Category Archives: Mediterranean Diet

Is There a Single Healthiest Diet?

Amby Burfoot has an article that asks, “what is the healthiest diet?”  for the general public. His answer comes from the Journal of Nutrition. Looks like there are four winners. Quoting Mr. Burfoot:

They differ slightly in the degree to which they favor, or disfavor, certain foods and food types, such as the following:

  • The Healthy Eating Index 2010: Considers low-fat dairy products a plus.
  • The Alternative Healthy Eating Index 2010: Considers nuts/legumes a plus, as well as moderate alcohol consumption. Trans fats, sugary beverages, salt, and red meat get a minus.
  • The Alternate Mediterranean Diet: Considers fish, nuts/legumes, and moderate alcohol a plus; red meat, a minus.
  • The DASH Diet: Considers low-fat dairy and nuts/legumes a plus; sugary beverages, salt, and red meat get a minus.

I think the Mediterranean diet has the most and best data to support it.

Steve Parker, M.D.

 

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Prevent Weight Regain With the Mediterranean Diet

Italian seaside tangentially related to this post

Italian seaside tangentially related to this post

Investigators affiliated with universities in Italy and Greece wondered about the effect on obesity of two ketogenic “Mediterranean” diet spells interspersed with a traditional Mediterranean diet over the course of one year. They found significant weight loss, and perhaps more importantly, no regain of lost weight over the year, on average.

This scientific study is right up my alley. I was excited when I found it. Less excited after I read it.

The Set-Up

This was a retrospective review of medical records of patients of a private nutritional service in three fitness and weight control centers in Italy between 2006 and 2010. It’s unclear whether patients were paying for fitness/weight loss services. 327 patient records were examined. Of these, 89 obese participants met the inclusion and exclusion criteria and started the program; 68 completed it and were the ones analyzed. (That’s not at all a bad drop-out rate for a year-long study.)  The completers were 59 males and 12 females (I know, the numbers don’t add up, but that’s what they reported). Ages were between 25 and 65. Average weight was 101 kg (222 lb), average BMI 35.8, average age 49. All were Caucasian. No diabetics.

Here’s the program:

  1. 20 days of a very-low-carb ketogenic diet, then
  2. 20 days of a low-carbohydrate non-ketogenic diet for stabilization, then
  3. 4 months of a normal caloric Mediterranean diet, then
  4. repeat #1 and #2, then
  5. 6 months of a normal caloric Mediterranean diet

In the ketogenic phases, which the authors referred to as KEMEPHY, participants followed a commercially available protocol called TISANOREICA. KEMEPHY is combination of four herbal extracts that is ill-defined (at least in this article), with the idea of ameliorating weakness and tiredness during ketosis. The investigators called this a ketogenic Mediterranean diet, although I saw little “Mediterranean” about it. They ate “beef & veal, poultry, fish, raw and cooked green vegetables without restriction, cold cuts (dried beef, carpaccio and cured ham), eggs and seasoned cheese (e.g., parmesan).” Coffee and tea were allowed. Items to avoid included alcohol, bread, pasta, rice, milk, and yogurt. “In addition to facilitate the adhesion to the nutritional regime, each subject was given a variety of specialty meals constituted principally of protein and fibers. “These meals (TISANOREICA) that are composed of a protein blend obtained from soya, peas, oats (equivalent to 18 g/portion) and virtually zero carbohydrate (but that mimic their taste) were included in the standard ration.” They took a multivitamin every morning. Prescribed carbohydrate was about 30 grams a day, with macronutrient distribution of 12% carb, 36 or 41% protein, and 51 0r 52% fat. It appears that prescribed daily calories averaged 976 (but how can that be prescribed when some food items are “unrestricted”?).

I found little explanation of period #2 mentioned above, the low-carb non-ketogenic diet. Prescribed macronutrients were 25 or 33% carb, 27 0r 31% protein, 41 or 44% fat, and about 91 g carbohydrate. Prescribed daily calories appear to have averaged 1111.

After the first and second active weight loss ketogenic phases, participants ate what sounds like a traditional Mediterranean diet. Average prescribed macronutrient distribution was 57% carbohydrate, 15 % protein, and 27% fat. Wine was allowed. It looks like 1800 calories a day were recommended.

Food consumption was measured via analysis of 3-day diaries, but you have to guess how often that was done because the authors don’t say. The results of the diary analyses are not reported.

What Did They Find?

Most of the weight loss occurred during the two ketogenic phases. Average weight loss in the first ketogenic period was 7.4 kg (16 lb), and another 5.2 kg (11 lb) in the second ketogenic period. Overall average weight loss for the entire year was 16.1 kg (35 lb).

Average systolic blood pressure over the year dropped a statistically significant 8 units over the year, from 125 to 116 mmHg.

Over the 12 months, they found stable and statistically significant drops in total cholesterol, LDL cholesterol (“bad cholesterol”), triglycerides, and blood sugar levels. No change in HDL cholesterol (“good cholesterol”).

Liver and kidney function tests didn’t change.

The authors didn’t give explanations for the drop-outs.

Although the group on average didn’t regain lost weight, eight participants regained most of it. The investigators write that “…the post dietary analysis showed that they were not compliant with nutritional guidelines given for the Mediterranean diet period. These subjects returned to their previous nutrition habits (“junk” food, high glycaemic index, etc.) with a mean “real” daily intake of 2470 Kcal rather than the prescribed 1800 Kcal.”

Comments

A key take-home point for me is that the traditional Mediterranean diet prevented the weight regain that we see with many, if not most, successful diets.

However, most formulas for calculating steady state caloric requirements would suggest these guys would burn more than the 1800 daily calories recommended to them during the “normal calorie” months. How hard did the dieters work to keep calories around 1800? We can only speculate.

Although the researchers describe the long periods of traditional Mediterranean diet as “normal caloric,” they don’t say how that calorie level was determined  and achieved in the real world. Trust me, you can get fat eating the Mediterranean diet if you eat too much.

I’ll be the first to admit a variety of weight loss diets work, at least short-term. The problem is that people go back to their old ways of eating regain much of the lost weight, typically starting six months after starting the program. It was smart for the investigators to place that second ketogenic phase just before the typical regain would have started!

There are so few women in this study that it would be impossible to generalize results to women. Why so few? Furthermore, weight loss and other results weren’t broken down for each sex.

I suspect the results of this study will be used for marketing KEMEPHY and TISANOREICA. For all I know, that’s why the study was done. We’re trusting the investigators to have done a fair job choosing which patient charts to analyze retrospectively. They could have cherry-picked only the good ones. Some of the funding was from universities, some was from Gianluca Mech SpA (what’s that?).

How much of the success of this protocol is due to the herbal extracts and TISANOREICA? I have no idea.

The authors made no mention of the fact the average fasting glucose at baseline was 103 mg/dl (5.7 mmol/l). That’s elevated into the prediabetic range. So probably half of these folks had prediabetes. After the one-year program, average fasting glucose was normal at 95 mg/dl (5.3 mmol/l).

The improved lipids, blood sugars, and lower blood pressure may have simply reflected successful weight loss and therefore could have been achieved  by a variety of diets.

The authors attribute their success to the weight-losing metabolic effects of the ketogenic diet (particularly the relatively high protein content), combined with the traditional Mediterranean diet preventing weight regain.

The authors write:

The Mediterranean diet is associated with a longer life span, lower rates of coronary heart disease, hypercholesterolemia, hypertension, diabetes and obesity. But it is difficult to isolate the “healthy” constituents of the Mediterranean diet, since it is not a single entity and varies between regions and countries. All things considered there is no “one size fits all” dietary recommendation and for this reason we have tried to merge the benefits of these two approaches: the long term “all-life” Mediterranean diet coupled with brief periods of a metabolism enhancing ketogenic diet.

I’ve attempted a similar merger with my Low-Carb Mediterranean Diet. Click here for an outline. Another stab at it was the Spanish Ketogenic Mediterranean Diet. And here’s my version of a Ketogenic Mediterranean Diet.

Steve Parker, M.D.

Reference: Paoli, Antonio, et al. Long Term Successful Weight Loss with a Combination Biphasic Ketogenic Mediterranean Diet and Mediterranean Diet Maintenance Protocol. Nutrients, 5 (2013): 5205-5217. doi: 10.3390/nu5125205

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Filed under ketogenic diet, Mediterranean Diet, Prediabetes, Weight Loss, Weight Regain

“Doc, Will I Get Mercury Poisoning From the Fish You Recommend?”

paleo diet, low-carb, Steve Parker MD

 A beautiful brown trout

The Environmental Working Group published an article reviewing the risk of mercury poisoning from seafood consumption. I’m not familiar with EWG. I’m trying not to hold it against them that Dr. Mark Hyman is on the board of directors.

Anyway, the EWG has some advice for you if you worry about mercury toxicity from fish. I try to stay up to date on the issue since I’m convinced that consumption of cold-water fatty fish twice a week is good for your health, in general. If the mercury doesn’t kill you. Seafood is key component of the Ketogenic Mediterranean Diet, the foundation of the Low-Carb Mediterranean Diet.

Here are some quotes from the EWG article:

…EWG has compiled a list of “moderate mercury” species that would pose a mercury risk for pregnant woman and children who eat fish regularly. This list is more comprehensive than the 2004 EPA/FDA advisory, which warned that women of childbearing age and young children, who are most susceptible to the damage done by mercury, should eat only six ounces a week of albacore tuna and should avoid four other high-mercury species – swordfish, tilefish, king mackerel and shark.

EWG rightly points out that much of the “seafood” consumed in the U.S. really doesn’t provide much of the healthful omega-3 fatty acids.

Among popular seafood species, salmon stands out as an excellent choice.  Four to eight ounces of salmon weekly, depending on the species, can provide 100 percent of the recommended amount of omega-3s. Some types of farmed salmon present significant environmental health concerns. EWG recommends that people choose wild salmon instead.

EWG’s analysis highlights several other affordable and sustainably produced species, including anchovies, sardines, farmed trout, and mussels.  Just four to eight ounces of these species weekly would meet recommended omega-3 requirements for pregnant women and people with heart disease.

***

Americans eat more than 400 million pounds of canned imported tuna because it is affordable and can be stored for a long time. Canned tuna is the second most popular seafood in the U.S., after shrimp.  An average American eats an average of 2.5 pounds of tuna every year (NOAA 2012).  Albacore tuna, also called “white” tuna, contains significant amounts of omega-3s, but tests indicate that it also contains significant amounts of mercury. “Light” tuna is usually skipjack tuna but can also contain yellowfin tuna. Skipjack and yellowfin have lower mercury levels than albacore, but fewer omega-3s.

As Jim Gaffigan asked, “Has anyone even bothered to ask why the tuna are eating mercury?”

In 30 years of practicing medicine, including 12 years right on the Gulf Coast, I’ve never seen a case of mercury toxicity. Maybe I’ve missed it. Maybe it’s quite rare.

Read the whole enchilada.

Steve Parker, M.D.

h/t Conner Middelmann-Whitney

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Low-Fat Diet Loses to Mediterranean Diet in Heart Disease Prevention

The American Journal of Medicine has an article entitled “Diets to Prevent Coronary Heart Disease 1957- 2013: What Have We Learned?” The authors conclude:

The Mediterranean-style diet, with a focus on vegetables, fruit, fish, whole grains and olive oil, has proven to reduce cardiovascular events to a degree greater than low fat diets, and equal to or greater than the benefit observed in statin trials.

The only bone I’ll pick with that quote today is that folks with diabetes and prediabetes often have unacceptable blood sugar spikes when they eat whole grains. That’s one reason I designed the Low-Carb Mediterranean Diet.

Steve Parker, M.D.

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Filed under Diabetes Complications, Grains, Health Benefits, Heart Disease, Mediterranean Diet

Which Tree Nut Provides the Most Omega-3 Fatty Acid?

David Mendosa says the answer is the macadamia nut.

Paleobetic diet

Macadamia nuts

A great thing about the macadamia nut is that it’s one of the few nuts with a good omega-6/omega-3 fatty acid ratio. In other words, it’s high in omega-3 and low in 6. This may have important cardiovascular health implications. Macadamias are one of the nuts I recommend in the Low-Carb Mediterranean Diet and  Paleobetic Diet.

David writes:

The first Australian macadamia plantation didn’t begin until the 1880s. And not until 1954 with the introduction of mechanised processing did commercial production became viable. Nowadays about 90 percent of the the world’s macadamia nut production comes from Hawaii, where it has become its third most important crop, according to The Wellness Encyclopedia of Food and Nutrition, University of California at Berkeley (1992).

Read the rest, where you’ll learn that macadamia nuts are the highest of all nuts in calories, gram for gram.

Steve Parker, M.D.

Paleobetic diet

Macadamia nuts on the tree

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Another Study Finds the Mediterranean Diet Preserves Brain Function During Aging

Well, maybe that’s a bit of an overstatement. Preserved brain function and the Mediterranean diet were  positively associated in a study involving Americans in Utah. This fits with prior observations that the Mediterranean diet prevents dementia.

In the study at hand, the DASH diet (Dietary Approaches to Stop Hypertension) also protected the brain:

Higher levels of compliance with both the DASH and Mediterranean dietary patterns were associated with consistently higher levels of cognitive function in elderly men and women over an 11-y period. Whole grains and nuts and legumes were positively associated with higher cognitive functions and may be core neuroprotective foods common to various healthy plant-centered diets around the globe.

See the American Journal of Clinical Nutrition for details.

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Live Longer With The Mediterranean Diet Even If You Already Have Cardiovascular Disease

Conquer Diabetes and Prediabetes, Steve Parker MD

Olive oil and vinegar: prominent components of the Mediterranean diet

We’ve known for years that the Mediterranean diet helps prolong life and prevent cancer, heart attacks, type 2 diabetes, dementia, and strokes in folks who start out healthy.

What about patients with existing cardiovascular disease? I’m talking about history of heart attacks, strokes, angina, and coronary artery disease.

Yep. The Mediterranean diet helps them live longer, too.

Details of the study are at the American Journal of Clinical Nutrition. The research was done at Harvard.

Steve Parker, M.D.

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Filed under coronary heart disease, Health Benefits, Heart Disease, Longevity, Mediterranean Diet, Stroke