Advanced Mediterranean Diet

This news is a bit stale, but I wanted my readers to be sure to see it.

An article in the July 28, 2008, issue of Archives of Internal Medicine teaches us the role of regular physical activity in keeping lost weight from returning to once-overweight women.

Methodology

201 overweight women (body mass index 27-40) aged 21 to 45 wanted to lose excess weight.  They were sedentary at baseline, exercising fewer than three days a week for under 20 minutes.  Sound familiar?  Depending on baseline weight, the participants were assigned to eat either 1200 or 1500 calories per day, and to exercise according to one of four different exercise programs.  Exercise recommendations were to burn a certain number of calories per week (1000 or 2000 calories) at either moderate or vigorous intensity.  There were weekly group meetings for discussion of eating and exercise for the first six months, twice monthly meetings during the next 6 months, and monthly for the next six months.  There was telephone contact for between months  19 to 24.  This is pretty intense contact.  Each participant was given a treadmill to use at home, but my impression is that other forms of exercise were permitted and discussed.

Ten subjects were excluded from follow-up analysis, mostly because they got pregnant.  Nineteen others lost interest and dropped out.

Participants self-reported their physical activity levels.

At 24 months into the study, 170 of the original 201 participants were able to provide objective weight loss data.

Findings

Of the 170 subjects available for full analysis at 24 months, 54 either gained weight or lost none.  Thirty-three lost 0 to 4.9% of initial body weight, 36 lost 5 to 9.9% initial body weight, and 47 (24.6%) lost 10% or more of initial body weight.  [Who says diets don’t work?]

People who lost 10% or more of initial body weight at 24 months reported performing more physical activity - 275 minutes a week - compared with those who lost less than 10% of initial body weight.  This amount of exercise equates to 55 minutes of exercise on five days per week above the baseline level of activity, which was sedentary as you recall.  Whether they were assigned to “moderate” or “vigorous” exercise intensity didn’t seem to matter.  Whether they actually performed at the assigned level is unclear.

These women who sustained a weight loss of 10% or more of initial body weight at 24 months were burning 1835 calories a week in physical activity.

Women who lost less than 10% of initial body weight, or lost no weight, exercised an average of 34 minutes a day on five days a week.

By 24 months, participants on average had regained about half of the weight they had lost during the first six months  [which is typical].

Take-Home Points

After six months of dieting, many people start to regain half of what they lost.  We saw this phenomenon recently in the Israeli study of low-fat vs low-carb vs Mediterranean diet.

If you have a lot of excess fat to lose, you have to wonder if it would make sense to start a different diet program every six months, until you reach your weight goal.  Maybe there’s something about the novelty and excitement of a new diet program that keeps you motivated and disciplined for six months.  Joel Gates is trying a new one every month for a year, with great success.  Read about his experience at DozenDiets.com.

The authors note there are few similar long-term studies examining the amount and intensity of physical activity needed to improve weight loss success.  So this is important new information.

In using exercise to help prevent weight regain, it may not matter whether the exercise is moderate or intense.

The authors write:

…the inability to sustain weight loss appears to mirror the inability to sustain physical activity.

Long-term sustained weight loss is possible for a significant portion of overweight women.  Although most women won’t do it, success is enhanced by exercising for 55 minutes on five days a week.  Most men won’t exercise that much either.  Which camp do you fall into?

[For physical activity instruction and information, visit Shape Up America!, Physical Activity for Everyone, or Growing Stronger: Strength Training for Older Adults.]

Steve Parker, M.D.

Reference:  Jakicic, John M., et al.  Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women.  Archives of Internal Medicine, 168 (2008): 1,550-1,559.  

Are we fat becuase we eat too much, or lack physical activity?

Most people would say, “It’s both.”  Most people would be wrong, at least in terms of populations rather than individuals.

Obesity results from a protracted imbalance between energy intake (calories we eat) and energy expenditure (physical activity and resting metabolism).

Overweight and obesity have increased significantly over the last 25 years in most of the developed world.  Is it because we started eating more, or that we have so many energy-saving devices that we now expend less energy on physical activity?  If we are less active due to technologic advances, yet keep eating as much as in the past, we will gain weight as the excess calories are stored as fat.

Technologic advances over the last 150 years have allowed us to transform from a labor-intensive agrarian economy to one based on services and information.  Computers, in particular, have made it much less labor-intensive to get our jobs done.  For example, when I was a hospital intern 25 years ago, I made multiple daily trips from the patient care floors downstairs to Radiology to look at x-ray films.  Now, the “films” are at my fingertips on computers close to the bedside.

Have trends in technology over the last 25 years continued to reduced the energy expenditure needed to get through our days?  Alternatively, are we exercising less?  Either explanation would lead to weight gain if caloric intake remained the same.

Researchers recently studied populations in Europe and North America, examining trends in physical activity energy expenditure over time, since the 1980s.  Energy expenditure was evaluated with a highly accurate method called “doubly labelled water.”  They found that physical activity energy expenditure actually increased over time, although not by much.  They conclude that the ballooning waistlines in the study populations are likely to reflect excessive intake of calories.

[All I have is the abstract of the article.  I’ll try to get the full article and report back here if anything additional is interesting.]

So according to Westerterp and Speakman, the problem has not been lack of physical activity.  We’re simply eating too much.

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

Reference:  Westerterp, K.R., and Speakman, J.R.  Physical activity energy expenditure has not declined since the 1980s and matches energy expenditures of wild mammals.  International Journal of Obesity, 32 (2008): 1256-1263.  Published online May 27, 2008.  doi: 10.1038/ijo2008.74

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.

For the last 10 years, the answer has been “Mediterranean.”  But a new study challenges that conclusion.

By the way, “diet” in this blog post refers to “a habitual way of eating” rather than a weight-loss program.

Researchers at The Heart Institute of Spokane (Washington) set out to compare the effects of a Mediterranean-style diet and a conventional “heart-healthy” low-fat diet in people who had suffered a heart attack within the last six months.  To test whether diet intervention per se had any effect, a “usual-care” group of patients (101 participants) was also studied.

Methodology

Dietary intervention participants were randomized to either:

1. A low-fat diet (American Heart Association Step II) (50 participants).  Main goals were to reduce cholesterol intake to under 200 mg/day and saturated fat to under 7% of total calories, or
2. A Mediterranean-style diet (51 participants) with the same cholesterol and saturated fat goals, plus an increased intake of omega-3 fatty acids (to over 0.75% of calories) and monounsaturated fats (to 20-25% of calories).  Emphasis was on consumption of cold-water fish 3-5 times per week, and on oils from olives, soybeans, and canola.

Both diets encouraged intake of fresh fruits and vegetables - at least 5 servings a day - and whole grains.  Loss of excess weight was not a goal.

Diet intervention participants were given two individual counseling sessions with a dietitian within the first month, with additional sessions at months 3, 6, 12, 18, and 24.  Participants also attended six group sessions.  Three-day food diaries were examined periodically to assess compliance with dietary recommendations.  Various lipids and omega-3 fatty acids were measured in plasma.  I assume that judicious wine consumption was at least mentioned as part of the Mediterranean diet, but actual intake was not reported.

The “usual-care” group, also known as controls, “received dietary advice from medical center dietitians.  American Heart Association Step II guidelines were presented as a nutrition class or video and written materials.”  Just one presentation, apparently.

All participants were followed on average for almost four years.  “The primary outcome [emphasis added] was a composite of end points including all-cause and cardiac deaths, myocardial infarction, hospital admission for heart failure, unstable angina, or stroke.”  Obviously,  you want to avoid these primary outcome end points.

Results

• Avoidance of the primary outcome end points was the same in both the low-fat and Mediterranean diet groups.  Each intervention group had eight primary outcome end points.
•  Forty of the 101 people in the usual care group suffered one or more of the primary outcome end points.  Only 16 of the 101 dietary intervention patients suffered one or more of the primary outcome end points.  Compared to the usual care group, the dietary intervention patients were only one-third as likely to suffer cardiac death, death from any cause, heart attack, hospital admission for heart failure, unstabe angina, or stroke.  This is a significant difference.
• Goals for cholesterol, saturated fat, and omega-3 intake were achieved, or nearly so, in the dietary intervention groups.
• Neither diet intervention group lost weight.
• After two years, there were no differences between low-fat and Mediterranean groups in terms of HDL cholesterol, LDL cholesterol, triglycerides, and fasting glucose.
• Among the diabetics (10 in each intervention group), there were no differences in fasting glucose.
• The drop-out rate was low.

Take-Home Points

In the researchers’ words:

[This study] demonstrates that low-fat and Mediterranean-style diets can be similarly effective strategies for therapeutic lifestyle change, particularly when applied with equal intensity of intervention.

[This study] highlights the importance of heart-healthy diets in patients who have recently had [heart attacks].  The 2 intervention groups had relatively low intakes of cholesterol and saturated fat, but only Mediterranean-style diet partipants increased omega-3 fat consumption.  Because neither cardiovascular events nor risk factors differed between interventions , [this study] does not substantiate claims that increased omega-3 fat intake, predominantly from eating fish, adds benefit beyond a diet emphasizing reduced cholesterol and saturated fat.

The authors admit that the small number of participants is a weakness of their study.

They also cite another study, Medi-RIVAGE, that tends to support their findings.  Yet the Medi-RIVAGE “data predicted a 9% reduction in cardiovascular disease risk with the low-fat diet and a 15% reduction with this particular Mediterranean diet.”  According to the Medi-RIVAGE study abstract, ”After a 3-mo intervention, both diets [low-fat and Mediterranean] significantly reduced cardiovascular disease risk factors to an overall comparable extent.”

The seeming equality of the low-fat and Mediterranean diets is a surprise to me.  I would have predicted superiority of the Mediterranean diet.  Alcohol and nut consumption have been associated with improved cardiovascular outcomes in several observational studies.  I wonder if these two intervention groups had the same or different consumption of alcohol and nuts.

But these researchers may be on to something here.  That is,  low-fat and Mediterranean diets - with intensive dietary instruction - are equally good diet interventions for preventing future cardiac events in people who have had a recent heart attack.  Dr. Dean Ornish’s vegetarian program might also stack up well against these two diets and ”usual care.”

Before I abandon my preference for the Mediterranean diet in prevention of cardiac disease, I’d like to see the findings of this study confirmed by a larger one.  In addition to cardiovascular benefits, the Mediterranean diet is associated with:

• longer life span
• reduced incidence of cancer
• reduced incidence of dementia
• reduced incidence of chronic obstructive pulmonary disease
• improved control of asthma
• prevention of type 2 diabetes mellitus

No diet other than the Mediterranean can legitimately claim all these benefits.  And it tastes good.

Steve Parker, M.D.

References:

Tuttle, Katherine R., et al.  Comparison of Low-Fat Versus Mediterranean-Style Dietary Intervention After First Myocardial Infarction (from The Heart Institute of Spokane Diet Intervention and Evaluation Trial).  American Journal of Cardiology, 101 (2008): 1,532-1,531.

Vincent-Baudry, Stephanie, et al.  The Medi-RIVAGE study: reduction of cardiovascular disease risk factors after a 3-mo intervention with a Mediterranean-type diet or a low-fat diet.  American Journal of Clinical Nutrition, 82 (2005): 964-971.

High dietary fiber intake helps prevent constipation, diverticular disease, hemorrhoids, irritable bowel syndrome, and perhaps colon polyps.  Soluble fiber helps control blood sugar levels in people with diabetes, and it reduces LDL cholesterol levels, thereby reducing risks of coronary heart disease.

An upcoming article in the journal Nutrition suggests how fiber may have beneficial effects in atherosclerosis (the cause of heart attacks and strokes), type 2 diabetes, and some cancers.  These conditions are felt to be related to underlying systemic inflammation.

Systemic inflammation can be judged by blood levels of inflammatory markers such as interleukin-6, tumor necrosis factor-alpha-receptor-2, and high-sensitivity C-reactive protein.

Researchers looked at 1,958 postmenopausal women in the Women’s Health Initiative Observational Study, comparing inflammatory marker levels with dietary fiber intake.  They found that high fiber intake was associated with significantly lower levels of inflammatory markers interleukin-6 and tumor necrosis factor-alpha-receptor-2.  This association was true individually for total fiber, insoluble fiber, and soluble fiber.  The researchers found no association with C reactive protein.

Bottom line?  High intake of dietary fiber seems to reduce chronic inflammation, which may, in part, explain the observed clinical benefits of fiber.

Rest assured that the Mediterranean diet is naturally high in fiber.

Steve Parker, M.D.

Reference:  Ma, Yensheng, et al.  Association between dietary fiber and markers of systemic inflammation in the Women’s Health Initiative Observational Study.  Nutrition, 24 (2008): 941-949.

Do-It-Yourself Mediterranean Weight Loss

So, you’ve heard good things about the Mediterranean diet and want to try it for weight loss.  I will assume you have excessive body fat or a body mass index over 25.  Maybe you have just 10 or 20 pounds to lose.  Perhaps you are much heavier and are concerned about the adverse health effects of obesity.

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).  Numerous adverse health effects are associated with obesity.

Why the Mediterranean Diet?

Observational and clinical studies have clearly shown that the traditional Mediterranean diet is associated with overall greater health and longevity, lower incidence of dementia and cancer (of the colon, breast, prostate, and uterus), and lower incidence of cardiovascular disease, including coronary heart disease that causes heart attacks. Furthermore, recent studies indicate that such a diet may improve asthma and prevent type 2 diabetes mellitus and chronic obstructive pulmonary disease.

What is the Traditional Mediterranean Diet?

I use the word “diet” in this section not as a weight-loss program, but “the usual food and drink of a person.” Twenty-one countries have a coastline on the Mediterranean Sea, and additional countries are in the Mediterranean region. “Traditional” refers to the mid-20th century. Observational studies around that time associated the Mediterranean diet with longer life spans, reduced rates of chronic disease (less cardiovascular disease and dementia), and fewer cancers of the colon, breast, prostate, and uterus. There is no monolithic, immutable, traditional Mediterranean diet. But there are similarities among many of the regional countries that tend to unite them, gastronomically speaking. Greece and southern Italy are particularly influential in this context.

Here are the general characteristcs of the traditional, healthy Mediterranean diet:

• It maximizes natural whole foods and minimizes highly processed ones
• Small amounts of red meat. Meat is used more as a garnish than as the
  centerpiece of the meal
• Less than four eggs per week
• Low to moderate amounts of poultry and fish
• Daily fresh fruit
• Seasonal locally grown foods with minimal processing
• Concentrated sugars only a few times per week
  Wine in low to moderate amounts, and usually taken at mealtimes
• Milk products - mainly cheese and yogurt - in low to moderate amounts
• Olive oil as the predominant fat
• Abundance of foods from plants: vegetables, fruits, beans, potatoes, nuts,
  seeds, breads and other whole grain products
• Naturally low in saturated fat, trans fats, and cholesterol
• Naturally high in fiber, phytonutrients, vitamins (e.g., folate),
  antioxidants, and minerals (especially when compared with concentrated,
  refined starches and sugars in a modern Western diet)
• Naturally high in monounsaturated and polyunsaturated fats, particularly as a
  replacement for saturated fats

Oldways Preservation and Exchange Trust, in Boston, MA, has done great work promoting the traditional Mediterranean diet.  Oldways produced a traditional Mediterranean diet pyramid in 2000.

Can the Traditional Mediterranean Diet of the Mid-20th Century be Improved?

Scientific breakthroughs, mostly over the last decade, should allow us to fine-tune the traditional Mediterranean diet, leading to greater improvements in health and longevity.  Specific modifications to the traditional Mediterranean diet will ensure that you get the optimal amount of various foods that have been clearly associated with lower rates of disease and longer lifespan.

Please consider the following modifications - which we’ll call the Advanced Mediterranean Diet - as you eat Mediterranean-style:

• How much fish?  Two servings per week, to prevent sudden death and heart attacks.
• What kind of fish? Cold-water fatty fish (albacore tuna, salmon, mackerel, sardines, trout, sea bass, swordfish, herring, anchovies, halibut, pampano).  Many of these fish were not available to the Mediterraneans of the mid-20th century.
• How many nuts?  Three to five 1-ounce servings per week.
• How much olive oil?  Aim for a minimum of seven to 14 tablespoons weekly.
• How much fruits and vegetables?  At least 5 servings daily, to reduce risk of cancer, heart attacks, and stroke.
• How much legumes?  Four servings per week, to prevent coronary artery disease.
  How much wine, for those who choose to drink?  No more than one glass (4-5 ounces) daily for women and two glasses for men, to prolong lifespan and reduce coronary artery disease and dementia.  Before taking up the wine habit, carefully consider the pros and cons.
• How much whole grain?  Three servings daily, to reduce risk of premature death, coronary artery disease, diabetes mellitus, and cancer.
• The traditional Mediterranean diet was generally high-fiber but how much fiber do we need?  Twenty-five to 30 grams daily, to prevent diverticulosis, constipation, irritable bowel syndrome, and hemorrhoids.
• The Advanced Diet encourages usage of heart-protective omega-3 polyunsaturated fatty acids in vegetable oils, especially flaxseed, canola, and soybean oils.  These were not significant contributors to the traditional diet.
• Full-fat versions of dairy products were the norm in the traditional diet.  We now believe that the saturated fats in them contribute to hardening of the arteries (atherosclerosis), so the Advanced Diet favors the low-fat versions.  For the same reason, the Advanced Diet favors leaner (lower fat) cuts of meat, poultry, and game.

What’s Next?

First, review the disclaimer at the end of this document.  It’s a good idea to get medical clearance from your personal physician before you begin any diet or exercise program.  You may have an underlying illness causing your excess weight, or medical conditions that dangerously complicate the weight-loss process.

Unfortunately, the Mediterranean diet does not magically lead to weight loss.  Make no mistake about it: you can become massively obese eating Mediterranean-style.  To lose weight, you need to determine the level of calorie intake that will allow you to convert your excess fat into weightless energy.  It really does come down to calories in versus calories out.  “Calories in” is the food you put in your body.  “Calories out” is the energy you need to move about, and the energy needed to run basic metabolic processes in your body.  Mild caloric restriction coupled with a mild-to-moderate exercise program usually is the best route to successful weight loss.  Let’s assume you have been sedentary but will start a walking program (eventully walking at 3-4 miles per hour) for 30 minutes on most days of the week.  To lose weight, your appropriate calorie intake level is based on your sex and weight:

• Overweight women between 130 and 210 pounds should reduce calories to about 1,500 calories per day.
• Women 210 to 300 pounds reduce to 1,900 calories.
• Overweight men between 150 and 220 pounds reduce to 1,900 calories daily.
• Men 220 to 350 pounds reduce to 2,300 calories.

Women over 300 and men over 350 pounds who have tried and failed many different diets should consider bariatric surgery, or reduce caloric intake to 1,900 (women) or 2,300 (men).

If you just won’t exercise regularly, reduce the above suggested daily calorie intake levels by 200-300.  If you exercise but fail to lose one to one-and-a-half pounds per week, reduce daily calorie intake by 200-300 and see what happens over the next week.  Many people lose two to four pounds in the first week.  If that happens the second week, you aren’t eating enough, so increase your calories!  You can adjust your daily caloric intake on a weekly basis until it’s clear how much you can eat but still lose one to one-and-a-half pounds per week.  One pound per week is more realistic and sustainable over the long run.

While actively losing weight, take a multivitamin daily and consider a calcium supplement, “just in case.”

For physical activity instruction and information, visit Shape Up America!, Physical Activity for Everyone, or Growing Stronger: Strength Training for Older Adults.

If you like to be part of a supportive online community while dealing with weight issues, visit SparkPeople, 3 Fat Chicks on a Diet, or Calorie Count Plus.  All are free.

Now the fun begins!  You start eating Mediterranean-style, following the aforementioned food guidelines and keeping track of daily caloric intake and exercise in a journal.  You can find caloric value of most foods at NutritionData or Calorie Count Plus.

After you reach your weight goal, add 200-300 calories back into your eating program.  For example, if you lost a pound a week on 1500 calories daily, increase to 1700 or 1800 calories.  You don’t need additional milk products or meat, so add back fruits, vegetables, nuts, whole grains, and healthy oils such as olive oil.  Keep exercising.

Remember: aim for at least 7-14 tablespoons of olive oil weekly, at least two servings of fish per week, and 3 to 5 1-ounce servings of nuts per week.  Favor fish and poultry over red meat.  Cold-water fatty fish - e.g., trout, salmon, albacore tuna, sardines, herring - are probably healthier than fried catfish.  The rest is up to you.

Help! This is Getting Complicated!

You can simplify the weight-loss process and enhance your success by reading books such as You: On A Diet: The Owner’s Manual for Waist Management, The Sonoma Diet: Trimmer Waist, Better Health in Just 10 Days!, or The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer.  These books are based on the Mediterranean diet and provide recipes using readily available foods.  My formal reviews of You and Sonoma are here.  You: On a Diet does not suppy enough calories for most men, but works fairly well for women under 210 pounds.  The Sonoma Diet is customizable, offering two levels of caloric intake and is a better overall program than You: On a Diet.  The Advanced Mediterranean Diet is highly customizable - with four different calorie intake levels - and updated with the latest scientific breakthroughs.

You can also get excellent Mediterranean dieting instruction from dietitians and nutritionists.

Why read a book when I have this wonderful six-page document?

The book I know the best is my own award-winning Advanced Mediterranean Diet.  Advantages of the book include:

• much more information is contained in a 304-page book
• extensive understandable information on nutrition and physiology
• explanation of the all-important Energy Balance Equation
• comprehensive exercise instruction, even if you have never exercised a day in your life, no matter what your current weight
• inspirational success stories stories from my patients
• adaptation of the program for people with type 2 diabetes mellitus
• learn about weight-loss pills and supplements
• learn all about bariatric (weight-loss) surgery, including complication and death rates
• list of numerous supportive, reliable Internet resources
• citations for 200 scientific journal articles that support my recommendations
• a grocery list of doctor-recommended Mediterranean diet foods
• Daily Logs that ensure you eat the proper proportions of grains, vegetables, fruits, fats, milk products, and proteins based on your total caloric intake (1100, 1500, 1900, or 2300 calories)
• easy, tasty recipes for breakfast, lunch, and dinner from the Parker Compound Test Kitchen
• less expensive than a single consultation with a dietitian or nutritionist
• less expensive than most popular diet programs
• less expensive than monthly fees for Internet-based weight-loss programs
• overall effect of the book is enhanced motivation, commitment, discipline, adherence, and success

If a new book breaks your budget, borrow one from a friend or library, or see if Amazon.com offers a used book at a discount.

Additional Resources

Advanced Mediterranean Diet Blog.  Ruminations on weight loss, health, and longevity via the Mediterranean diet.  Many blog posts are inspired by the latest published scientific research.  The most up-to-date and reliable Mediterranean diet information in the world.

Books on Mediterranean eating and cooking:

• The Essential Mediterranean : How Regional Cooks Transform Key Ingredients into the World’s Favorite Cuisines by Nancy Harmon Jenkins
• The Mediterranean Kitchen by Joyce Goldstein
• Mediterranean Diet Cookbook: A Delicious Alternative for Lifelong Health by Nancy Harmon Jenkins
• The Cooking of the Eastern Mediterranean : 215 Healthy, Vibrant, and Inspired Recipes by Paula Wolfert
• The Mediterranean Diet by Marissa Cloutier and Eve Adamson
• The Mediterranean Heart Diet: How It Works and How to Reap the Health Benefits, with Recipes to Get You Started by Helen Fisher with Cynthia Thompson and Kaja LeWinn

The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer book website.  Click here for book and program description.

Allrecipes.com.  Over 30,000 free recipes with detailed nutritional analysis, including calories per serving.  Numerous Mediterranean-style dishes (enter search word “Mediterranean”).  Also check out the “healthy living collection.”  You’ll find more than recipes here, such as tips on selecting and cooking fresh fish.

ArabicNews.com.  See Food and Recipes under “Resources” heading.

Gourmed.  Hundreds, if not thousands, of authentic Mediterranean recipes, sortable by country of origini, andy of 22 main ingredients, and by dish (e.g., salad, soup, main dish).

NutritionData.  In addition to nutrient content of foods, this site has a combined body mass index calculator and “calories burned calculator,” which predicts calories you will burn in most types  of exercise, accounting for your weight, age, and sex.  Another calculator allows you to determine nutrient content of your own recipes.  Also find nutritional analysis of menu items at many fast food restaurants.

Recipezaar.  200,000 recipes.  Need a recipe for whole wheat pancakes?  You’ll find several here, rated by website users who have prepared the dishes submitted for publication by other users.  200,000 recipes, usually accompanied by nutritional analysis per serving: calories, amounts of various fats, cholesterol, total carbohydrates, several vitamins and minerals.

The Whole Grains Council.  Many recipes here, plus links to hundreds of recipes at other websites.

Weight-Control Information Network.  A service of the (U.S.) National Institute of Diabetes and Digestive and Kidney Diseases.  Information for the public and healthcare professionals on obesity, weight control, related nutritional matters, and physical activity.

Finally… 

Don’t be discouraged by admonitions that “diets don’t work.” They require discipline and willpower, but many diets do indeed work. Losing excess weight and adopting a Mediterranean diet will be well worth the effort over the long run. Why not get started now?

Best wishes, and best of health to you!

Steve Parker, M.D.

Email: steveparkermd@gmail.com

DISCLAIMER
These ideas and suggestions written by Steve Parker, M.D., are provided as general educational information only and should not be construed as medical advice or care.  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 physican before making any dietary or exercise changes.  Steve Parker, M.D., disclaims any liability or warranties of any kind arising directly or indirectly from use of this information.  If any medical problems develop, always consult your personal physician.  Only your physician can provide you medical advice.

Throughout this document are links to external sites.  These external sites contain information created and maintained by other individuals and organizations and are provided for the user’s convenience.  Steve Parker, M.D., does not control nor can he guarantee the accuracy, relevance, timeliness, or completeness of this information.  Neither is it intended to endorse any view expressed nor reflect its importance by inclusion in this site.