June 2008

Return to Roots: A Mediterranean Makeover for “American” Italian Cuisine
By Diane Welland, MS, RD
Today’s Dietitian
Vol. 10 No. 6 P. 30

A side of pasta and vegetables with a dusting of cheese—doesn’t sound like an Italian dish in the States, does it? That’s because the American version is generally portion distorted, heavy on fat, and light on heart-healthy greens. Help your clients kick their cuisine up a healthy notch with a few tips straight from southern Italy.

When it comes to counseling clients about eating right, diets heavy in Italian food often raise a red flag for dietitians—and for good reason. Popular picks such as pizza, lasagna, and fettuccini alfredo are usually nutritional disasters, loaded with saturated fat, cholesterol, and sodium, not to mention calories.

Yet, authentic Italian food barely resembles the Americanized version. In Italy, portion sizes are smaller, vegetables are the norm, and fresh fruit is eaten daily. While Western culinary influences have not left Italians untouched, their traditional cuisine, especially in the southern regions, remains intact, forming the essence of the Mediterranean diet. Often regarded as the healthiest diet in the world, this way of eating is considered the gold standard among nutrition professionals worldwide.

When it comes to Italian cuisine, what’s the best advice? Get back to basics—basic Italian cuisine, that is. Healthy, simple, and easy to prepare, this is the Mediterranean diet at its best.

In the Beginning
Shortly after World War II, a young professor from the University of Minnesota, surprised by the low rate of coronary heart disease in Naples, Italy, conducted a series of pilot studies on diet, risk, and heart disease that eventually led to a larger, more extensive study. His name was Ancel Keys, PhD, and his research, known as the Seven Countries Study, revolutionized nutrition science and the way we think about food and health. From 1958 to 1964, Keys surveyed more than 12,700 men in 16 cohorts from seven different countries. He analyzed the results, eventually tracking death rates as much as 25 years later.1,2

By the time it was published in 1970, the study claimed many new ideas that are often considered firsts in the field. It was the first to compare coronary heart disease among populations from different cultures, the first to link high serum cholesterol levels to high coronary heart disease mortality, the first to relate total dietary fat intake—specifically saturated fat intake—to the risk of heart disease, and the first to imply dietary and lifestyle patterns can influence cholesterol levels and rates of coronary heart disease.2,3

The last two findings, culled from data showing northern Europeans were five times more likely to die from coronary heart disease than their southern Mediterranean counterparts, prompted Keys to promote dietary intervention and produce what we now call the Mediterranean diet, a dietary pattern high in fruits, vegetables, beans, and grains; low in red meat; and including modest amounts of fish, eggs, poultry, and dairy. Red wine is another component of the diet, as a small glass or two was typically consumed every day, usually with meals. Olive oil is the primary source of added fat.1,4,5

A Boon for Heart Health
Luckily for us, Keys’ diet theories are well accepted today, and scientific research supporting the Mediterranean diet’s heart-protective effects is plentiful. The strongest evidence comes from the four-year Lyon Diet Heart Study, which found that people eating a Mediterranean diet had a 50% to 70% lower risk of repeat heart attacks compared with those following a Western diet, despite having similar blood pressure and cholesterol levels.5-7

Exactly how the Mediterranean diet accomplishes this is still uncertain, but researchers speculate the diet works in multiple ways. First is its positive effect on lipid levels. The Mediterranean diet lowers total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides and raises high-density lipoprotein (HDL) cholesterol.8,9 Antioxidants and phenolic compounds, particularly in olive oil, fruits, and vegetables, prevent LDL cholesterol from being oxidized, effectively squelching its ability to form atherosclerotic plaque.10

These three dietary components (olive oil, fruits, and vegetables) also counteract another cardiovascular risk factor: high blood pressure. According to a Greek study, the Mediterranean diet was inversely associated with blood pressure levels, both systolic and diastolic, in more than 20,000 men and women.11,12 Furthermore, it didn’t matter whether the study participants had normal blood pressure or were hypertensive—both groups benefitted.

Other heart-healthy advantages of the Mediterranean diet include improved carbohydrate metabolism, better weight control, and thinner blood.9 The diet can even improve the effectiveness of heart medication. A 2002 Finnish study compared men taking a statin drug with their usual diet with men taking a statin drug and following a Mediterranean-style diet. The researchers discovered that LDL levels dropped 11 percentage points more in the group of men using a combination of drug and diet therapy compared with the group taking only the drug.13

Other Healthy Perks
The Mediterranean diet can offer protection from more than just heart disease. Over the years, researchers have uncovered a host of benefits and are continuing to discover more.

“Several new scientific studies reinforcing the health benefits of the Mediterranean diet come out every week,” says Dun Gifford, president and founder of the Oldways Preservation + Exchange Trust, a nonprofit think tank dedicated to preserving the old foodways headquartered in Boston. “It’s hard for us to keep up.”

The following are several hot topics:

Combats cancer: Although the cancer link is not as strong as the heart disease link, Mediterraneans do have lower rates of certain cancers, such as upper digestive tract, stomach, and urinary cancer, than Americans, thanks in large part to the abundant amount of fruits and vegetables they eat.14 Other research points to the antioxidants in extra-virgin olive oil. A staple in the southern Italian diet, extra-virgin olive oil has been shown to protect against breast and colon cancer.15,16

Even pizza has gotten into the act. A 2004 study from the International Journal of Cancer claimed that eating pizza cut the risk of mouth, throat, and colon cancer in a group of northern Italians. While authentic pizza is quite different from the American version, most scientists attribute the findings to two ingredients used in pizza—tomato and olive oil—rather than to the pizza itself.17,18

Controls diabetes and metabolic syndrome: The Mediterranean diet is chock-full of foods rich in fiber, antioxidants such as beta-carotene and vitamins C and E, and magnesium. It also contains plenty of olive oil, cold water fatty fish, nuts, and seeds, as well as small amounts of red wine, which has been shown to enhance insulin sensitivity. Consequently, it’s no surprise that this way of eating benefits people with type 2 diabetes and metabolic syndrome. Studies show it may even reduce the risk of developing these diseases.19-21

Fights fat: The same dietary components that protect against diabetes and heart disease also keep obesity at bay. Italians, like all Europeans, are generally more physically active than Americans. But that aside, their body mass index (BMI) levels are typically low. The secret may lie in the Mediterranean diet, as it emphasizes low-calorie, nutrient-dense foods and restricts high-calorie, processed ones.22,23

Benefits the brain: As we age, oxygen molecules known as free radicals damage cells. In the brain, this can lead to memory loss and slower processing time. Because of its ability to prevent oxidative injury, high olive oil intake (85% of total fat) such as that in the typical Mediterranean diet was found to protect older southern Italians from age-related cognitive decline.9,24,25 Eating fish and drinking red wine also provided a degree of protection. The effect is even greater for patients with Alzheimer’s disease and dementia, according to Columbia University researchers who followed diet patterns of 2,200 New Yorkers (average age of 76) for four years. Those who most closely followed the Mediterranean diet were 40% less likely to develop Alzheimer’s disease than those whose diets were the least Mediterraneanlike.26

Prolongs life: It’s been said that good nutrition can add years to your life, and when it comes to the Mediterranean diet, it’s true. A large-scale study showed that people who followed a Mediterranean diet were 20% less likely to die of cancer, heart disease, or any other cause during a five-year period.27 Only a few years earlier, an article reported similar results when researchers found that those who followed a Mediterranean diet, exercised regularly, didn’t smoke, and drank alcohol in moderation were one half as likely to die (from all causes) than those who didn’t adhere to that lifestyle.28

And Olive Oil for All
The health benefits of olive oil go far beyond simply replacing saturated fats with monounsaturated ones. Powerful antioxidants, along with plenty of phytochemicals, fight heart disease, cancer, high blood pressure, and cell damage caused by aging. Now we can add another bad guy to the list: inflammation.

Early on, most of these anti-inflammatory effects were credited to red wine and the compounds responsible for its deep, dark color.29-31 While this is still true, we now know that other foods such as fruits, vegetables, and beans contribute, too.32 “The anti-inflammatory properties of olive oil were discovered quite by accident,” says Gifford.

While attending a scientific conference in Italy, Gary Beauchamp, PhD, head of the Monell Chemical Senses Center in Philadelphia, attended an olive oil tasting. He noticed that the extra-virgin olive oil he tasted caused a sting in the back of his throat (the sign of a high-quality oil) and produced a familiar burn. It reminded him of a substance he was currently working on in the lab back home: ibuprofen.

On a whim, Beauchamp and his Monell colleagues decided to run a few tests. Ultimately, he discovered that oleocanthal, the compound in extra-virgin olive oil, was responsible for this burn. In the body, oleocanthal is a natural anti-inflammatory agent, acting just like ibuprofen and even inhibiting COX-1 and COX-2 enzymes, which is important for people with arthritis. So how much do you need? Beauchamp estimates that 50 grams of extra-virgin olive oil (about 2 ounces) daily would probably be equivalent to taking one baby aspirin every day.33

While consuming this much olive oil may seem excessive in America, not so in southern Italy. (Although low in saturated fat—only 7% or 8% of calories—the Mediterranean diet is not necessarily low in total fat, reaching as high as 40% of calories).1,34 “This could explain, at least partly, why certain diseases like heart disease, cancer, and Alzheimer’s are lower in these countries,” says Beauchamp.

This spring, Beauchamp returned to Italy to speak on the topic at a scientific symposium called the “Rebirth of Learning: Olive Oil, Health and the Mediterranean Diet” held in Palermo, Sicily, and hosted by Oldways. “Health is important, but you can’t forget taste. Olive oil makes food taste wonderful,” says Gifford. “In Italy, they have a saying: ‘Just a little bit of olive oil helps the vegetables go down.’ And it does. It can transform a dish.”

Mangia!
Aside from choosing olive oil over butter, what else should you recommend that your clients do when they sit down for an Italian meal? Gifford says, “Italians usually start their meal with a soup or salad. Not a heavy cream soup or elaborate salad, just a simple broth or vegetable soup and the salad—greens with olive oil and some vinegar or lemon.”

Offer your clients these additional valuable tips:

• Several times per week, eat pasta dressed with vegetables, tomato sauce, or a sprinkle of cheese. Partnering pasta with some protein and fat also lowers its glycemic index, making it a healthy choice.35 In Italy, pasta is served as a serious side, but in the United States it is often a main course. Encourage clients to try whole grain varieties and watch their portion sizes.

• Focus on fish. Saltwater fish is higher in omega-3 fatty acids than lake fish, making it a better choice. Try to eat a variety of fish at least two times per week.

• Watch the cheese. Rather than load up on the dairy, try using it more like the Italians do: as a condiment to finish a dish or a dessert to nibble on at the end of a meal. Go for more intense varieties to kick up the taste without volume.

• Eat whole fruit every day. Italians are big fruit eaters, including it in nearly every meal. It makes a difference.

• Forgo the sweets. Sweets are a force to be reckoned with no matter what kind of eating pattern you follow. In Italy they are luxury items, reserved for special occasions and eaten only once or twice per week.

Remember that Italians regard food differently than Americans. They pay attention to their food. They enjoy eating it and talking about it. In essence, they care about what they put in their bodies. While this is a hard concept to get across, particularly when time and convenience are often priorities, the following are several things you can do to help your clients make the right choice:

1. Teach clients how to cook. Cooking skills are essential for healthy eating, and many Italian dishes are simple to prepare, featuring only three or four ingredients. Most can be whipped up in no time.

2. Visit an ethnic grocery store. Ethnic grocery stores can introduce clients to new and interesting produce, and even regular grocery stores sometimes feature exotic items. Educate your clients about what’s available and encourage them to try a new fruit or vegetable.

3. Keep an eye out for Med Mark. It’s a packaging symbol designed to help consumers identify healthy Mediterranean-type products. The Med Mark is part of Oldways’ Mediterranean Foods Alliance (MFA), a nonprofit consumer advocacy group dedicated to helping consumers eat better with the Mediterranean diet. Started last June, the MFA will be launching a turnkey educational kit for dietitians this year. Visit www.mediterraneanmark.org for more information.

4. Beware of dining out. Eating out can be particularly tricky, since few Italian restaurants follow the Mediterranean way of eating. Steer clear of fatty meats, heavy cream sauces, lots of cheese, and dishes swimming in olive oil—a little goes a long way, and more is definitely not better. Portion control can be a big problem when dining out, so suggest strategies to help clients, such as ordering appetizers, splitting an entrée, or putting half in a takeout container at the start of the meal.

Italian cuisine may be the most popular ethnic food, but it certainly isn’t the only kind. There are more than 16 countries that border the Mediterranean Sea, and each one has its own unique qualities. What’s most important is that you teach clients to eat in the spirit and style of the diet—emphasizing lots of fruits and vegetables, small amounts of protein, and a good balance of nutrients. Now that’s Italian!

— Diane Welland, MS, RD, is a dietitian and a freelance food and nutrition writer based in Springfield, Va.

Resources
Eat Out, Eat Right: The Guide to Healthier Restaurant Eating, Third Edition by Hope Warshaw, MMSc, RD, CDE

The Essential Mediterranean: How Regional Cooks Transform Key Ingredients Into the World's Favorite Cuisines by Nancy Harmon Jenkins

Mediterranean Harvest: Vegetarian Recipes From the World's Healthiest Cuisine by Martha Rose Shulman

The Oldways Table: Essays & Recipes From the Culinary Think Tank by K. Dun Gifford and Sara Baer-Sinnott

References
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3. McLaren DS. The kingdom of the Keyses. Nutrition. 1997;13(3):249,253.

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13. Research roundup: A Mediterranean-style diet can enhance the effect of cholesterol-lowering statin drugs in men. Environmental Nutrition. 2002;25(4):8.

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18. Lerche Davis J. Pizza prevents cancer? WebMD. July 21, 2003. Available at: http://www.webmd.com/cancer/news/20030721/pizza-prevents-cancer

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22. Keep weight off by adding unsaturated fats. Environmental Nutrition. 2000;23(7):8.

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24. Panza F, Solfrizzi V, Colacicco AM, et al. Mediterranean diet and cognitive decline. Public Health Nutr. 2004;7(7):959-963.

25. Battino M, Ferreiro MS. Ageing and the Mediterranean diet: A review of the role of dietary fats. Public Health Nutr. 2004;7(7):953-958.

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29. Avellone G, Di Garbo V, Campisi D, et al. Effects of moderate Sicilian red wine consumption on inflammatory biomarkers of atherosclerosis. Eur J Clin Nutr. 2006;60(1):41-47.

30. Marfella R, Cacciapuoti F, Siniscalchi M, et al. Effect of moderate red wine intake on cardiac prognosis after recent acute myocardial infarction of subjects with type 2 diabetes mellitus. Diabet Med. 2006;23(9):974-981.

31. Sacanella E, Vazquez-Agell M, Mena MP, et al. Down-regulation of adhesion molecules and other inflammatory biomarkers after moderate wine consumption in healthy women: A randomized trial. Am J Clin Nutr. 2007;86(5):1463-1469.

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33. Beauchamp GK, Keast RSJ, Morel D, et al. Phytochemistry: Ibuprofen-like activity in extra-virgin olive oil. Nature. 2005;437(7055):45-46.

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35. Oldways Preservation Trust. Healthy pasta meals: Scientific consensus statement. February 18, 2004. Available at: http://oldwayspt.org/pdf/press_room/consensus_statements/2004PastaConsensus.pdf

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