The Mediterranean diets in health and disease

295 Pages·1991·41.324 MB·English

by  Gene A Spiller

1
Comparison of Current Eating
Habits in Various Mediterranean
Countries
Rosalba Giacco
Gabriele Riccardi
The Mediterranean diet, as a model of a healthful diet, has been the
subject of several studies since World War II. The term Mediterranean diet
was first used by Ancel Keys, an American physiologist, in his book
How to Eat Well and Stay Well: the Mediterranean Way (Keys and Keys 1975).
At the end of World War II, the Keyses' theory regarding the importance
of a well-balanced diet in maintaining health began to solidify: They
proposed a relationship between the eating habits of populations of dif
ferent geographical areas and the distribution of morbidity and mortality
from cardiovascular diseases. Prof. Keys's insight was confirmed by the
results of the Seven Countries Study, which showed that the Mediterra
nean countries, where cardiovascular disease morbidity and mortality
are low, have particularly low serum cholesterol levels compared to
countries such as Finland and the United States, where the incidence of
cardiovascular diseases is higher. These diversities can be partly ex
plained by the difference in the intake of saturated fatty acids in the
various popUlations (Keys 1970; Keys et al. 1986).
Intervention studies on eating habits have greatly strengthened ac
ceptance of the role played by diet in the etiology of cardiovascular dis
eases. In a study conducted in northern Karelia, Finland, a group of
middle-aged volunteers was invited to replace their usual diets, rich in
saturated fatty acids, with a typical Mediterranean diet (with a low con
tent of saturated fatty acids) for six weeks. The results showed a signifi
cant decrease in plasma cholesterol concentrations, but these returned
to their previous high levels when the subjects returned to their custom
ary diets (Ehnholm et al. 1982). At about the same time, a complemen
tary study with a similar methodology was being conducted in the area
3
G. A. Spiller (ed.), The Mediterranean Diets in Health and Disease
© Van Nostrand Reinhold 1991
4 R. Giacco and G. Riccardi
of Cilento in southern Italy. Its aim was to evaluate the effects of tempo
rarily replacing the habitual Mediterranean diet with a typical northern
European diet. In this case, plasma cholesterol levels declined to their
initial values when the participants returned to their usual diets. This
study further confirms. the relationship between dietary habits and
plasma lipid levels (Ferro-Luzzi et aL 1984).
MEDITERRANEAN DIET: MYTH OR REALITY?
Although the Mediterranean diet has often been proposed as a model
of healthful eating habits, many uncertainties still exist concerning the
nutritional characteristics of this type of diet. A research study carried
out by the European Atomic Energy Community (EURATOM) in the
1960s represents one of the major sources of information on the quality
and quantity of food intake in Europe. This study showed remarkable
dissimilarities among the different countries studied, in particular, con
sumption of more cereals, fruit, and vegetables and less meat, sugar,
milk, and dairy products in Italy than in other European countries. It
was particularly interesting to note that in Italy, the quantity of fat con
sumed was the same as that of other countries, but it was very different
in terms of quality: almost exclusively olive oil, with irrelevant quantities
of margarine, butter, and lard (Cresta et al. 1969).
Unfortunately, when speaking of the Mediterranean diet, we are in
clined to conceive of it as a homogeneous nutritional model, although
there are several Mediterranean nations with varied cultures, traditions
and, probably, dietary habits as well. On first consideration, it would
not seem correct to extrapolate the eating habits in Greece or southern
Italy to all the other Mediterranean countries; but further reflection sug
gests that beyond the 'apparent diversities, some nutritional characteris
tics could be common to all or most of the Mediterranean area.
Ferro-Luzzi and Sette (1989) provided further information on this is
sue by means of a study that compared the nutritional intakes of 16
Mediterranean and 12 northern European countries from 1961 to 1963.
This research confirms the results of the EURATOM study on the differ
ent intakes of fat in the two groups of countries compared. However,
the study does not give much additional information as to other charac
teristics of the Mediterranean diet, although it seems to indicate that
consumption of vegetables in both northern Europe and the Mediterra
nean area is similar. Moreover, it investigated the eating habits of the
Mediterranean countries only from 1961 to 1963, and it is possible that
modifications in eating styles did occur as a consequence of socioeco
nomic evolution, making the present diet in Mediterranean countries
COMPARISON OF CURRENT EATING HABITS 5
more similar to that of highly industrialized countries with higher
cardiovascular risk.
Therefore, we have undertaken a nutritional study aiming at (1) de
fining the nutritional characteristics of all the countries in the Mediterra
nean area through evaluation of their food intakes, and (2) examining
the possibility that there is a common nutritional pattern for all Mediter
ranean countries that could be defined as "Mediterranean diet" and
determining whether this type of diet corresponds to the current recom
mended allowances for the prevention of coronary heart disease (CHD).
We have adopted the 1979 to 1981 Food Balance Sheets published by
FAO (FAO 1984) to gain information on the dietary intake of 14 Mediter
ranean countries (Portugal, Spain, France, Italy, Yugoslavia, Greece,
Malta, Israel, Libya, Algeria, Tunisia, Turkey, Egypt, and Morocco) and,
for comparison, of the United States, chosen as an example of a typical
industrialized country at high risk for cardiovascular diseases. The Food
Balance Sheets show for each country the foods available (produced
and/or imported) but do not take into account the losses that may occur
before consumption. Despite this limitation, the FAO report represents
the only standard source currently available for a comparison of food
consumption among countries.
Our research shows that the consumption of eggs, milk, and dairy
products is lower in all Mediterranean countries (62-430 g/d) than in the
United States (505 g/d). The result is in good agreement with previous
studies and confirms that a lower intake of these food items is still a
constant feature of the present-day Mediterranean diet. A high con
sumption of olive oil (Fig. 1-1) represents another important characteris
tic of this type of diet, although the intake varies greatly from country
to country. The importance of olive oil as a substitute for animal fat in
the diet has been demonstrated by clinical and biological research; the
results support its role in preventing cardiovascular diseases (Trevisan
et a1. 1990).
Our study has led to another interesting result concerning the high
intake of cereals in the Mediterranean countries. These countries derive
30-60% of their daily caloric intake from cereals, whereas in the United
States, the average is only 19%. The high consumption of food rich in
starch in the Mediterranean countries is similar to that reported for the
Far East, where cardiovascular mortality risk is also low. Another typical
aspect of the dietary habits of the Mediterranean area is the low con
sumption of meat, although people from European countries tend to eat
more meat than do North African people: 89 ± 44 g/d versus 78 ± 64
g/d (means ± standard deviation).
As expected, the intake of legumes, which are rich in soluble fiber
and complex carbohydrates, is also higher in the Mediterranean area as
6 R. Giacco and G. Riccardi
UBYA
GREECE
rrALY
SPAIN
TUNISIA
PORTUGAL
TURKEY
MOROCCO
ALGERIA
FRANCE
ISRAEL
MALTA
YUGOSlAVIA
UM
EGYPT
0 20 40 60 g(day 80
Figure 1-1. Per capita consumption of olive oil in Mediterranean countries and
United States.
compared to the United States, 6 gld, with the exception of France, 5
gl d; the levels range from a maximum of 21 gl d for Yugoslavia to a mini
mum of 7 gld for Malta. However, the intake of legumes is lower than
expected, averaging a portion less than twice a week. This result raises
the possibility that changes in eating habits have occurred in recent dec
ades because of the improvement in socioeconomic conditions. This
phenomenon can help to explain the absence of very striking differences
between the United States and the Mediterranean countries regarding
consumption of other foods usually believed to be typical of the Mediter
ranean diet, namely fruit and vegetables.
In summary, the Mediterranean diet is characterized by a high intake
of cereals and olive oil and a low intake of animal fat and meat.
COMPARISON BETWEEN THE PRESENT-DAY DIET
IN MEDITERRANEAN COUNTRIES AND CURRENT
DIETARY RECOMMENDATIONS FOR CHD
PREVENTION
In analyzing the composition of the diet in Mediterranean countries (Fi
danza and Versiglioni 1987), we have expressed the nutrients as percent
age of total daily calories (Fig. 1-2) and compared their distribution with
the current allowances recommended by the European Atherosclerosis
COMPARISON OF CURRENT EATING HABITS 7
DIETARY
RF.<XHmNDATIONS
USA
FRANCE
SPAIN
ITALY
GREECE
MALTA
ISRAEL
LIBYA
PORTIJGAL
YUGOSLAVIA
TUNISIA
'l'URKEY
ALGERIA
EGYPT
MOROCCO
0 20 40 60 80 III 100
iiiliI SFA
~ UFA
0 PROlEINS
fill CHO
Figure 1-2. Diet composition in Mediterranean countries and United States.
Society (EAS) for the prevention of cardiovascular diseases (Study
Group of the EAS 1987). These recommendations can be summarized
as follows:
• Limit the total fat intake to less than 30% of caloric intake.
• Reduce saturated fatty acids to less than 10% and cholesterol to less
than 300 mg/d.
• Keep the intake of complex carbohydrates above 50% of total caloric
intake, especially of foods rich in fiber and of vegetable origin.
In addition, avoidance of overweight and moderation in salt intake are
also recommended.
For eight of the Mediterranean countries, saturated fatty acids repre
sent less than 10% of the total caloric intake; for five of them, the intake
ranges between 11% and 14%, whereas for France it is 18%, the same
8 R. Giacco and G. Riccardi
as that reported for the United States. Total fat represents less than 30%
of total energy intake in six countries: Yugoslavia, Tunisia, Turkey, Alge
ria, Egypt, and Morocco. It is just slightly above the recommended in
take, between 31 % and 37%, for seven countries: Spain, Portugal, Italy,
Libya, Greece, Israel, and Malta. The only country to have a very high
fat intake (43%) is France, this figure again being the same as that for
the United States. With the exception of France, populations in the Med
iterranean countries use chiefly unsaturated fat, which does not contrib
ute to the risk of cardiovascular diseases (Grundy and Bonanome 1987).
The consumption of cholesterol is lower in the Mediterranean countries,
with the exception of France, than in the United States (656 mg/d). How
ever, it falls within the recommended allowance «300 mg/d) for only
five countries: Egypt, Algeria, Morocco, Tunisia, and Turkey.
The carbohydrate fraction in the Mediterranean diet, however, corre
sponds to the recommended allowance, >50%. The exception once
again is France, where carbohydrate intake is 43% of total energy and is
similar to that reported for the United States, 44%.
In all the Mediterranean countries and in the United States, protein
allowance is in line with the EAS recommendations. It is mainly of vege
table origin for North African countries.
Contrary to our expectations, the daily intake of fiber, which is
known to have beneficial effects on glucose and lipid metabolism and
also to contribute to cancer prevention (Jenkins et al. 1979; Rivellese et
al. 1980), seems to be lower than the recommended intake, 20 gllOOO
kcalld, in the whole Mediterranean area. It varies from 7 g/1000 kcalld
in Malta to 11 g/1000 kcalld in Turkey, quantities that do not differ
greatly from those reported for the United States, 7 gllOOO kcalld.
In short, there is a common nutritional profile for the Mediterranean
countries characterized by low intake of saturated fat, moderate intake
of total fat with prevalence of monounsaturated fat, and high intake of
complex carbohydrates. These characteristics confirm the adequacy of
the Mediterranean diet for preventing cardiovascular diseases and other
chronic degenerative diseases typical of industrialized countries (Stam
ler 1985; Riccardi et al. 1988).
The socioeconomic development that has occurred in this area in the
last few decades has unfortunately begun, probably, to bring with it
some poor dietary habits, particularly the high intake of cholesterol and
the low intake of vegetable fiber by people of the whole Mediterranean
area. It is hoped that awareness of the nutritional value of the Mediterra
nean diet will help maintain and spread these beneficial dietary practices
and possibly reverse the dangerous trend, caused by urbanization and
socioeconomic progress, toward discarding this model of a healthful
diet.
COMPARISON OF CURRENT EATING HABITS 9
REFERENCES
Cresta, M., S. Ledermann, A. Gamier, E. Lombardo, and G. Lacourly. 1969.
Etude des consommations alimentaires des populations de onze regions de la commu
naute europeenne en vue de la determination des niveaux de contamination radioac
tive. Rapport etabli au Centre d'Etude Nucleaire de Fotenay-aux-Roses,
France: EURATOM, Commissariat 11 l'energie atomique (CEA).
Ehnholm, c., J. K. Huttunen, P. Pietinen, et al. 1982. Effect of diet on serum
lipoprotein in a population with a high risk of coronary heart disease. New
Eng/. ]. Med. 307:850-855.
FAO (Food and Agriculture Organization of the United Nations). 1984. Food Bal
ance Sheets, 1979-1981 Average. Rome.
Ferro-Luzzi, A., and S. Sette. 1989. The Mediterranean diet: an attempt to de
fine its present and past composition. Eur. J. Clin. Nutr. 43(suppl. 2):13-29.
Ferro-Luzzi, A., P. Strazzullo, C. Scaccini, et al. 1984. Changing the Mediterra
nean diet: effects on blood lipids. Am. J. Clin. Nutr. 40:1027-1037.
Fidanza, F., and N. Versiglioni. 1987. Tabelle di Composizione Degli Alimenti.
Naples: Idelson.
Grundy, S. M., and A. Bonanome. 1987. Workshop on Monounsaturated Fatty
Acids. Arteriosclerosis 6:644-648.
Jenkins, D. J. A., A. R. Leeds, B. Slavin, et al. 1979. Dietary fiber and blood
lipids: reduction of serum cholesterol in type II hyperlipidemia by guar gum.
Am. J. Clin. Nutr. 32:16-18.
Keys, A. 1970. Coronary heart disease in seven countries. Circulation 41(1):1-
211.
Keys, A., and M. Keys. 1975. How To Eat Well and Stay Well the Mediterranean
Way. New York: Doubleday.
Keys, A., A. Menotti, M. J. Karvonen, et al. 1986. The diet and 15 year death
rate in Seven Countries Study. Am. J. Epidemiol. 124:903-915.
Riccardi, G., A. A. Rivellese, and M. Mancini. 1988. Current dietary recommen
dations for coronary heart disease prevention. Diab. Nutr. Metab. 1:7-9.
Rivellese, A., G. Riccardi, and A. Giacco, et al. 1980. Effect of dietary fibre on
glucose control and serum lipoproteins in diabetic patients. Lancet 2:447-450.
Stamler, J. 1985. The marked decline in coronary heart disease mortality rates
in USA 1968-1981; summary of findings and possible explanations. Cardiology
72:11-22.
Study Group, European Atherosclerosis Society. 1987. Strategy for prevention
of coronary heart disease: a policy statement of European Atherosclerosis
Society. Eur. Heart]. 8:77-88.
Trevisan, M., V. Krogh, J. Freudenheim, et al. 1990. Consumption of olive oil,
butter, and vegetable oils and heart disease risk factors. JAMA 263(5):688-
692.
2
Ancient Mediterranean Food
Thomas Braun
THE EVIDENCE
Our survey of ancient Mediterranean food deals with the world of the
Bible, the Greeks, and the Roman Empire, covering a period of fifteen
hundred years from the beginning of the first millennium B.C. to the
barbarian invasions of the fifth century A.D. The ecologically distinct
river civilizations of Egypt and Mesopotamia cannot be fully taken into
account, although the Nile flows into the Mediterranean and the lands
of the eastern Mediterranean were, from time to time during this period,
under the same rulers as Mesopotamia. Nor is there scope to consider
at length the adaptation of Mediterranean civilization by central and
northwestern Europe and Britain while .under Roman rule. But the evi
dence from these neighboring regions is sometimes relevant.
The greatest innovations of human history had been successfully
completed thousands of years earlier. Since the beginning of Neolithic
times hunting, fishing, and fowling had been supplemented by agricul
ture and husbandry; how this had come about, and how the transport
of goods by sea had further transformed the diet of the Mediterranean
peoples, was already beyond human memory. Sophocles in Antigone
(332-352) ponders these achievements:
Wonders are many, and none more wonderful than man,
who crosses the sea, driven by the stormy south wind,
making his path under engulfing waves.
The oldest of the gods, Earth,
imperishable, unwearied, he wears away,
as his ploughs go up and down, year by year,
turning the soil with the offspring of horses.
And the blithe race of birds he snares,
the tribes of beasts, and the brood of the salt sea,
10
G. A. Spiller (ed.), The Mediterranean Diets in Health and Disease
© Van Nostrand Reinhold 1991
ANCIENT MEDITERRANEAN FOOD 11
in the twisted mesh of his nets, this cunning man;
and by his craft he controls the beasts of the open country
who roam the hills; the shaggy-maned horse
he tames, putting the yoke around his neck,
and the tireless bull of the mountain. . . .
New archaeological techniques in our own generation have given us
the knowledge of these remote beginnings that the biblical and classical
world lacked. Mediterranean agriculture-the cultivation of wheat and
barley and domestication of sheep, goats, pigs, and, where possible,
cattle-can today be traced back some six thousand years before the be
ginning of Hebrew and Greek literature. What people ate, and when,
can now be deduced from the leftovers of animal food, from material
that has been carbonized or waterlogged, and from the impressions and
silica skeletons of grains in mudbrick or pottery. Jane Renfrew's Palaeo
ethnobotany (1973) and N. W. Simmonds's Evolution of Crop Plants (1976)
provide excellent comprehensive surveys of the development of culti
vated vegetable foods. By the time these were completed, this kind of
evidence had transformed our knowledge of the diet of prehistory but
had not been fully utilized for historical times: Excavators of Greek and
Roman sites had not been much concerned with food remains. Paleoeth
nobotany is a fast-changing subject. The detailed work of the past fifteen
years needs to be brought together in an updated survey: The account
here presented is the worse for its absence but has benefited from the
evidence presented by M. S. Spurr (1986), "Arable Cultivation in Ro
man Italy 200 B.C.-c. A.D. 100." Archaeology can provide help: Food
preparation is often represented in ancient art, and deductions can be
made from finds of tableware, cooking vessels, and the equipment of
food processing. An outstanding example is L. A. Moritz's (1958) Grain
Mills and Flour in Classical Antiquity. But the literary evidence is fullest of
all, even more than for the two thousand years of literate Egyptian and
Near Eastern civilization that precede our chosen period. Much that ar
chaeology today confirms was already known from ancient texts when
Victor Hehn put together his great work on the migration of domestic
plants and animals from Asia to Europe, KulturpJlanzen und Haustiere,
which went through many editions in the last century.
Except for mathematical and technical treatises, it would be hard to
Editor's Note: In this chapter the references to ancient works (e.g., Odyssey, XIX
113) are placed within the text rather than at the end of the chapter. References
to recent works are listed at the end of the chapter. This format was chosen as
more appropriate for the historical perspective given here.
12 T. Braun
find a book in the enormous corpus of Greek literature that does not at
some point touch on food. The same is true of the smaller body of Ro
man literature and of the books of the Bible. Some caution is admittedly
needed. In literature of a high moral or poetical tone there may be a
certain lack of realism. Fitzgerald's translation of the Rubaiyat of Omar
Khayyam contains a famous quatrain describing a desert picnic in medi
eval Iran:
A jug of wine, a loaf of bread, and thou
Beside me, singing in the wilderness.
Fitzgerald was more faithful to his original than is generally realized;
but in this case he could not bear to include the third item in Omar's
original menu, a leg of mutton. His readers would have thought this
unpoetic. But in real life bread and wine alone make an unsatisfying
picnic, even in the company of the most tuneful beloved. The same con
siderations affect Homer. An ancient critic noticed that the Homeric he
roes never ate fish, except once when Odysseus's men were stranded
on the Island of the Sun God where they had been forbidden to touch
the god's cattle. The poet thought roast meat more appropriate for he
roes: it cost him nothing to provide it. But Odysseus (Odyssey xix 113)
speaks of the fish of the sea as a gift comparable to wheat and barley,
tree-fruit, and sheep. Similarly, boiled meat must have been thought to
fall below the dignity of Epic, as it is never served to Homeric heroes;
but boiling occurs in Homeric similes. By contrast, the Gospels are strik
ingly matter-of-fact in this as in other respects: one of their most vivid
scenes is in the 21st chapter of John, where the risen Christ is seen cook
ing fish and bread for His breakfast over a charcoal fire.
But there was plenty of far~from-elevated literature in which food was
described with relish and in detail. It was a favorite topic for Greek com
edy, where the comic action frequently ends in feasting and fun, and the
audience-which, especially in times of war, might be hungry-enjoyed
down-to-earth but mouth-watering descriptions of the feasting. Com
edy had occasion to mention the diet of the poor as well. Among the
stock characters of New Comedy, from the fourth century B.C. onward,
was the comic cook: He would be expected to talk about the items of
his trade. And comedy provided much wistful looking back to the
Golden Age, imagined to have preceded the days of hard work and
slavery, when every kind of delicacy had been there for the taking.
There were many hundreds of Greek comedies. Only a few survive
complete, but thousands of fragments (quoted in this chapter from
Kock's Comicorum Atticorum Fragmenta) are preserved in other texts. The
fragments about food mostly derive from Athenaeus's Deipnosophistai