Advanced Mediterranean Diet

The Los Angeles Times health blog (Booster Shots) reported on a study Sept. 23, 2009, that associates teenager attendance at family dinner with better academic performance and less abuse of alcohol and drugs. 

Leisurely family meals are characteristic of the traditional Mediterranean diet and may partially explain the health benefits of the diet.  Food for thought, no?

Steve Parker, M.D.

Success is the sum of small efforts, repeated day in and day out…

                                                          -Robert Collier

Chocolate consumption dramatically reduces the odds of dying from a future heart attack in folks who have already had a first heart attack, according to new research out of Sweden.  Read on for the proper “dose” of chocolate.

Stockholm and Boston-based researchers examined over a thousand people who had suffered a first heart attack.  Surveys determined their chocolate consumption over the year prior to the heart attack.  Investigators followed their clinical course over the next eight years.

The risk of dying from heart disease gradually lessened as more chocolate was consumed: up to 65% less than those who never ate chocolate.

Now, don’t use this as an excuse to go hog-wild on chocolate.  The consumption categories in the survey were 1) never, 2) less than once a month, 3) up to once a week, and 4) twice or more per week.  The “twice or more per week” people had the lowest risk of dying from heart disease over the eight years after their first heart attack. 

Maybe “twice or more per day” would be even better, but I doubt it.  This study provides no data on it.

Flavonoids are chemicals in chocolate, especially dark chocolate, that have strong antioxidant properties.  This may be the source of the cardiac and other health benefits.

If we look at the ability of dark chocolate to reduce C-reactive protein levels, a marker of systemic inflammation, the healthy dose of dark chocolate may be very small: no more than 20 grams every three days, and perhaps quite a bit less.  Twenty grams every three days would be less than a typical bar weekly. 

The study at hand didn’t break down chocolate intake into dark versus milk chocolate.  Forget about white chocolate if you want lots of antioxidants.  Some countries don’t even recognize white chocolate as chocolate.

If you’re a heart attack patient, it’s probably a good idea to eat dark chocolate.  Check with your personal physician.  Regarding the healthy “dose,” twenty grams of dark chocolate twice a week is as good an estimate as any.

Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

References: 

Janszky, I., et al.  Chocolate consumption and mortality following a first acute myocardial infarction: the Stockholm Heart Epidemiology Program.  Journal of Internal Medicine, 266 (209): 248-257.

Di Giuseppe, Romina, et al.  Regular Consumption of Dark Chocolate Is Associated with Low Serum Concentrations of C-Reactive Protein in a Healthy Italian Population.  Journal of Nutrition, 138 (2008): 1,939-1,945.

He who enjoys good health is rich, though he knows it not.

                                          -Italian proverb

A low-carbohydrate Mediterranean diet dramatically reduced the need for diabetic drug therapy, compared to a low-fat American Heart Association diet.  The Italian researchers also report that the Mediterranean dieters also lost  more weight over the first two years of the study. 

Investigators suggest that the benefit of the Mediterranean-style diet is due to greater weight loss, olive oil (monunsaturated fats increase insulin sensitivity), and increased adiponectin levels.

The American Diabetes Association recommends both low-carbohydrate and low-fat diets for overweight diabetics.  The investigators wondered which of the two might be better, as judged by the need to institute drug therapy in newly diagnosed people with diabetes.

Methodology

Newly diagnosed type 2 diabetics who had never been treated with diabetes drugs were recruited into the study, which was done in Naples, Italy.  At the outset, the 215 study participants were 30 to 75 years of age, had body mass index over 25 (average 29.5), had average hemoglobin A1c levels of 7.73, and average glucose levels of 170 mg/dl.

Participants were randomly assigned to one of two diets:

1. Low-carb Mediterranean diet (”MED diet”, hereafter):  rich in vegetables and whole grains, low in red meat (replaced with poultry and fish), no more than 50% of calories from complex carbohydrates, no less than 30% of calories from fat (main source of added fat was 30 to 50 g of olive oil daily).  [No mention of fruits.  BTW, the traditional Mediterranean diet derives 50-60% of energy from carbohydrates.]
2. Low-fat diet based on American Heart Association guidelines:  rich in whole grains, restricted additional fats/sweets/high-fat snacks, no more than 30% of calories from fat, no more than 10% of calories from saturated fats.

Both diet groups were instructed to limit daily energy intake to 1500 (women) or 1800 (men) calories.

All participants were advised to increase physical activity, mainly walking for at least 30 minutes a day.

Drug therapy was initiated when hemoglobin A1c levels persisted above 7% despite diet and exercise.

The study lasted four years.

Results

By the end of 18 months, twice as many low-fat dieters required diabetes drug therapy compared to the MED dieters—24% versus 12%.

By the end of four years, seven of every 10 low-fat dieters were on drug therapy compared to four of every 10 MED dieters. 

The MED dieters lost 2 kg (4.4 lb) more weight by the end of one year, compared to the low-fat group.  The groups were no different in net weight loss when measured at four years: down 3–4 kg (7–9 lb).

Compared to the low-fat group, the MED diet cohort achieved significantly lower levels of fasting glucose and hemoglobin A1c throughout the four years.

The MED diet group saw greater increases in insulin sensitivity, i.e., they had less insulin resistance.

The MED group had significantly greater increases in HDL cholesterol and decreases in trigylcerides throughout the study.  Total cholesterol decreased more in the MED dieters, but after the first two years the difference from the low-fat group was not significantly different. 

Comments

The MED diet here includes “no more than 50% of calories from complex carbohydrates.”  The authors don’t define complex carbs.  Simple carbohydrates are monosaccharides and disaccharides.  Complex carbs are oligosaccharides and polysaccharides.  Another definition of complex carbs is “fruits, vegetables, and whole grains,” which I think is definition of complex carbs applicable to this study.

The editors of the Annals of Internal Medicine conclude that:

A low-carbohydrate, Mediterranean-style diet seems to be preferable to a low-fat diet for glycemic control in patients with newly diagnosed type 2 diabetes.

I’m sure the American Diabetes Association will take heed of this study when they next revise their diet guidelines.  If I were newly diagnosed with type 2 diabetes, I wouldn’t wait until then.

This study dovetails nicely with others that show prevention of type 2 diabetes with the Mediterranean diet, reversal of metabolic syndrome—a risk factor for diabetes—with the Mediterranean diet (supplemented with nuts), and prevention of type 2 diabetes and pre-diabetes in people who have had a heart attack.

For instruction on how to lose weight with a Mediterranean-style diet, click here (it’s not the low-carb diet used in the study at hand).

For general information on Mediterranean eating, visit Oldways.

Update May 27, 2010:  For one version of a very low-carb Mediterranean diet, see the Diabetic Mediterranean Diet.

Steve Parker, M.D.

Reference:  Esposito, Katherine, et al.  Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes.  Annals of Internal Medicine, 151 (2009): 306-314.

Grape products favorably affect four risk factors for heart disease, according to a scientific review published last year.

The “French Paradox” refers to the fact that certain regions of France have low levels of heart disease despite high consumption of saturated fats that supposedly cause heart disease.  Some have explained away the paradox by noting high consumption of red wine in those areas, which could counteract the adverse effects of saturated fats.  Others have used the paradox to indict the Diet-Heart Hypothesis itself. 

Wine, especially red wine, is an integral part of the Ketogenic Mediterranean Diet.  However, many people just don’t like wine, and others shouldn’t be drinking it.  Grapes and grape juice have too many carbohydrates for a very low-carb diet like the KMD.  So, I’ve been wondering if grape products other than wine might have the healthy effects of wine.

The reference article below reviewed grape product trials published over the previous 13 years: 34 studies in animals, 41 in humans.  Non-wine grape products included grape juice, grape seed, grape skin, and polyphenol-rich extracts.  The authors conclude that grape products have the following beneficial effects on cardiovascular risk factors:

• lower blood pressure, mainly due to release of nitric oxide from cells lining the arteries
• reduced levels of total cholesterol, LDL cholesterol (”bad cholesterol”), and trigylcerides, especially if these values are high at baseline
• reduced development of early-stage atherosclerosis (less LDL oxidation and plaque formation)
• improved antioxidant status

Here are some grape product “fun facts” from the article:

• healthy effects are primarily attributed to polyphenols, which are strong antioxidants that disable free radicals and chelate metals
• major grape polyphenols are anthocyanins in red grapes, flavon-3-ols in white grapes
• red grapes have more total polyphenols than white grapes
• the main polyphenols in wine are resveratrol, tannins, flavan-3-ols, flavan-3,4-diols, anthocyanins, flavonols, flavones, anthocyanins, and anthocyanidins
• red wine has a much higher phenolic content than white wine

Unfortunately, the authors never make any specific recommendations for people wanting to substitute grape products for wine. 

But I bet if you went down to your local vitamin or health food store, you could find some grape extracts or other grape products to try.  Anyone on a very low-carb diet would want to be sure the grape product wouldn’t supply more than 3-4 grams of digestible carbohydrate per day.  For those not on such a diet, purple grape juice like Welch’s—4 to 8 fl oz a day—is a good alternative to wine.  Welch’s has 42 g of carbohydrate per 8 fl oz.  

Or just eat 1-2 cups of grapes - red or purple grapes might be the healthiest. 

Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Reference:  Perez-Jimenez, Jara and Saura-Calixto, Fulgencio.  Grape products and cardiovascular disease risk factors.  Nutrition Research Reviews, 21 (2008): 158-173.

Gertrude Baines died yesterday in Los Angeles at the age of 115, according to the Associated Press.

She liked to eat fried chicken, bacon, and ice cream.

Her physician, Charles Witt, M.D., said, “She told me that she owes her longevity to the Lord, that she never did drink, and never did smoke, and she never did fool around,” according to CNN.com (Sept. 12, 2009)

Steve Parker, M.D.

Canadian researchers recently reported that Canadian men who are regular alcohol drinkers - on a daily or weekly basis - have a higher risk of cancer of the esophagus, stomach, colon, liver, lung, and prostate.  The more men drink, the greater the risk.

The investigators suspect that alcohol may be responsible for up to 5% of all invasive cancer deaths.  Their article abstract does not address the possibility that regular drinkers may live longer than non-drinkers despite increased risk of cancer. 

Readers of this blog will note that I am a bit of an advocate of alcohol consumption - for carefully selected people - for prolongation of life and reduction of cardiovascular disease.  I’m also on record as favoring wine over other alcoholic beverages for these potential benefits.

I happy to report that the Canadians did not find an association between wine consumption and cancer. 

Steve Parker, M.D.  

Reference:  Benedetti, Andrea, et al.  Lifetime consumption of alcoholic beverages and risk of 13 types of cancer in men:  results of a case-control study in Montreal.  Cancer Detection and Prevention, 32 (2009): 352-362. 

Wine is time-honored component of the healthy Mediterranean diet and, traditionally, is consumed with meals.

For science and food geeks, Bix at the Fanatic Cook blog has a post outlining how red wine consumption with meals might be healthy: it reduces blood levels of cytotoxic lipid peroxidation products like malondialdehyde.

By no means is Fanatic Cook always this esoteric.  Check out some of the other topics there.

Steve Parker, M.D.

Today I’m starting a very low-carb diet, the Ketogenic Mediterranean Diet, to lose only about 10 lb (4.55 kg) of fat I’ve accumulated around my waist over the last six months. I gained the weight intentionally, so I’d have something to experiment on.  Cookies, candy bars, ice cream, cinnamon rolls and other pastries, pies, cakes, fried pies, french fries, shakes and malts—all these reliably put extra weight on me.  It’s not been a burden to gain the weight.  I did it for Science!

My current stats

Weight: 170 lb (77.3 kg)

Height: 71 inches (180 cm)

Body mass index: 23.8

Waist circumference: 36.5 inches (92.7 cm)

Usual  caloric intake: 2400/day (from prior self-experimentation and food diaries)

Activity level:  somewhat active

Health status:  Good.  No trouble with high cholesterol or trigylcerides, diabetes, heart disease, high blood pressure.

Comments

My body mass index is in the healthy range, so the 10 pounds I want to lose are “vanity pounds.”  You wouldn’t call me fat.  Maybe “a little chubby.”  My daughter and mother both spontaneously mentioned the excess weight to me.  My usual adult weight is around 160 pounds.  I dropped to 148 once through caloric restriction; my wife thought that was too low. 

My Plans

I’ll report daily at the Diabetic Mediterranean Diet Blog regarding my weight, dietary transgressions, exercise, random thoughts, etc.  Check under the category “My KMD Experience” if you want to follow along. 

If it’s not too much hassle, I’ll track my food intake at NutritionData.com and share the nutritional analysis weekly.  I’m hoping I don’t get too busy to keep this up.

Steve Parker, M.D.