The True Mediterranean Diet

Mark Dymiotis

What is the Mediterranean diet

The term Mediterranean diet (MedDiet) refers to the traditional diet of this region in the 1950s and beyond. This was also the decade that this diet has been identified by the epidemiological “Seven Countries Study” as healthy, with long life expectancy and protective against chronic disease. Subsequently it was confirmed by several clinical studies. The Greek version of this diet, especially the Cretan one, is regarded as the prototype MedDiet.

Main features

The main features of the MedDiet are:

• Home prepared meals using unprocessed seasonal plant foods with rare use of animal derived foods. In the prototype Greek MedDiet, due to frequent periods of religious fasting, no animal derived foods were consumed on more than half the days of the year.
• Rich in flavours from the use of natural plant foods, olives, olive oil and herbs.
• Easy to implement – the hard work was in the food production.
• Substantial health, environment, climate change and family budget benefits.

Background

The term MedDiet was first used in the 1950s by Prof. Ancel Keys, the leader of the Seven Countries Study. It was formalised in the 1990s but by this time the traditional diet has suffered a severe decline. While the general composition of the MedDiet is well-established, little is known of its practical details – what, when and how food was prepared and eaten.

Mass urbanisation after World War II, combined with powerful marketing, has flooded the market with highly refined, processed and packaged foods, supplanting the MedDiet’s traditional reliance on local, natural and seasonal foods. However, the proven health benefits of the MedDiet pattern have been displaced by a modern obsession with transient ‘super-foods’, ‘healthy-foods’ and vitamin pills of questionable value, as add-ons to modern nutrient-poor diets. Furthermore, a burgeoning marketing and celebrity culture together with relentless promotion of modern industry created and processed foods, has resulted in excessive emphasis on the benefits of single foods, rather than an appreciation of the benefits inherent in the totality of the MedDiet.

In 2010, the MedDiet received a UNESCO heritage listing. Although the cultural elements of this diet are highlighted, no attempt was made to record its practical aspects. Therefore, UNESCO and member countries are called to urgently mandate the recording of the practical aspects of this diet while its last custodians are alive. In the meantime, authorities at local, state, national and international levels are called to promote substantial elements of the MedDiet for its multiple benefits such as richness in natural flavours, healthy, long-life expectancy, lower chronic disease, low-cost, protection of the environment and helpful in the fight against climate change.

For successful outcomes policy development should be freed from the misleading and deceptive influence of powerful lobby groups and the food industry.

Main components and practices:

• The bread of the prototype MedDiet (recently misnamed sourdough bread) was the most frequently consumed food. It was made with only stone-ground flour, water, salt, and natural, home-cultivated yeast. This historic bread, together with a large variety of vegetables, provided the bulk for the genuine MedDiet.
• Legumes, eaten in combination with the historic bread and vegetables provide for nutritious meals, balanced protein intake and dietary fibre.
• Genuine olives, olive oil, vinegar, lemon, garlic, onion, and herbs were the main flavour enhancers.
• Salads made with raw or boiled vegetables and dressed with lemon or vinegar and olive oil accompanied most meals and provided the highly desirable increased intake of vegetables. Onion and garlic were frequent ingredients in most salads. In addition, some legumes were also served as salads. Contrary to modern practices there was no salad dressing, a recent unnecessary and wasteful food industry creation. Adding the olive oil and other dressing directly in the diced vegetable and the thorough mixing created the superb flavours of the traditional salads. Dipping the historic bread in the salads’ juices was very special. At the end of the meal there was competition among adults and children alike for the salad juices either to drink or to dip bread in them. Contrary to modern practices, there was no addition of olives or feta cheese in the salads – a wasteful and alien to the Mediterranean diet practice.
• Olives, olive oil, vinegar, lemon, garlic onions and herbs were the main flavour
• Fresh or dried fruit and nuts were used for desserts, snacks, or light meals.
• Yogurt and cheese, in small quantities, provide additional protein, calcium and flavour.
• Animal–derived foods in very small quantities were traditionally eaten mainly on Sundays and festive occasions, provide additional nutrients less available in non-animal foods e.g. readily absorbable iron, zinc and vitamin B12 from meat and omega-3 fatty acids from oily fish.

What was not part of this diet:

• Restaurant foods, highly processed fast foods and food industry creations.
• Celebrities’ creations and inspirations, confusing and misleading food labels often associated with compromised nutritional value.
• The term ‘healthy foods or ingredients’ did not exist in the everyday diet of the Mediterranean people.
• Also non-existing, were modern manufactured flavouring ingredients, highly refined industrially produced seed oils, margarine, stock cubes and processed sugars.
• Misinformatione. irrelevant, misleading and incorrect terminology and deceptive marketing and advertising.

Dietary pattern and customs

The reputed health benefits of the MedDiet came from the totality of the diet and the associated customs and food combinations – not from ‘super-foods’, ‘healthy nutrients’, or individual food components. As an old Cretan saying suggests, “Everything is stomach’s weft, bread is the warp, and the humble wine supports everything” (Όλα είναι (αλ)φάδια της κοιλιάς και το ψωμί στημόνι και το καημένο το κρασί όλα τ’ αντιστυλώνει.) This old wisdom was confirmed by Prof. A. Trichopoulou and co-workers, “the overall dietary pattern is more important for health and longevity than individual components” (2).

Natural flavours came from the combination of ingredients during food preparation, appropriate food combination during eating and from dipping bread in the food juices.

Interestingly, for best flavour, an old Italian saying suggests:

• Bread a day old
• Olive Oil a month old
• Wine one year old

Of equal importance to what people ate are the how and when food was eaten, the food combinations and eating practices, the related customs and how flavour was developed. Learning came from the parents and the extended family – without influence from the modern marketing, advertising and celebrities. Although the diet was healthy, the Mediterranean people were practicing it without talk of healthy foods or nutrients. This simple and easy to implement home-based diet, has evolved naturally using local foods and was free of commercial interests and chefs’ creations and inspirations.

Respect and restoration of linguistic integrity is essential!

*Markos Dymiotis has a special interest in the traditional Mediterranean Diet of the 1950s – the diet he was born and grew up with in Cyprus. He has been teaching the practical aspects of this diet (including olive oil and olives) since 1989 with the CAE, Melbourne and has written several articles including peer reviewed papers. He has been an Honourary Research Fellow, La Trobe University, Melbourne.

Mediterranean diet – food components

The following information is based on my experience in growing up with this diet, and on extensive contacts and interviews with older people:

Breast-feeding for infants.

Bread i.e. the historic genuine bread, was a staple food and consumed virtually with every meal, untoasted and without spreads. It was made once a week or a fortnight using genuine whole grain flour, salt, water and a piece dough from the previous bread-making acting as a rising agent of the dough. Best flavour was developed on the second day after baking and it lasted another two to three days. Eventually the bread became dry and hard. It was softened by the customary dipping into the food juices. If it was very hard, it was dipped into water and “dried” by wrapping it with tea towel. When, on rare occasions, other ingredients were added to the dough, such as olive oil, olives, pumpkin or cheese, the bread became a specialty bread and took its name from the extra ingredient(s) e.g. olive bread, cheese bread.

Vegetables and wild greens were eaten frequently and in large quantities – fresh or cooked. Vegetables, together with bread, constitute the two most important foods of the MedDiet in frequency and volume. In winter, when not many cultivated vegetables were available, the wet weather allowed for the growth of wild greens which were harvested and eaten regularly – usually cooked.

Onion and/or garlic were used in most salads and in cooking for the special flavours they impart. They were also on the table for self-serving to accompany plant foods. Occasionally, the onion was eaten with bread and olives for a light meal – often accompanied by wine. Although small in volume, the onion made you feel full.

Legumes – mainly lentils, beans, chickpeas, peas, black eye beans and broad beans – in combination with bread, were the main source of protein. After soaking the legumes overnight in cold water, the water was changed, and the cooking continued until the legumes started to split. At this stage the water was changed again, and the vegetables and the olive oil were added and soon after the tomatoes (if used). Everything was then cooked well on low heat. Salt was added towards the end. Note: Tomatoes, due to their phytic acid, and the salt, if added early, harden the legumes making them difficult to digest. Also, the double changing of water helps in the removal of the phytic acid, in reduction of flatulence and in making the legumes’ protein easier to digest. Legumes are cooked until very soft to ensure good digestion and increased flavour. They were cooked alternately (one type at a time) and were consumed a few times a week – always eaten with bread – which ensures complete intake of amino acids. They were served with a salad, olives and often raw onion.

Fresh fruit was consumed regularly. For best flavour it was eaten when fully ripe – often straight from the tree. Juicy fruits such as grapes and watermelon were occasionally eaten with bread and olives or cheese for breakfast or as part of a light meal.

Dried fruit (mainly figs and raisins) were eaten mostly in winter, on their own, or in combination with nuts and even with bread as a snack or as a light meal.

Nuts (walnuts, almonds, and hazelnuts) were also eaten as snacks or dessert – alone or with dried fruit and sometimes with bread. They were deshelled at the time of eating, which is especially important for walnuts which oxidise easily due to their omega-3 content.

Traditional vs. modern Olives, Historically, olives were debittered using salt and used as flavour enhancers to plant origin foods. They were never eaten on their own and never added to salads and rarely used in cooking. Interestingly, when a Cyprus University student, as part of an assignment, asked his grandfather whether olives were oiled, he replied, “no we were out in the fields working”. The old man was referring to the customary practice of picking the olives by hand – not with a fork or a spoon. Modern industrially and chemically processed olives suffer loss of nutrients and flavour and require flavour-enhancing! Nowadays olives are spiced, oiled and even stuffed with spices – a recent development catering for the western palate. Most importantly, consumers are entitled to know that in recent times green olives are debittered chemically following the well-established California-style using caustic soda. These olives are served as green (called Spanish style) or are turned black chemically with ferrous gluconate (called California style) – a process that leads to significant loss of nutrients, and worse, there is formation of acrylamide, a carcinogenic compound. For green olives, unlike the traditional method which allows for lactic acid fermentation that improves the flavour and nutritional value of these olives enabling longer storage life, modern green olives are enriched with added lactic acid to compensate.

Olive oil, historically, was the main source of fat in the MedDiet and was used as a flavouring ingredient for plant foods. An extra benefit was the enriching of the food with strong antioxidants and other micronutrients – even during frying. Importantly, olive oil, by imparting its rich flavours to plant food dishes, enabled high consumption of vegetables and legumes that so characterises the MedDiet. Oddly, the generic name ‘olive oil’ is now reserved for the industrially refined olive oil – a dishonest and deceptive term that is confusing to the consumers, academics and scientists outside the olive oil industry. To obtain the original olive oil, one must ask for virgin olive oil, albeit with reduced antioxidants from the modern irrigation and fertilising of the olive trees and from the customary use of water at various production stages and from the filtering that follows.

Regrettably, modern virgin olive oil has been priced out of the MedDiet – the result of inept and profit-making production and marketing practices.

Lard was used for cooking and occasionally as a spread on bread, especially in high-altitude areas where olive growing was difficult. Interestingly, lard, which unlike other animal fats, is relatively high in mono-unsaturated fatty acids (about 45%).

Dairy foods (cheese, yoghurt and milk) were consumed occasionally and in small quantities. Bites of cheese were tiny, just enough to act as a flavour enhancer to plant foods to, as my mother said to us, “eat the bread to fill you up.” Similarly, a Greek friend recalls her mother’s advice, “sprinkle the feta cheese on the vegetable pie to feed the family with less cheese.”

Eggs were consumed occasionally as omelettes, boiled, fried or used for the very appetising egg-lemon (avgolemono) dishes.

Meat (mainly goat, game, chicken and pork) was eaten once a week and often less than that. It was cooked with the bones for extra flavour and less waste. Often, the small pieces of meat were hidden among the vegetables they were cooked with. At the end of the meal the bones were very “clean”.

Fish was consumed in moderate quantities, almost exclusively in coastal areas or adjacent to rivers or lakes. The obvious question is, ‘How did inland Mediterranean people get their omega-3 essential fatty acids’? From plant foods such as purslane, walnuts, green vegetables and from the meat, cheese and eggs of self-foraging animals.

Honey, reduced grape juice and carob juice were the main traditional sweeteners and were used only in small quantities – very unlike modern large portions of sugar-loaded sweets and cakes.

Herbs, such as mint, parsley, dittany, fennel, marjoram, oregano, rosemary, sage and thyme were commonly used as flavour enhancers and for therapeutic purposes.

Alcohol, mainly wine and grappa, was drunk in moderation and always with food, never on their own – grappa first (if it was consumed), wine afterwards. In Greece and Cyprus, no alcohol was consumed on Wednesdays and Fridays due to religious fasting.

Salt (unprocessed sea salt) was used as a flavour enhancer and to preserve food.

Water was the major drink. Herbal teas (e.g., sage, mint) and rarely a glass of milk was also consumed. Despite the plethora of fresh fruit there was no fruit juice.

Health authorities advise reduction of salt intake.

A more appropriate action is to call on the food industry to reduce the excessive use of salt in their foods.

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*Markos Dymiotis has a special interest in the traditional Mediterranean Diet of the 1950s – the diet he was born and grew up with in Cyprus. He has been teaching the practical aspects of this diet (including olive oil and olives) since 1989 with the CAE, Melbourne and has written several articles including peer reviewed papers. He has been an Honourary Research Fellow, La Trobe University, Melbourne.

Notable Quotes

Prof. Ancel Keys, credited for the finding that the Mediterranean diet is healthy and for creating the term MedDiet, suggests:

The heart of this diet is mainly vegetarian and differs from the American and northern European diets in that it is much lower in meat and dairy products and uses fruit for dessert. … In the 1950s coronary heart disease was a medical rarity; now [1995] Crete has a medical school and coronary heart disease is no longer confined to medical textbooks.

We learn something from the Italian restaurants in the United States and England. Those restaurants are increasingly popular but the food they serve is commonly far from the Mediterranean pattern. Everything has to be loaded with butter or margarine and ground meat. Serving only fruit for dessert is not common; ice cream or pie is common. Whereas Italian restaurants brag about the healthy Mediterranean diet, they serve a travesty of it [emphasis added].

Unhappily, the current changes to the Mediterranean countries tend to destroy the health virtues of the diet as we saw them 40 years ago. Efforts are needed to reverse this change [emphasis added] (1).

Prof. Miguel A Martinez-Gonzalez provides a conceptual definition:

The concept ‘Mediterranean diet’ was developed to reflect the typical dietary habits followed during the early 1960s by inhabitants of the Mediterranean basin, mainly in Crete, much of the rest of Greece and Southern Italy.  It is essentially a frugal diet that is followed by poor rural societies (2).

Prof. Christopher Lam offers interesting observations:

The Mediterranean diet has evolved over several millennia. While the Mediterranean diet varies from one country to another, the commonalities include a plant-based diet with substantial amounts of greens, pulses, fruits, seeds, whole grains, and olive oil.

With thousands of years of history, the MedDiet, exemplified by the traditional diet of Crete, has evolved to become one of the healthiest diets in the world.

Numerous studies … have shown convincingly strong links between a plant-based diet of whole foods, and health longevity – not just longer lives but also more disease-free years. The closer the adherence to the Mediterranean diet the better the health outcomes. The data is compelling [emphasis added] (3).

Prof. Dariush Mozaffarian calls for a dietary Renaissance:

Unfortunately, diets in the Mediterranean region have worsened over time. In Crete, the Mediterranean island with historically low rates of chronic disease, the diets now contain less fruit and olive oil and more meats than diets of earlier generations, with associated population increases in serum cholesterol and adiposity. A global dietary Renaissance is required [emphasis added], returning the traditional Mediterranean diet to its primacy in the region and, crucially, incorporating our knowledge of its numerous health benefits to practical, regionally tailored dietary guidance and policies worldwide. (3)

Modified/Distorted Mediterranean diets

In addition to the total abandonment of the Mediterranean diet, authorities are contributing to the confusion as to what is the MedDiet. In their dietary recommendation the Greek Health Authorities and Harvard University (see Pyramid) other than providing a general description of the diet, they do not reflect the overall dietary pattern i.e. food combinations, seasonality, customs and food practices.  Also, their recommendations are influenced by modern industrially produced foods and they incorrectly call their recommendations Mediterranean diet. For example:

• The recommend modern whole grain bread is made with highly refined flour that is deprived of the most nutritious part of the grain i.e. the embryo and with a plethora of refined ingredients added. In addition, unlike the historic bread of the MedDiet, modern bread is made with fast acting industrially produced yeast.
• Authorities use the term Olive Oil, without explaining that under modern regulations it refers to a highly refined industrially produced olive oil. They also fail to advise that virgin olive oil, compared to the historic olive oil, comes with reduced antioxidants.
• Plant oils are recommended without advising they are highly industrially refined and deprived of all their antioxidants.
• They recommend substantially increased intake of poultry and fish overlooking that the poultry is industrially produced and that fish supplies are depleted and polluted.
• Dairy is recommended daily overlooking that it clashes with the Greek fasting and its consumption was much reduced in quantity and regularity and only consumed for less than half days of the year.
• In their MedDiet food pyramids Authorities recommend calcium supplements and multivitamins. In effect, such recommendations are an indication of failure of such diets.
• Nuts are recommended daily without advising that for walnuts it is essential to deshell them at the time of eating.
• Olives, one of the most common foods in regularity but very small in quantity, do not rate a mention. Although olives are mentioned elsewhere in the description of the overall MedDiet, health authorities have failed to expose the modern customary industrial debittering of green olives with caustic soda and are traded either as green olives or are artificially darkened with ferrous gluconate which causes destruction of the olives’ nutrients as well as being tainted by the creation of acrylamide – a carcinogenic compound.
• It is overlooked that the daily diet has a great influence on the types of bacteria that grow in the human gut and influences susceptibility to many chronic diseases including heart disease and cancer. Studies show that the traditional starter for the making of the historic bread improves gut health as do other components of the MedDiet like vegetables, legumes and yoghurt. In contrast, modern ultra-processed foods can have a harmful effect to human health.

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*Markos Dymiotis has a special interest in the traditional Mediterranean Diet of the 1950s – the diet he was born and grew up with in Cyprus. He has been teaching the practical aspects of this diet (including olive oil and olives) since 1989 with the CAE, Melbourne and has written several articles including peer reviewed papers. He has been an Honourary Research Fellow, La Trobe University, Melbourne.

HARVARD: Mediterranean Food Pyramid

REFERENCES

1. Keys A. Mediterranean diet and public health: personal reflections. Am J Clin Nutr. 1995;61(6 Suppl):1321S-3S.
2. Trichopoulou A, Martinez-Gonzalez MA, Tong TY, Forouhi NG, Khandelwal S, Prabhakaran D, et al. Definitions and potential health benefits of the Mediterranean diet: views from experts around the world. BMC Med. 2014;12:112.
3. Lam C. The Traditional Mediterranean Diet: Lessons Learned. Journal of Orthomolecular Medicine. 2011;26(3):109-16.