Advanced Mediterranean Diet

How do you live a long life? 

“Take a two-mile walk every morning before breakfast.”

                                                                -Harry S. Truman

Researchers at Harvard and the University of Athens (Greece) report that the following specific components of the Mediterranean diet are associated with lower rates of death:

• moderate ethanol (alcohol) consumption
• low meat and meat product intake
• high vegetable consumption
• high fruit and nut consumption
• high ratio of monounsaturated fat to saturated fat
• high legume intake

Minimal, if any, contribution to mortality was noted with high cereal, low dairy, or high fish and seafood consumption. 

The researchers examined diet and mortality data from over 23,000 adult participants in the Greek portion of the European Prospective Investigation into Cancer and nutrition.  You’ll be hearing more about the EPIC study for many years.  Over an average follow-up of 8.5 years, 1,075 of participants died.  652 of these deaths were of participants in the lower half of Mediterranean diet adherence; 423 were in the upper half.

Alcohol intake in Greece is usually in the form of wine at mealtimes. 

The beneficial “high ratio of monounsaturated fat to saturated fat” stems from high consumption of olive oil and low intake of meat. 

It’s not clear if these findings apply to other nationalities or ethnic groups.  Other research papers have documented the health benefits of the Mediterranean diet in at least eight other countries over three continents. 

The researchers don’t reveal in this report the specific causes of death.  I expect those data, along with numbers on diabetes, stroke, and dementia, to be published in future articles, if not published already.  Prior Mediterranean diet studies indicate lower death rates from cardiovascular disease and cancer.   

Steve Parker, M.D.

Reference:  Trichopoulou, Antonia, et al.  Anatomy of health effects of the Mediterranean diet: Greek EPIC prospective cohort study.  British Medical Journal, 338 (2009): b2337.  DOI: 10.1136/bmj.b2337.

Additional Information:  Childs, Dan.  Take it or leave it?  The truth about 8 mediterranean diet staples.  ABC News online, June 24, 2009.  Accessed June 25, 2009.

Update June 26, 2009:

Here’s a direct quote from the study at hand:

Among the presumed beneficial components of the Mediterranean diet score, high consumption of all but fish and seafood was inversely associated with mortality, although none of these associations was statistically significant.

“. . . none of these associations was statistically significant.”  So I can understand some skepticism about this journal article. The researchers had to use some very sophisticated statistical manipulation to come up with the “healthy components” list. I’m not saying that’s wrong. I will admit that the statistical analysis is beyond my comprehension, so I’m trusting the authors and peer-review process to be honest and effective. My college statistics course was too many years ago.

The take-home point for me is that the health benefits of the Mediterranean diet probably stem from an overall combination of multiple foods rather than any single component.

Steve Parker, M.D.

And remember to exercise regularly, maintain a healthy weight (BMI 18.5-25), keep your blood pressure under 140/90, and don’t smoke.

-Steve

Yo-yo dieting isn’t so bad after all.

Ten years ago there was lots of hand-wringing in the medical community about the potential dire physical consequences of “weight cycling” - also known as yo-yo dieting.  You know, lose a bunch of weight, gain it back, lose it again, gain it back, etc.

Then you didn’t hear so much about it.  It was a bit of a fad.  Like “detoxing,” although certainly more legitimate. 

A recent study in the Archives of Internal Medicine reported on the cardiovascular and mortality effects of yo-yo dieting in women in the massive Nurses’ Health Study.  One in four of these women could be classified as weight cyclers.  The worst ones were defined as those who lost at least 9.1 kg ( 20 pounds) at least three times.

It turns out the weight cyclers had the same rates of death from cardiovascular disease or any cause as the women who didn’t cycle.  They did eventually gain more overall weight as they aged, compared to the non-cyclers. 

Note that this study investigated death rates only.  So there may have been effects on rates of high blood pressure, diabetes, gout, stroke, etc, that we wouldn’t know about. 

Steve Parker, M.D.

Field, Alison, et al.  Weight cycling and mortality among middle-aged or older women.  Archives of Internal Medicine, 169 (2009): 881-886.

U.S. researchers found an association between decreased all-cause mortality - i.e., the chance of dying from anything - and religiosity.

The Women’s Health Initiative observational study has spawned numerous scientific research articles.  It generated data based on a survey of nearly 95,000 U.S. women between 50 and 79 years old at the start of the study.  Average follow-up time was 7.7 years.

The survey included religiosity variables: religious affiliation, frequency of religious service attendance, and religious strength and comfort.

These variables were associated with 10 to 20% reductions in all-cause mortality compared to non-religious women or those who expressed their religiosity in other ways.  For instance, weekly religious service attendance was associated with a 20% lower risk of death.

Nobody knows if the results apply to men, but I suspect they do.  You might say I have faith.

Steve Parker, M.D.

Reference:  Schnall, Eliezer, et al.  The relationship between religion and cardiovascular outcomes and all-cause mortality in the women’s health initiative study.  Psychology and Health, November 17, 2008.  DOI: 10.1080/08870440802311322

Italian researchers reported in the September 11, 2008, online issue of the British Medical Journal what is already known:

“Greater adherence to a Mediterranean diet is associated with a significant improvement in health status, as seen by a significant reduction in overall mortality (9%), mortality from cardiovascular diseases (9%), incidence of or mortality from cancer (6%), and incidence of Parkinsons’s disease and Alzheimer’s disease (13%).  These results seem to be clinically relevant for public health, in particular for encouraging a Mediterranean-like dietary pattern for primary prevention of major chronic diseases.”

Methodology

Researchers, mostly at the University of Florence, performed a meta-analysis of 12 other published studies that looked at the effects of a Mediterranean-style eating pattern on health and longevity.  [Meta-analyses are popular, in part, because they are cheap.  This study required no specific funding.]

Most, if not all, of these 12 studies were observational, and involved 1,574,299 participants.  Six of the 12 studies were in Mediterranean countries, the others were in the U.S., northern Europe, and Australia.  Study participants were followed between 3.7 and 18 years.

The researchers devised their very own Mediterranean diet scale based on study participants’ intake of various foods.  Participants were given a point if they had higher than average intake of vegetables, fruits, legumes, cereals, fish, and red wine during meals.  They were given a point if they had lower than average intake of red meat, processed meats, and dairy products.  Due to differences among the 12 studies, “the total adherence scores…varied from a minimum of 0 points indicating low adherence to a maximum of 7-9 points reflecting high adherence to a Mediterranean diet.”

[This version of a Mediterranean diet score is problematic.  Curiously, olive oil - the predominant source of fat in the traditional Mediterranean - is not in the score.  Olive oil is a key characteristic of the Mediterranean diet.  Furthermore, the study authors also state that dairy products are ”presumed not to form part of a Mediterranean diet.”  Most experts would argue that cheese and yogurt are a significant part of the Mediterranean diet, if only in low amounts.  I also doubt that participants in the 12 original studies  were surveyed whether they drank red wine -as contrasted with white - and whether it was with meals or not.  I admit I did not read each of the 12 component studies.  The underlying cause of this idiosyncratic definition of the Mediterranean diet is that the 12 original studies themselves used different definitions of the Mediterranean diet.  The meta-analysts had to pigeonhole the data.  There are a handful of respected Mediterranean diet scores in existence, but the authors of this study couldn’t apply them across the board due to database inconsistency or inadequacy.]

Results

“The cumulative analysis of 12 cohort studies shows that a two point increase [emphasis added] in the score for adherence to a Mediterranean diet determines a 9% reduction, in overall mortality, a 9% reduction in mortality from cardiovascular diseases, a 6% reduction in incidence of or mortality from neoplasm [cancer], and 13% reduction in incidence of Parkinson’s disease and Alzheimer’s disease.”

The only one of the 12 original studies focused on Alzheimer’s disease, and it showed a 17% reduction in participants with high adherence to the Mediterranean diet.  The two studies that focused on Parkinson’s disease revealed a 7% reduction in men, and 15% reduction in women.  These reduced incidence figures, again, apply to a two-point increase in Mediterranean diet adherence score.

Discussion

The authors indicate that their report is the first ever meta-analysis of the data associating the Mediterranean diet with reduced mortality and chronic disease in the general population.  Congratulations, guys!

The authors’ idiosyncratic Mediterranean diet score is unusual and won’t be widely adopted.  However, the 12 studies comprising the meta-analysis did have reasonable Mediterranean diet characteristics.

Combining Alzheimer’s data with Parkinson’s data doesn’t make sense to me, nor did the authors try to explain it.   You could lump them into the category of “neurodegenerative diseases,” but they aren’t the only ones by any means.  The single Alzheimer’s study, by the way, was quite small compared to the two Parkinson’s studies.

Nearly all the popular media stories reported the findings as I did in my first paragraph above, which may be  misleading.  The specific improvements in mortality and various disease rates is per two-point increase in Mediterranean diet score.  For example, consider the 9% reduction in overall mortality.  If a population increased its Mediterranean score by four points, would overall mortality be reduced by 18%?  I’ve read this study four times and cannot answer my own question.  But I suspect that the answer is “yes.”  So the news here may better than it seems at first blush.

In other words: If a population’s score goes from 5 to 7, the death rate is reduced by 9%.  If that same population then moved its score from 7 to 9, would mortality improve another 9%?  I think so, but this study as written does not make it clear.

I’m starting to see why the popular media simplified the study findings.  The reporting on this study is amazingly uniform.  They must have all gotten the same news release.

Of course, “populations” don’t die or get cancer, heart attacks, strokes, Alzheimer’s, or Parkinson’s disease.  Individuals do that.  If I as an individual had a low Mediterranean diet score, I would try to improve my score by at least two points.  A good place to start would be a review of the Mediterranean Diet Pyramid promoted by Oldways Preservation and Exchange Trust (reproduced with permission):

Steve Parker, M.D., author of The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer

Reference:  Sofi, Francesco, et al.  Adherence to Mediterranean diet and health status: Meta-analysis.  British Medical Journal, 337; a1344.  Published online September 11, 2008.  doi:10.1136/bmj.a1344

Jesus turned water into wine at a wedding.  His mother asked him to do it.  Of all the miracles he performed and could have performed, I wonder why this is the first one recorded in the Holy Bible.

We have known for years that low or moderate alcohol consumption tends to lower the risk of cardiovascular disease such as heart attack and stroke, and prolongs life span.  Physicians have been hesitant to suggest that nondrinkers take up the habit.  We don’t want to be responsible for, or even accused of, turning someone into an alcoholic.  We don’t want to be held accountable for someone else’s drunken acts.  Every well-trained physician is quite aware of the ravages of alcohol use and abuse.  We see them up close and personal in our patients.

A scientific study earlier this year, however, lends support to a middle-aged individual’s decision to start consuming moderate amounts of alcohol on a regular basis.  It even provides a positive defense if a doctor recommends it to carefully selected patients.

This research, by the way, was supported by a grant from the National Heart, Lung, and Blood Institute, not the wine/alcohol industry.

Methodology

Researchers at the Medical University of South Carolina examined data on 15,637 participants in the Atherosclerosis Risk in Communities (ARIC) study over a 10-year period.  These men and women were 45 to 64 years old at the time of enrollment, living in four communities across the U.S.  Of the participants, 27% were black, 73% nonblack, 28% were smokers, and 80% of them had high blood pressure, high cholesterol, or diabetes.

Out of 15,637 participants at the time of enrollment, 7,359 indicated that they didn’t drink alcohol.  At baseline, these 7,359 had no cardiovascular disease except for some with high blood pressure.    Subsequent interviews with them found that six percent of the nondrinkers - 442 people - decided independently to become moderate alcohol drinkers.  Or at least they identified themselves as such.

“Moderate” intake was defined as 1-14 drinks per week for men, and 1-7 drinks a week for women.  Incidentally, 0.4% of the initial non-drinking cohort - 21 people - became self-identified heavy drinkers.

93.6% of the 7,359 non-drinkers said that they continued to be non-drinkers.  These 6,917 people are the “persistent nondrinkers.”

Type of alcohol consumed was also surveyed and broken down into 1) wine-only drinkers, or 2) mixed drinkers: beer, liquor, wine.

Researchers then monitored health outcomes for an average of 4 years, comparing the “new moderate drinkers” with the “persistent nondrinkers.”

Results

•  Over 4 years, 6.9% of the new moderate drinkers suffered a cardiovascular event, defined as a heart attack, stroke, a coronary heart disease procedure (e.g, angioplasty), or death from cardiovascular disease.
• Over 4 years, 10% of the persistent nondrinkers suffered a cardiovascular event.
• The new moderate drinkers were 38% less likely than persistent nondrinkers to suffer a new cardiovascular event (P = 0.008, which is a very strong association).  The difference persisted even after adjustment for demographic and cardiovascular risk factors.
• There was no difference in all-cause mortality (death rate) between the new moderate drinkers and the persistent nondrinkers.
• New  drinkers had modest but statistically significant improvements in HDL and LDL cholesterol and mean blood pressure compared with persistent nondrinkers.
• 133 new moderate drinkers consumed only wine
• 234 new moderate drinkers consumed mixed types of alcohol
• Wine-only drinkers were 68% less likely than nondrinkers to suffer a cardiovascular event.
• “Consumers of moderate amounts of beer/liquor/mixed (which includes some wine) tended to also be less likely to have had a subsequent cardiovascular event than nondrinkers…but the difference was not significant.”

A Few Study Limitations

• Four years is a relatively brief follow-up, especially for cancer outcomes.  Alcohol consumption is associated with certain types of cancer.
• If moderate alcohol consumption indeed lowers death rates as suggested by several other studies, this study may not have lasted long enough to see it.
• The alcohol data depended on self-reports.

Take-Home Points

The study authors cite four other studies that support a slight advantage to wine over other alcohol types.  It’s a mystery to me why they fail to stress the apparent superiority of wine in the current study.  Several other studies that found improved longevity or cardiovascular outcomes in low-to-moderate drinkers suggest that the type of alcohol does not matter.  Perhaps “the jury is still out.”  In the study at hand, however, it is clear that the reduced cardiovascular disease rate in new moderate drinkers is associated with wine.

In all fairness, other studies show no beneficial health or longevity benefit to alcohol consumption.  But at this point, the majority of published studies support a beneficial effect.

Wine is a component of the traditional healthy Mediterranean diet.  The Mediterranean diet is associated with prolonged life span and reduced cardiovascular disease.  This study strongly suggests that wine is one of the causative healthy components of the Mediterranean diet.

Starting a judicious wine habit in middle age is relatively safe for selected people and may, in fact, improve cardiovascular health, if not longevity.

Now the question is, red or white.  Or grape juice?

Steve Parker, M.D.

Reference:  King, Dana E., et al.  Adopting Moderate Alchohol Consumption in Middle Age: Subsequent Cardiovascular Events.  American Journal of Medicine, 121 (2008): 201-206.

As a physician, I see many illnesses and conditions that are caused or aggravated by overweight and obesity.  Both terms refer to excess body fat; obesity is a greater degree of fat.

Body mass index (BMI) is used to define overweight and obesity.  Your BMI is your weight in kilograms divided by your height in meters squared.  A BMI between 18.5 and 25 is considered healthy.  BMIs between 25 and 30 are overweight.  Here’s an online BMI calculator.  For example, a 5-foot, 4-inch person enters obesity territory - BMI over 30 - when weight reaches 174 pounds (79 kilograms).  A 5-foot, 10-incher is obese starting at 208 pounds (94.5 kilograms).

People trying to lose excess fat typically have days when willpower, discipline, and commitment waver.  On those days, it can help to remember why they started this adventure in the first place.  The reasons for many involve improved health and longevity.  Even if you have just 20 pounds of excess fat to lose, it will often take twenty weeks.  Your weight-loss goal is one to one-and-a-half pounds a week.  This race is won not by the swift, but by the slow and steady.

Here’s a laundry list of obesity-related conditions to remind you why you want to avoid obesity:

• Premature death.  It starts at BMI of 30, with a major increase in premature death at BMI over 40.  The U.S. has 200,000 yearly deaths directly attributable to obesity.
• Arthritis, especially of the knees.
• Type 2 diabetes melllitus.  Eight-five percent of people with type 2 diabetes are overweight.
• Increased cardiovascular disease risk, especially with an apple-shaped fat distribution as compared to pear-shaped.  Cardiovascular disease includes heart attacks, high blood pressure, strokes, and peripheral arterial disease (poor circulation).
• Obstructive sleep apnea.
• Gallstones are three or four times more common in the obese.
• High blood pressure.  At least one third of cases are caused by excess body fat.  Every 20 pounds of excess fat raises blood pressure 2-3 points (mmHg).
• Tendency to higher total and LDL cholesterol, higher triglycerides, while lowering HDL cholesterol.  These lipid changes are associated with hardening of the arteries - atherosclerosis - which can lead to heart attacks, strokes, and peripheral arterial disease.
• Increased cancers.  Prostate and colorectal in men.  Endometrial, gallbladder, cervix, ovary, and breast in women.  Kidney and esophageal adenocarcinoma in both sexes.  Excess fat contributes to 14-20% of all cancer -related deaths in the U.S.  Over 550,000 people die from cancer in the U.S. yearly.  Twenty percent of us will die from cancer.
• Strokes.
• Low back pain.
• Gout.
• Varicose veins.
• Hemorrhoids.
• Blood clots in legs and lungs.
• Surgery complications: poor wound healing, blood clots, wound infection, breathing problems.
• Pregnancy complications: toxemia, high blood pressure, diabetes, prolonged labor, greater need for C-section.
• Fat build-up in liver.
• Asthma.
• Low sperm counts.
• Decreased fertility.
• Delayed or missed diagnosis due to difficult physical examination or weight exceeding the limit of diagnostic equipment.

I hope you find this information motivational rather than depressing.  For those already obese, weight loss can significantly improve, alleviate, or prevent these conditions.  Many obesity-related medical conditions and metabolic abnormalities are improved with loss of just five or 10% of total body weight.  For instance, a 240 pound man with mild diabetes and high blood pressure may be able to reduce or avoid drug therapy by losing just 12 to 24 pounds.  He’s still obese, but healthier.

Steve Parker, M.D. 

Shelley Wood wrote a brief article for heartwire in which she interviewed several cardiologists regarding the untimely demise of Tim Russert.  Mr. Russert suffered sudden cardiac arrest from a ruptured atherosclerotic plaque in a major heart artery.  In other words, a heart attack.  Prominent cardiologist Eric J. Topol noted that Mr. Russert’s  weight was a major uncontrolled risk factor.

This intersting article that contains much more information than you would see in your typical television or newspaper coverage.  Commentators provide lively debate after the article.

Miranda Hitti wrote a similar article  for WebMD in which she interviewed three prominent cardiologists about the death.  They discuss various cardiac risk factors and strategies for prevention and detection of coronary artery disease.

But in neither article is mentioned a role for the Mediterranean diet, despite proven efficacy in prevention of cardiovascular disease such as heart attacks.  Diet modification too often plays second fiddle to drug therapy, angioplasty, and coronary artery bypass surgery.

My thoughts and prayers are with the Russert family in this time of loss.

Steve Parker, M.D.

References:

Parikh, Parin, et al.  Diets and cardiovascular disease: an evidence-based assessment.  Journal of the American College of Cardiology, 45 (2005): 1,379-1,387.

Gau, Gerald T.  The search for the perfect heart-healthy diet.  Mayo Clinic Proceedings, 78, (2003): 1,329-1,330.

I often talk to people interested in improving their health or losing weight via lifestyle modification, mostly changes in diet and exercise.  Many of them are motivated by health-related facts.  Here is a smattering of facts, starting out worrisome and ending hopeful: 

• 65% of U.S. adults are overweight or obese.  Half are overweight, half are obese. 

• 12% of deaths in the U.S. are due to lack of regular physical activity - 250,000 deaths yearly.

• 11% of U.S. adults have diabetes mellitus.

• 24 million in the U.S. have diabetes.  Another 57 million have pre-diabetes, a condition that increases your risk for diabetes.

• 23% of U.S. adults over 60 have diabetes. 

• 85% of people with type 2 diabetes are overweight.

• 200,000 yearly deaths in the U.S. are due to obesity.

• Excess body fat causes 14 to 20% of all cancer-related deaths in the U.S.

• 550,000 people die yearly of cancer in the U.S. 

• Obesity-related cancers in men: prostate and colorectal.  Obesity-related cancers in women: endometrial (uterine), cervix, ovary, breast.  Both sexes: kidney, esophageal adenocarcinoma.

• 20% of us in the U.S. will die of cancer.

• Lifetime risk of developing invasive cancer in the U.S. is four in 10 (a little higher in men, a little lower in women).

• At least one-half of high blood pressure cases are caused by excess body fat.  Every 20 pounds of excess fat increases blood pressure by two to three points.

• Peak aerobic power (a measure of physical fitness) decreases by 50% between age 20 and 65.

• Middle-aged and older people through regular exercise can increase their aerobic power by 15 to 20%, equivalent to a 10 or 20-year reduction in biological age. 

• Regular aerobic exercise reduces blood pressure by 8 to 11 points.  

• Have you already had a heart attack?  If so, regular exercise reduces the odds of fatal recurrence by 25% and adds two to three years to life.

• The Mediterranean diet is associated with lower incidence of cancer (colon, breast, prostate, uterus), cardiovascular disease (e.g., heart attacks), and dementia (both Alzheimers and vascular types). 

• High fruit and vegetable consumption protects against cancer of the lung, stomach, colon, rectum, oral cavity, and esophagus.  The protective “dose” is five servings a day.

• Coronary artery disease is the cause of heart attacks and many cases of sudden cardiac death.  Legume consumption lowers the risk of coronary artery disease.  The protective dose is four servings of legumes a week. 

• Whole grain consumption is associated with reduced risk of coronary artery disease (e.g., heart attacks), lower risk of death, lower incidence of type 2 diabetes and several cancers.  The protective dose is three servings a day. 

The good news is that we can significantly reduce our risk of premature death and common illnesses such as high blood pressure, cancer, diabetes, coronary artery disease, and dementia.  How?  Weight management, diet modification, and physical activity.     

Steve Parker, M.D., author of the award-winning Advanced Mediterranean Diet 

The U.S. Centers for Disease Control and Prevention, along with the National Vital Statistics System, reported this month on death rates and life expectancy for the year 2006, the latest year for which numbers are available.

• From 2005 to 2006, death rates decreased significantly for 11 of the 15 top causes of death in the U.S.
• There were fewer age-adjusted deaths from heart disease, cancer, strokes, high blood pressure, and diabetes mellitus.
• Life expectancy in the U.S. rose to an unprecedented 78.1 years.  [Japan holds the record at 83 years.]

Please keep these optimistic statistics in mind as you fret about the risks of overweight and obesity, shoddy medical care, high fructose corn syrup, chemical additives in plastic water and baby bottles, fish contaminated with mercury and PCBs, lead paint on toys, overpopulation, medical errors in hospitals, high-carbohydrate diets, saturated fats, trans fats, food coloring and other chemical food additives, municipal water supply contamination by medications, global warming, childhood vaccinations, killer tomatoes (Salmonella contamination), cancer from cellphones, and staph gone wild (MRSA: methicillin-resistant staph aureus).

- Steve Parker, M.D., author of the award-winning Advanced Mediterranean Diet

Additional information:  CDC’s graphical presentation of declining death rates for heart disease, cancer, and cerebrovascular disease from 2001 to 2006.