COMMENTARY

Mediterranean Diet: Not Only Great Food But Great Lifestyle

Henry Black, MD; Lisa Sasson, MS, RD

Disclosures

October 05, 2011

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Introduction to the Mediterranean Diet

Henry R. Black, MD: Hi. I am Dr. Henry Black, Clinical Professor of Internal Medicine at the New York University (NYU) School of Medicine, member of the Center for the Prevention of Cardiovascular Disease at that institution, and immediate past president of the American Society of Hypertension. I am here with my colleague, Lisa Sasson, who is a registered dietician. Something that has always struck me, especially as I have gotten older and wiser, is how little physicians know about nutrition. Lisa's main interest is the Mediterranean diet. Can you tell us what interests you about the Mediterranean diet?

Lisa Sasson, MS, RD: Sure. I am on the nutrition faculty at NYU, and I direct a study abroad program every year in Italy. We study food, culture, health, and dietary habits of the Mediterranean culture, focusing on Italy. I became very interested to understand, historically, the Mediterranean diet. What are the health benefits, and what is it like now in Italy? How do Italians eat? Are they healthier than American counterparts with respect to their diets? I was very intrigued by this diet, and I can't think of a better place to study food than Italy.

Dr. Black: What is it about the Mediterranean diet that you think is beneficial? How would you describe it or characterize it?

Ms. Sasson: The Mediterranean diet is not a diet, per se. It's a lifestyle. It's a wonderful diet. It's something that I embrace because it's based on foods, rather than food products. It's based on eating foods that are as close to nature as possible.

Dr. Black: Fresh foods, you mean?

Ms. Sasson: Fresh foods, not highly processed foods, and lots of plant-based foods. It also means eating meals -- sitting down with family, friends, and having meals -- not eating on the go.

The Mediterranean Diet: A Change in Lifestyle as Well as Food

Dr. Black: Now, you have described a lifestyle, which I support if we can do it, sitting down and talking at dinner. But how do you do that in an environment where you are standing in a McDonald's eating a Big Mac or at Burger King and you have only 10 minutes for lunch. How do we change that?

Ms. Sasson: We have to make a change because if we continue to eat and live the way we are currently doing it, we are going to see exorbitant rates of heart disease, obesity, etc. The first thing is that something has to change. The reason I would like people to adopt the Mediterranean diet is that it is such a delicious, palatable diet. It's something that you could eat anywhere. If it becomes a priority to become healthier, people will make time to eat. It just has to be something that is valued. I'm not saying you have to have hour-long meals, but it may involve a little bit of planning. It may mean making healthier fast food choices. It doesn't mean you have to give up fast food, but instead of going to McDonald's, could you go to a healthier fast food option? Many are available.

Dr. Black: In an environment where people have trouble getting jobs, they want to keep them, and they want to be productive 24/7. How are we going to train employers and employees to give people adequate time for lunch to go out and do that?

Ms. Sasson: Most people have 15-20 minutes to eat lunch.

Dr. Black: Is that enough?

Ms. Sasson: The more you have, the better, but I'm trying to be practical. What is important is that when you take time to eat, you get away from your desk. You even use utensils because if you're using a fork and a knife, there is a better chance you are not eating hamburgers and fast foods. You focus on the taste of your food and the enjoyment of your food, and you don't have a million distractions because that could lead to something known as "mindless eating" where you don't even realize that you're eating, or you don't even recognize your own body's satiety -- eg, when you're full, when you're satisfied, or when you're hungry. When we ignore all this and just eat on the run, we don't listen to our own bodies. Many people don't even know when they're hungry or full any longer.

Dr. Black: How do you train people who answer every email immediately or who are Twittering or Facebooking, as this is just a metaphor, in some ways, for what's happened to our lifestyle? I want to ask you a question since you've been to Italy often, one of my favorite places. I have gotten a sense as I go to Europe that I see Starbucks popping up everywhere. I see McDonald's popping everywhere. It seems that we have exported some of our bad habits. I have also read that people are concerned that the "Italian way of eating" is starting to be overwhelmed by what we're doing. Do you see that there?

Ms. Sasson: Absolutely. There's no doubt. In fact, the highest incidence of pediatric obesity is in southern Italy. There are definitely changes. I think there are still some wonderful things that are happening in Italy, and that's why it's still a great country in which to do research on food and food habits. First of all, it's a food culture, and people have food memories, and they eat seasonally and locally, not because of sustainability issues but because that's how they have always eaten. They know when artichokes are in season. They know when asparagus is in season, and that's important because when you eat seasonal foods, they are more nutritious. The foods have more vitamins and more nutrients, which are really important for our overall health.

They also sit down and eat meals. That whole idea of eating as you walk doesn't exist in Italy. It's just not accepted. People take time to sit down to have food. It may be 10 minutes, but they don't walk or check their cell phone and eat.

Can Society Impose Healthy Food Changes in the United States?

Dr. Black: I wish I was as optimistic as you are. I'm not, and I wonder how we are going to change so many things, like eating fresh foods, for example. We're told -- and I think this is true -- that fresh foods are not available to some of the people who need them most. What are we going to do about that?

Ms. Sasson: It's complex, and I don't think the answers are easy. Everyone needs to be involved in the solution: physicians, nutritionists, urban planners, teachers, and the government because food, especially the more nutritious food, can be more expensive, especially fresh fruit and vegetables.

Dr. Black: Speaking of the government, the pyramid is out and the circle is in. Do you think this is a better way to educate people?

Ms. Sasson: Yes, because I think it's easier to see. The food pyramid was very complex. There was a lot of value to it, but I think the plate is easier because it emphasizes fruits, vegetables, lean choices of dairy, meat, protein, and lots of whole grains. You can see it. You have a visual representation, and it shows you the portion sizes. The pyramid was very complex. The plate is a good visual reminder of what to eat and how to eat.

Dr. Black: I would like to take an analogy from smoking. We made dramatic progress with smoking, and some people fail to realize how long that took. As late as 1984 the smoking rates were still going up, in spite of a 20-year campaign against them. One of the things that convinced people not to smoke was that we told their children, and they told their parents, "Why are you smoking? I heard how bad it was." Is any of that happening in the schools right now?

Ms. Sasson: Yes, there are changes. Smoking is a great analogy because now food and obesity have become public health concerns. I may not have said that to you 20 years ago, but now I feel very comfortable saying that something has to happen. We have to make changes because we can't have all these kids growing up at the age of 11 and 12 obese, with elevated lipid levels and diabetes. We can't. We'll have the first generation that won't outlive their parents. Something has to be done, and maybe smoking is a great analogy. Smoking is now exorbitantly expensive, so maybe we have to rethink the cost structure.

Dr. Black: You know what's happened with trying to tax sugar-free sodas less than regular sodas and how the politicians didn't have the will to do that.

Ms. Sasson: Right, it may take time, but there should be a benefit when you eat healthier. The default should be eating healthier. It should be easier to eat healthier. It's not in this country. It's easier for me to go to the supermarket and buy processed foods, especially on a reduced budget and having a family of 4 or 5, than to buy a basketful of fresh fruits and vegetables.

Dr. Black: What can we do to change that?

Ms. Sasson: You have to vote with your fork. You have to make sure you vote toward the right government or politicians who are going to change agricultural policy. Right now we're in a good position with President Obama in the White House because the platform is to change America. Michelle Obama is doing a lot. It's going to take time, but it starts with breastfeeding, with doctors reinforcing the importance of breastfeeding. It starts with schools and education. What are our kids being served in school? Bring back home economics. Let kids learn where food comes from and learn to cook. These are valuable experiences for kids. Bring back nutrition education. This is critical because kids don't even know where food comes from. They think it comes from the microwave.

Dr. Black: It doesn't come from the microwave?

Ms. Sasson: You're still a kid at heart. It's not simple, but I'm not pessimistic. I believe if we all believe this is important we can make changes.

Meds vs Lifestyle: What If a Weight-Loss Pill Worked?

Dr. Black: Let me ask you a question, because as doctors, we always get accused of caring much more about pills or devices than we care about lifestyle.

Ms. Sasson: Right.

Dr. Black: I don't think that's because we care about pills and devices.

Ms. Sasson: Right.

Dr. Black: It's because we're not sure that we can implement the lifestyle changes. If there was a lifestyle, of course, we would support it. If vitamins did all the things that they were thought to do, we'd certainly support them. If nutraceuticals did all the things we're told about, we would certainly support them. But if there was a pill that came along that dealt with obesity or its consequences, how would you feel about that relative to a lifestyle?

Ms. Sasson: We do have pills on the market, and we know what happens. We find out, after many years, about the side effects. Every medication has a side effect. We know that. That's one of the biggest problems with medication. The most important thing about eating, and the Mediterranean diet, is to enjoy your food. Food is one of the greatest pleasures of life.

Dr. Black: I don't think people gain weight to be perverse.

Ms. Sasson: No, a lot of people overeat for emotional reasons. A lot of people overeat because they just don't know portion sizes, and they do mindless eating. It's cheap to eat junk food. You need to enjoy your food, and that's why we shouldn't take food away with a pill. What we need to do is start young.

Dr. Black: I don't think we are taking away food with a pill. We take away the consequences of being overweight with the pill.

Ms. Sasson: Yes, but you can't be on medication for the rest of your life.

Dr. Black: Why not?

Ms. Sasson: Because there are consequences. We know that.

Dr. Black: With respect to statins, which revolutionized how we treat hypercholesterolemia, I'm from the day when we gave a resin to lower cholesterol, and then we operated on people to lower cholesterol, those were either risky or ineffective. Now we have an agent that has been tested in hundreds of thousands of individuals, not to mention all the people who take it otherwise, and the rates or coronary disease and its consequences are going down, something that a diet could never achieve.

Ms. Sasson: Right, but you still want people on statins to have a healthy lifestyle and to be physically active. If there is a pill, then people will think, "Oh, I can take this pill and I can be sedentary."

Dr. Black: I'm not sure that's the case. I think it's an assumption that people say, "Should I take a pill or take the lifestyle?" That's not the case at all.

Ms. Sasson: People who are concerned about the outcomes of what happens will do both. What is really important is to make the pill the last resort. It's analogous to gastroplasty. Let's try lifestyle changes, and what does that mean? It means that the knee-jerk reaction isn't medications. It's to have that 2-minute conversation with your patients.

How Do You Talk Lifestyle to a Patient in 5 Minutes?

Dr. Black: So, to focus a little bit on this, you're a doctor who has 10 minutes to see a patient, who has 5 complaints, and you will be able to take care of 3 or 4 or them. What would you tell them about what they should tell their patients about eating?

Ms. Sasson: You have a lot of power in that white jacket behind that desk -- if it's reinforced by a physician that it's very important for the patient to change his or her lifestyle, to be more active, to change eating habits. The physician should just give them some basics.

Dr. Black: What are the basics you would give them?

Ms. Sasson: The first is to be more active. Move more. It doesn't mean you have to join the gym. It means move. Your body was meant to be used. That's how our bodies were designed, so be less sedentary and be more active. That's number 1. The second thing is to be more aware of what you are consuming. Eat more fruits and vegetables.

Dr. Black: That is a nice, simple message: fresh fruits, fresh vegetables.

Ms. Sasson: Absolutely, because the more fruits and vegetables you're eating, the more aware you are of your eating habits. They have lots of fiber. They fill you up. So you would tell them eat more fresh fruits and vegetables.

Dr. Black: So, should we tell them to use olive oil instead of something else?

Ms. Sasson: Well, olive oil is probably the healthiest oil.

Dr. Black: Patients are going to ask.

Ms. Sasson: Some people believe that the Mediterranean diet is great -- wine, olive oil and pasta, the best diet! What they fail to understand is it's much more complex than that, and it's not just consuming more olive oil. It is supplanting the animal products with olive oil so that you're no longer eating butters.

Dr. Black: Supplanting the animal fats with the olive oil.

Ms. Sasson: Exactly, so you're no longer eating lots of butters and fried foods. You're using good quality olive oil, because it comes from a plant, and it has phytochemical activity. It has a lot of health benefits. That being said, it is high in calories because it's a fat, so you want to use it in moderation. So, olive oil, nuts, seeds -- these are really healthy types of fats that I would tell my patients to eat.

And Then There's Salt

Dr. Black: What about salt?

Ms. Sasson: Salt is another problem because salt makes foods taste really good, and we grow up eating a lot of salty foods, especially if you eat a lot of fast food and processed food. It's cheap, it's a preservative, and it makes food taste good. A lot of people don't even know they are consuming a lot of salt. They just grew up eating 5-6 g of salt a day. The great thing about salt is that if you start to reduce it, you lose your salt addiction and start to taste other foods. I've noticed that with my patients.

Dr. Black: There was a classic experiment done in the 1950s where Louis Dahl from Brookhaven surveyed an audience, asking people to raise their hands if they put salt on their food before they even tasted it, and 60%-70% at that time did. How many never put salt on their food? It was very few. In between were people who put it on food but didn't seem to need it. He repeated that experiment 20 years later, and it switched. Because as you say, salt is a taste we develop.

Ms. Sasson: Exactly.

Dr. Black: If we gradually reduce the salt, foods that we used to think were fine now taste too salty. It may be the same thing with fats.

Ms. Sasson: Right. It's just what we get used to.

Dr. Black: Skim milk, do you favor that?

Ms. Sasson: Skim milk or 1%. Personally, I don't use skim milk in my coffee. I prefer to have 1%. You need to choose wisely. If you're having a bowl of cereal, skim milk seems appropriate. In your coffee, instead of cream, if you want a little whole milk, that seems like a fine compromise.

Dr. Black: You use the salt analogy, so then if you start to use whole milk where you used to use skim milk, it's going to taste too fatty.

Ms. Sasson: It can, and that's why you have to see where it tastes too fatty because in something like coffee you may not notice it, because you use so little. But I want to go back to the salt because there's not much salt naturally in food. Salt comes from food processing, so if you eat a highly processed diet, you have a lot of salt, and then even more if you're heavy handed with the salt shaker. Eat foods that are not as processed, and when you go shopping, don't buy foods that have lots of ingredients on the label. You'll be consuming a lower-salt diet automatically. If you look at the Mediterranean diet, at least historically, the sodium was very low.

Conclusion

Dr. Black: But that's if you can afford the fresh fruits. This is something we have to work on.

Ms. Sasson: Right, that's something we have to work on. In New York at least we have these fresh fruit carts, which is wonderful. Frozen vegetables are a great alternative if you can't afford the fresh vegetables or they are not in season. We have farmer's markets, and people who are on food stamps can now use them in farmer's markets. There has to be an awareness, and that message has to be delivered by physicians because it can't just come from the nutritionists. It has to be reinforced by doctors that lifestyle change is first. Let's make some simple changes, because once a person can make a few simple changes they feel more confident. They think "okay, I can do that." Then we work on snacking in front of the TV.

Dr. Black: This is in the 7 minutes you have every 4 months. It's tough to do.

Ms. Sasson: If for 2 minutes, you think it's important before you give them a medication (because there are always side effects), their insurance is going to reimburse you, and you prefer to see a lifestyle change, then these are the 5 basic things you need to do. Move more, eat less, have more fruits and vegetables, have fewer animal fats and red meats, have fish twice a week, and less snacking, and make your snacks healthier.

Dr. Black: Yes.

Ms. Sasson: Just move more. You can reinforce that message along with nutrition educators and teachers.

Dr. Black: You're optimistic that you can get that done in 7 minutes -- way too optimistic. Thank you very much. I really appreciate your time.

Ms. Sasson: You're very welcome.

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