was the only trial to dramatically reduce omega-6 consumption, to below 4% of calories, while increasing omega-3 consumption from plant and seafood sources. In my opinion, that combination is the only plausible explanation for the large reduction in heart attacks and total mortality. That combination also happens to be a consistent feature of the real Mediterranean diet. In both Crete and France, omega-6 intake is relatively low, and omega-3 intake is relatively high. They also eat more real food than processed food in general, a factor that I don't underestimate.
Where do we go from here? Obviously I'm not going to recommend eating omega-3 enriched margarine. Mediterranean countries don't need industrial goop to avoid a heart attack, and neither do you. Anyone who's been to France knows they don't deprive themselves over there. They eat real food and they enjoy it.
The way to preserve the essential elements of the Mediterranean diet without becoming an ascetic is to eat fats that are low in omega-6, and find a modest source of omega-3. That means eating full-fat dairy if you tolerate it, fatty meat if you enjoy it, organs, seafood, olive oil in moderation, coconut oil, butter, lard, and tallow. Along with a diet that is dominated by real, homemade food rather than processed food. Some people may also wish to supplement with small doses of high-vitamin cod liver oil, fish oil or flax. I consider the latter to be inferior to animal sources of omega-3, but it can be useful for vegetarians.
36 comments:
Stephan, thanks for your brilliant blogging.
That means eating full-fat dairy if you tolerate it, fatty meat if you enjoy it...
Does the fatty meat need to be grass-fed, in your opinion? I've been eating a lot of beef, but it's not grass-fed so I have to presume its fatty acid profile is heavy on the omega-6 fatty acids...or am I mistaken?
France is not a Mediterranean country. In Crete they used to use BIG amounts of olive oil and very little animal fat, since Orthodox church lent ban animal products 200d/year.
Mirka
France is a big country but does have a significant amount of Mediterranean coast line.
The observation on the diet of the Orthodox Church is interesting.
Christian dietary rules would also have formerly lead to many more fish days, maybe 50% (180 days plus)
This is an abstract from an Orthodox site. I have not seen an figure on observance rates current or historic.
http://www.antiochian.org/1157652263
"On the fast days mentioned above Orthodox Christians abstain from all meat, meat products, dairy products, fish, olive oil and alcoholic beverages. Shellfish is traditionally permitted. We also moderate the amount of food we consume on these days. We should not eat between meals. We should also eat smaller portions at our regular meals. Under the advice of a Spiritual Father some people may only eat one (1) meal per day during fasting periods."
A. Special Days of Fasting
1) The eve of the Feast of the Nativity of our Lord (Dec. 24)
2) the eve of the Feast of Theophany (Jan. 5)
3) Feast of the Beheading of John the Baptist (Aug. 29)
4) Feast of the Exaltation of the Honorable Cross (Sep. 14)
5) All Wednesday and Fridays throughout the year, with the exception of the following weeks and days when fasting is relaxed:
a. the week following the Sunday of the Publican and the Pharisee
b. Cheese Fare Week (meat and meat products not permitted)
c. Paschal Bright Week (the week after Pascha)
d. the week after Pentecost
e. the Nativity Season (Dec. 25 – Jan. 5)
f. the 50 days after Pascha (strict fasting is relaxed; consult your Father Confessor about fasting during this period)
g. the Leave-taking of Pascha
On the fast days mentioned above Orthodox Christians abstain from all meat, meat products, dairy products, fish, olive oil and alcoholic beverages. Shellfish is traditionally permitted. We also moderate the amount of food we consume on these days. We should not eat between meals. We should also eat smaller portions at our regular meals. Under the advice of a Spiritual Father some people may only eat one (1) meal per day during fasting periods. Please remember that all fasting in under the direction of the Pastor. In certain circumstances he may relax the traditional fast at his discretion.
B. Special Seasons of Fasting
Diet of Crete
The figures for the diet of Crete were historic.
Based on responses to posts on the diet of Crete on a breast cancer site, the modern processed diet is becoming more prevalent in Crete, and rates of western conditions are increasing.
It would be interesting to know if there are other Orthodox Communities that do not eat processed foods / vegetable oils and what the disease incidence is.
Marseilles area yes, but generally, France is thought to be a Middle European, not so much a Mediterranean country.
The list on fasting periods is incomplete, in addition there is Christmas Fast Nov 15 - Dec 24, Great Lent 40 + 7 days before Easter, Fast of Holy Apostles in June and Fast for the Assumption of the Virgin Mary in August.
Russian fast rules differ from Greek ones, because in the North the winter is cold and does not produce any veggies, so fish and flax seed oil were permitted.
Hi Stephen,
I live in Spain, where in some provinces you get up to 320 days of sun a year. Spaniards boast of being the most long-lived population in Europe. I'm almost sure this is due to the heavy sun exposure and subsequent daily vitamin D production.
Vitamin D is surely a confounding factor for the Lyon Study, considering that France is part sun-drenched Mediterranean and part cloudy and windy in the north (think Britany).
I assume Greece (Mediterranean and Aegean) will have similar weather patterns to Spain, and therefore similar health (their diet is pretty similar to Spain too).
However, in hot Mediterranean countries, we also sleep less (you have to work early in the morning and quite late in the evening, but you can't get to bed until at least 12 midnight because of the heat). Less sleep is associated with obesity, metabolic syndrome and ultimately heart attacks.
In short, the whole study basically falls apart because every country is going to have varying degrees of health factors and varying degrees of unhealthy ones. And we haven't even determined a baseline for what an ideal environment is yet. So comparing countries just doesn't work, in my opinion.
France is not a Mediterranean country? According to my globe, it is. Did it move or secede?
France is also a Middle European country. It's both. At least to me ;-D, not that I have the final say on the issue, though.
Italy and Spain also have varying diets and cuisines throughout their political boundaries; both are Mediterranean *and* European.
This "Mediterranean diet" as it is used in dietary advice terms drives me up a wall. I've seen a bit of an increase in the term "Anti-Inflammatory Diet" instead; perhaps that's a better term.
There is no one "Mediterranean diet". All around the Mediterranean Sea, the diets vary, just like the cultures and religions vary, and in reality none of the variations are anything like the "Mediterranean diet" version heaped on the public in the US.
My husband's lab currently includes a very engaging Southern Italian post-doc and let's just say he's not shy about expressing what's wrong with our "Italian-American" food, which is a great source of amusement (and confusion) for the lab staff (and excellent fodder for the good-natured ribbing and roasting that goes on during lab social gatherings). One of his most vocal complaints is the very common American practice of pairing chicken with pasta in the same dish (especially in restaurants), nothing short of sacrilege according to him. His view is the Americanized versions hardly get anything right about Italian food.
And the episode of Bizarre Foods of Sicily was fantastic. The Sicilian "street food" reflects the fusion of availability and necessity from earlier lean times - with local versions of offal and meat scraps transformed into tempting convenient "fast-comfort food". Last summer we found the same in "slow food" versions at a Rome restaurant that specialized in the "5th quarter", located near the historic stockyards of Rome (Pyramide underground station).
"Food in Medieval Times, by Melitta Weiss is a great book about the spread of food influences and certain agricultural crops (from Arabic culture into Europe via Italy in particular but the Mediterranean region in general) and how certain classes of people (mobility and middle classes that emulated the upper classes) enhanced their dietary variety or "got around" the many Christian days of food restrictions on meat and dairy. Much is included about the Middle Age views of food as medicine.
The book is divided by geographic regions which both makes the book a bit repetitious in parts, but also easy to make regional comparisons. Almond milk and simulated meat dishes made with
processed" fish were common on Christian "lean days". I was astounded at the amount of effort put into creating "ersatz' foods for the numerous Christian food restriction days. I found a copy in my local library last year.
The book "Cod: A Biography of the Fish that Changed the World" by Mark Kurlansky is a great little book with extensive discussion on the use of fish throughout Christendom during that time, though more in economic and political terms than dietary/nutrition. (great compact paperback for travel, btw).
I *think* it was in the Middle Ages book I noted a detailed discussion on the North-South European use of butter vs. olive oil and the south of France was included in the regions that favored olive oil over butter, but I don't have it handy to check. But in general the farther south one went, the less butter was used/valued for culinary purposes, and I'm guessing for practical storage purposes (it was used heavily in some places for lamp fuel and non-culinary purposes, though). Rome sticks in my head as a place heavily biased against butter as a food, but made heavy use of it for oil lamp fuel.
Great post Stephan. As always you provide thought provoking, fact based arguments.
@ Mirka and Robert ... so it seems that Orthodox Christians do Intermittent Fasting. Imagine the health benefits they must reap from it!
-Bryce
"One of his most vocal complaints is the very common American practice of pairing chicken with pasta in the same dish (especially in restaurants), nothing short of sacrilege according to him. His view is the Americanized versions hardly get anything right about Italian food."
SO TRUE. I'm from upstate NY, and we had a large Italian (and Polish and Irish) population there that immigrated late 1800s, early 1900s. The "Italian" food we eat in upstate NY is nothing like food in Italy, particularly in northern Italy. The use of chicken with pasta is like a religious ritual in upstate NY. I honestly think that's where it all started. We have a dish that everyone in upstate NY loves called "chicken riggies" aka "chicken rigatoni". You cannot get it anywhere else in the US. It uses a tomato/cream/vodka sauce. I think it's delicious, but every Italian whom I've met looks at this stuff like it's an alien with two heads. My best guess is that this sort of food evolution didn't happen mostly because of food costs and availability to poor immigrants, and the traditions then stuck.
This all became apparent when we had a musician exchange program with some students from Trento in 10th grade. They ate quite a bit of meat, vegetables, and cheese. Their pizza is also completely different.
I will say, though, the little old Italian ladies still in business in Utica, NY know what they are doing when it comes to pastries. :)
http://www.roadfood.com/Restaurant/Reviews/1343/florentine-pastry-shop
Sorry to hijack the thread in promotion of wheat and sugar. Haha.
Monica,
AS I think I've mentioned before, my roots are a few hours east of yours in NY's Capital District, so my experience of "localizd" Italian-American specialties is quite similar. Not having still-warm Perrecca's bread (www.yelp.com/biz/perrecas-bakery-schenectady) while "home" was one of the hardest things about going wheat-free (even when I went low carb I enjoyed limited indulgence since the opportunity was so limited).
My family knows to make sure they have "summer sausage" available for me when I return "home". It's fresh sausage sold in a casing formed into a "wheel" and held together by two skewers placed in a x-shape (there are fresh herbs and cheese in the sausage mixture). Grilled in the wheel shape then cut into sections, it's TDF. This is nothing like the nasty unspoilable cured "summer sausage" salami sold in supermarkets or by Hickory Farms-type vendors. Little Italian-American neighborhood markets make their own "secret family recipe" variations of summer sausage, for some reason only in the summer season (grilling season?). Near the end of Summer Sausage season, my mom and a neighbor split a whole batch as a special order and freeze it for off-season consumption.
While in college in Central NY, I had a roommate from Broom County and was introduced to "spiedies" (http://en.wikipedia.org/wiki/Spiedies), another localized Italian immigrant "comfort food" with a strong regional origin. Mmmmm, marinated meat on skewers, but served on the worst possible variation of soft plastic wrapped supermarket "Italian" bread. Now there are spiedies out here in the San Diego area at a local farmer's market - I knew the vendor had to have roots or a connection to NY's Southern Tier - yup, sure enough, he was from Vestal (near Binghamton/Endicott). Now I can again indulge in spiedies , sans the bread, of course. I am instantly transported back 25+ years.
Now I probably have everyone's mouth watering; I know mine is. Sorry...
Reminds me, today's farmer's market day and the spiedie guy will be there, as well as the Spring Hill jersey cream butter vendor. I'm outta here.
B
This needs an essay but in essence it is necessary to balance (more or less) the plant based Omega 3 and 6, maybe between 1:1 and 1:2 with a skew to 6 because that is what we see in nature.
An imbalance at low intake is as damaging as an imbalance at a high intake.
For example somebody eating grain fed chicken, salad, and olive oil who probably thinks they are being mega healthy, will actually have a BIG Omega 3:6 imbalance.
As Stephan previous post shows we only need low levels of Omega 6 and our cell membranes reach maximum capacity very quickly. So even on a low fat diet an Omega 3:6 imbalance is going to have a big influence on the way the body functions, with the inflammatory consequences etc.
Grain fed live stock have a significant plant based Omega 3:6 imbalance. The more grain they are fed the worse the imbalance. So grain fed chicken in seriously Omega 6 heavy.
Eggs from a true free range hen have 10 times as much Omega 3 as a grain fed chicken egg.
Livestock and particularly poultry can contain large quantities of fat so making the situation worse.
Check say New Zealand lamb (grass fed year round) v pork beef or chicken on Nutrition Data and you will see what I mean.
http://www.nutritiondata.com/
The problem is vegetable oils are every where in processed food, and so hard to avoid, if you use processed foods.
It is also necessary to ensure an adequate supply of long chain Omega 3s EPA and DHA. If you have no Omega 3 in your diet you cannot make the long chain fats. Many men are very poor converters of the plant fats to the long chain fats. Many factors in the diet and conditions like diabetes block the conversion pathways. So the safest option is to eat some food containing long chain Omega 3s.
Western intakes of DHA based on a Canadian and an Australian trial are generally lamentably low.
Women have a special need for Omega 3s
Author Omega Six The Devils Fat
www.Omegasixthedevilsfat.com
Revised improved expanded version in progress.
B,
I think pastured meat is ideal, but I don't think it needs to be your #1 priority from a health standpoint. Feedlot beef is low in omega-6, although it will contain less omega-3 than grass-fed. Any ruminant fat is low in omega-6 regardless of the feed used.
Mirka,
Your point is well taken about Crete, assuming they are observant!
"France is not a Mediterranean country". I think a lot of people from Marseille and Nice would disagree with you. In Southern France, they use olive oil in moderation because it's expensive. It's used as a flavoring drizzled on vegetables and fish, and in salads. They do eat less animal fat and more seafood than in other parts of France, but their fat still comes predominantly from animal sources. Although that's changing as people adopt processed vegetable oil. I can tell you this because I spent a good part of my childhood in southern France.
Gunther,
I agree with you that there are a lot of confounds. Controlled trials are the gold standard.
Thanks Stephan for another great post, and giving me the opportunity to add my bit without having to run a blog of my own.
You said
"Feedlot beef is low in omega-6, although it will contain less omega-3 than grass-fed. Any ruminant fat is low in omega-6 regardless of the feed used."
I agree but think it is important for people to be aware that processed fats from multiple sources can be a lot higher in Omega 6.
The Omega 3 content is generally low to very low. So even eating feed lot beef people will need to find a source of plant based Omega 3 like flax.
http://www.nutritiondata.com/facts/fats-and-oils/598/2
Chicken fat 20% Omega 6
http://www.nutritiondata.com/facts/fats-and-oils/483/2
Processed lard 10% Omega 6
http://www.nutritiondata.com/facts/fats-and-oils/482/2
Tallow 3% Omega 6
Author Omega Six The Devils Fat
www.Omegasixthedevilsfat.com
Revised improved expanded version in progress.
Dr Mary Enig in Know Your Fats pointed out that the conversion of ALA to EPA and DHA is in the range of some to little to none. Don Matesz elaborates on the conversion limits and more in his recent post on flax seed oil here:
http://donmatesz.blogspot.com/2009/06/top-ten-problems-with-applying_09.html
The trend to balance Omega 6 and Omega 3 has been a theme since the late 90’s. More recently, there is a trend to balance them, consume the omega 3 as EPA and DHA, and limit their overall intake within a range of about 1% of total calories. The thought being that having unused variants of these long chain polyunsaturated molecules floating around in the body is not good. If that reasoning is correct, using ALA to meet omega 3 needs is doubly bad.
Philip Thackray
Has it been mentioned before that Dr. Ancel Keys was the K-rations inventor?
He claimed it was a balanced diet but soldiers lost weight and muscle mass on it and there were vitamin deficiencies found. This was partly because the rations were only meant for short durations of less than 10 days but that was ignored as WWII progressed.
Interesting how a professional man's pronouncements affected millions of people, as it did again with the 7 Countries Study, and how, once again, despite reports from field hospitals, short-comings were ignored.
Great point Stephan. Leave it to modern influence to take an effective diet and mass market it with one of it's most important aspects excluded.
Modern science has clearly failed us in regard to blaming cholesterol and saturated fat as the cause of heart disease. Obviously we need a new approach ... something completely new that doesn't continue to latch on to the "diet-heart" dogma.
Anna,
When I went to grad school at SUNY Binghamton, the waiter looked at me a little funny when I asked what the spiedies (pronounced as in spider man) on the menu were. She quickly corrected my pronunciation and then informed me about the chicken-on-a-stick concept.
Speaking of home cooking; I was raised on spaghetti and chocolate chip cookies. Now I rarely have pasta (but with a 3yo at home it's difficult to avoid it completely) but I do --- gasp! --- have donuts once a week. I always bring a dozen to my lab meetings and eat one myself. Some of the best donuts I've ever had, btw, come from a donut shop I think called Claytons located in Sydney, New York where my dad was raised.
Just for info, France is not the country of one cuisine. There is great variation between the cooking in the north, and the south. It is not something unknown of. There was even a classic comedy movie playing on this division:
http://french.imdb.com/title/tt0056969/combined
This said, I think there is in fact not a bilateral divide, but a 4 part division.
South-East: Olive oil, fish, cured meat
South-West: Goose/Duck fat, truffels, foie gras, sea-food
North-West: Pork, Butter, Cheese, Fowl, sea-food
North-East: Belgic/German influenced (Alsacian food has a very good reputation on both sides of the Rhine) with Lard/Goose/Duck Butter
Btw, the Lyon heart study was done in Lyon, the gastronomy capital of France.
I read once (if I remember correctly, in an interview from Serge Renaud the guy who made that study) that they chose to call the intervention arm of the study "régime crétois" as a marketing ploy, they thought it sounded better than "Omega-3 enriched margarine diet".
Anyone willing to take a stab at explaining Finland's heart disease rate for contrast?
I could.
My mohter-in-law was working for the local margarine factory alrteady in the fifties. And his son used to have a ride to his granparents on the lorries loaded with margarine, on their weekly way from a south coast village to East Finland.
As a fact the consumption numbers are still available, on the year book of that factory (which we happen to have...)
We sold the our butter to the russians at that time, in order to gain much-wanted currency. So, the non-farmers were fed on margarine...
Once again, great post, thanks! Just wanted to add that for people avoiding omega-6, mid-tier and low-cost restaurants use vegetable oil very, very heavily. If you have added fat in your meal, it's almost certainly a very cheap vegetable oil - dressings, deep-fried food, fried eggs, etc, etc. When I worked in restaurants in college, vegetable oil in various forms was a huge part of our food delivery.
When I eat breakfast "out" I always request that my eggs be cooked with butter and not with "griddle grease". Once I was told (near Twenty-Nine Palms Marine Base/Joshua Tree - not exactly mecca for foodies) that the diner had NO butter, not even for the toast - they only had some sort of "spread". Oh, well, I ate the eggs reluctantly, but I'm more choosy now about diners.
I'm a recent iPhone convert and I love Yelp!. It's a great phone app to find a decent place to eat - something other than "griddle-grease" diners and fast food when you are out of your familiar area.
Sel,
That's right! Wow, how could you send your troops out with deficient food in good conscience? That would be almost as bad as feeding children government-subsidized processed junk for lunch.
Gallier2,
Very good point. France is remarkably diverse. Italy is pretty diverse too; food in the North is very different from the South.
Do either of you guys (Sel or Stephan) have some resources you could point me to where I could learn more about this Ancel Keys K ration issue? Books, articles?
given all this info, we should demand that food producers put polyunsaturated fats on the label!!
Monica said... "Do either of you guys (Sel or Stephan) have some resources you could point me to where I could learn more about this Ancel Keys K ration issue? Books, articles?"
http://en.wikipedia.org/wiki/K-ration
Too much omega-6 leads to Alzheimer's?
http://news.bbc.co.uk/2/hi/health/7676606.stm
Hello Stephan
Most of these studies on saturated fat do not last nearly long enough. There was no rigor in control of the diets in The Lyon Diet Heart Study.
What we need is an understanding of what is going on at the cellular level.
Population studies are just groping in the dark.
Stephan
Fish oil or Krill oil? I take krill. I hope this is OK and as effective if not more than fish oil.
Razwell,
Krill oil... I'm sure it's fine, although does it have any history of use? I'm a little bit wary of the astaxanthin content.
I just discovered your blog looking for information on soaking grains, it is beautifully written and very informative. I will be back..thanks
Dear Stephan,
If people in the Lyon study didn't need the refined goop (i.e. canola margarine) to get the results, why does de Logeril conclude that only the alpha linolenic acid (i.e. the canola margerine) was associated with the improved prognosis? (Circulation. 1999;99:779-785. See p. 784)
He's even written a paper on canola for the prevention of CHD:
http://www3.interscience.wiley.com/journal/85004768/abstract
Another question, Stephan.
If sat fat is harmless, why do investigators who study "healthy fat" diets continue to recommend reducing SF intake to 10-15%? Examples are de Lorgeril and other proponents of the Mediterranean diet, and Staffan Lindeberg, who criticizes the omega-3 data but still recommends eating a paleolithic diet with reduced sat fat content.
It's bad enough that we have to get beyond the untruths propagated by low fat crowd. When the alternative people disagree, it just leads to more confusion!
Makes you want to quit reading all the studies, pick up and move to rural Crete and eat whatever shows up on your plate.
how does this work with apo4?
Hi Stefan,
You say the gold standard is the RCT.
Then you can't say what you dared utter :
"The way to preserve the essential elements of the Mediterranean diet without becoming an ascetic is to eat fats that are low in omega-6, and find a modest source of omega-3. That means eating full-fat dairy if you tolerate it, fatty meat if you enjoy it, organs, seafood, olive oil in moderation, coconut oil, butter, lard, and tallow."
This is contrary to the methods in the LHS !
It is also contrary to what LHS's main author states in his book : "Prévenir l'infarctus et l'accident vasculaire cérébral" (2012).
As you wrote, ALA intake is a key component of the diet and then so is the rapeseed margarine !
Scientifically speaking you cannot assume pickingwhat you want in the LHS and adding what you deem right such as cream, will work.
Stick with the LHS methods.
The smart idea in the LHS was to ciompensate for the unnatural low level of alfalinolenic acid in the food we find in our western/northern shops. This is due to the modern methods for agriculture and animal breeding. Using rapeseed oil or margarine is sort of a crutch for us modern age people.
I suppose it would be acceptable (but not "as per protocol" to compensate for not using a rapeseed oil margarine by using more rapeseed oil.
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