The diet for living

When a recognised leader in dietetics and the Mediterranean diet publishes a book that conclusively shows the benefits of the diet, we took notice. Dr Catherine Itsiopoulos has written The Heart Health Guide, published this month, which features 80 delicious recipes, easy-to-follow meal plans and clear advice on how to sustain a diet that has been shown to prevent and reduce risk factors of heart disease. We asked Dr Itsiopoulos to explain the Mediterranean diet and the research.


What prompted you to start investigating the health benefits of a Mediterranean diet?
My interest spans over 20 years, when I began my doctoral studies and realised that Greek immigrants to Australia were protected from early death from heart disease and other chronic diseases, most likely due to their healthy Mediterranean diet habits. Although I grew up in a Greek Mediterranean family following this healthy diet, it wasn’t until years later as a researcher that I came to investigate and appreciate its health benefits.

The Heart Health Guide was inspired by a large multi-centre study that my colleagues and I are completing called the Australian Mediterranean (AUSMED) Heart Trial, where we are investigating the effects of the traditional Mediterranean diet in preventing a second heart attack in people who have heart disease. I worked closely with my AUSMED Heart Trial colleagues to report the latest evidence and illustrate how this dietary pattern protects the heart.

The recipes in The Heart Health Guide were inspired by the wonderful recipes passed down by my beloved late mother Theano, who was a very talented and fussy cook, and recipes were modernised by my gorgeous daughters, Tiana and Vivienne, who love to cook. They inspired many of the vegetarian and vegan-friendly recipes.

Your book examines the benefits of a Mediterranean diet, most specifically for the heart, but what other conditions are also known to benefit from this diet?
The traditional Mediterranean diet has been shown to be beneficial for many chronic diseases associated with a poor diet.

An extensive analysis of studies from around the world – including almost 13 million people and evaluating 37 different medical conditions – has shown that closer adherence to a traditional Mediterranean diet is strongly linked to lower risk of death from all causes: heart disease, stroke, diabetes, cancer and neurological diseases such as Alzheimer’s disease and Parkinson’s disease.

What are the main reasons the Mediterranean diet is so good for our bodies?
A Mediterranean diet is protective for many conditions and is so good for our bodies generally because it is rich in protective nutrients with antioxidant and anti-inflammatory properties – from extra virgin olive oil, nuts, seeds, fish and seafood, leafy greens, tomatoes, garlic and onions, herbs and spices and fresh fruit – and is low in highly processed high fat foods that are associated with heart disease and many chronic conditions.

The Mediterranean dietary pattern is rich in plant foods with a plant-to-animal food ratio of 4:1 compared with a Westernised diet which has a ratio of 1:1. This healthy dietary pattern focuses on eating fresh cooked meals using seasonal ingredients and is low in processed foods. It is a healthy high fat diet rich in good oils from extra virgin olive oil, nuts, seeds and oily fish, moderate in carbohydrate and high in fibre, moderate in lean proteins from free range meats and rich in plant proteins from legumes. This dietary pattern is ideal for management of conditions such as diabetes, metabolic syndrome and heart disease.

The Mediterranean diet is highly palatable, very tasty and satiating and easy to follow.

What about people who have not had the benefits of a life on the Mediterranean diet? Does a change in diet later in life offer significant health benefits?
The Mediterranean diet has been shown to have beneficial effects later in life.

My research collaborators and I have been studying the beneficial effects of this diet in adults in Australia with many different medical conditions such as diabetes, fatty liver, heart disease, depression and anxiety and, more recently, dementia. And we have observed important changes in disease markers in people on the Mediterranean diet who had never followed this pattern before.

A major Spanish study, PREDIMED, studied more than 7500 adults with risk factors such as high blood pressure and obesity and asked them to follow a Mediterranean diet enriched with extra virgin olive oil or nuts (almonds, walnuts, hazelnuts) or a standard low-fat diet. After five years, those on the Mediterranean diet had 55 per cent less chance of developing diabetes and 30 per cent less chance of dying from heart disease compared to those on the low-fat diet. This shows that this diet can have major protective effects even in later adulthood.

You provide great detail in your book, but could you offer a list of foods from the Mediterranean diet that we could easily incorporate into our existing diet?
The benefits of switching to a healthy diet for long-term health is unquestionable but maintaining healthy dietary habits long term can be difficult due to so many factors such as lack of time to prepare healthy meals, not knowing what diet is the best one to follow, lack of confidence in the kitchen, boredom with diets that are tasteless, or many failed attempts at eating healthy in the past.

Following a healthy dietary pattern such as the Mediterranean diet does not mean you have to slave over a hot stove for hours each day preparing complex dishes such as moussaka. You can leave the more complex dishes to weekends or days where you have more time up your sleeve.

You can follow some or all of the following tips to make your diet healthier and more Mediterranean:

    1. Enjoy fresh vegetables, including leafy greens and tomatoes, in abundance and flavour your foods with herbs and spices.
    1. Eat fresh fruit every day and snack on dried fruit, nuts and seeds in between meals.
    1. Use extra virgin olive oil as the main fat in cooked meals and in salads, and the occasional fried foods.
    1. Eat vegetarian by incorporating at least two legume dishes per week as the main protein source.
    1. Enjoy fermented dairy foods such as Greek-style plain yoghurt and crumble feta cheese into your salads.
    1. Try to have fish and seafood twice a week and include oily fish such as sardines or salmon.
    1. Eat smaller portions of lean meat by incorporating into tomato-based casseroles, choose free range wherever possible and keep processed meats to a minimum.
    1. Choose wholegrain bread and preferably sourdough to mop up juices from salads and casserole dishes.
    1. Enjoy wine (preferably red) in moderation, and always with meals, and try to have a couple of alcohol-free days per week.
    1. Keep sweets for special occasions and try adding nuts, seeds, dried fruit and honey.

You have interviewed renowned doctors who obviously understand the benefits of a Mediterranean diet, but do you think that knowledge is spread across the healthcare sector?

When I started investigating the health benefits of the traditional Mediterranean diet more than 20 years ago in Australia, little was known about the wider health benefits of this dietary pattern. Following the extensive research in Australia, and across the world, it is now well accepted that the Mediterranean diet is a healthy way of eating and important in the prevention and management of heart disease, diabetes and many other chronic diseases.

However, guidelines for the management of chronic diseases have only recently (in the past five years or so) started to incorporate the Mediterranean diet as part of the management of conditions such as heart disease and diabetes. The National Heart Foundation of Australia and Diabetes Australia now include the Mediterranean diet as an example of a healthy dietary pattern in the management of these conditions.

The uptake of a Mediterranean diet across the healthcare sector has been slow or inconsistent due to the perceived difficulty in following this type of eating pattern or the lack of practical information on how to incorporate this diet into everyday life. There is also a lot of misinformation out there about what a traditional Mediterranean diet is as many people believe that foods such as pizza, souvlaki, deep fried calamari, pita bread and dips, pies and pastries with spinach and feta, and creamy and syrupy cakes are typical Mediterranean foods. These foods are eaten on festive occasions, but are not the mainstay of this plant-based diet.

Low-fat versus a Mediterranean diet? Which is the winner and why?
Many studies comparing the traditional Mediterranean diet with a low-fat diet, including the studies that my collaborators and I have completed in Australia, have shown the Mediterranean diet to be superior to the low-fat diet for diabetes and heart disease management.

The PREDIMED Spanish study showed that the Mediterranean diet was protective for heart disease death and development of diabetes compared with the low-fat diet.

Although the low-fat diet is rich in fresh vegetables and fruits and low in saturated (animal) fats, it does not have the breadth of foods that have antioxidant and anti-inflammatory properties as the Mediterranean diet. A study completed by Dr Hannah Mayr showed that the Mediterranean diet was significantly higher in anti-inflammatory nutrients compared with the low-fat diet because of ingredients such as fresh herbs and spices, garlic, onions, tomatoes, nuts and seeds, and extra virgin olive oil. Furthermore, our studies have shown that the Mediterranean diet is easier to follow as it is filling and tasty compared with the low-fat diet.

Is alcohol a no-no?
Moderate amounts of alcohol, consumed mainly as red wine, has been part of the Mediterranean diet for centuries, and studies have shown that moderate consumption, one to two glasses per day, is protective for heart disease. This is probably due to the high polyphenol content of red wine (e.g. resveratrol) which has antioxidant properties and protects the coronary arteries from atherosclerosis (fat build up) which can lead to a heart attack.

Alcohol consumption is controversial, however, as regular and excess amounts of alcohol can lead to liver disease and some cancers and deaths due to accidents.

The National Health and Medical Research Council in Australian recommends: “To reduce the risk of harm from alcohol-related disease or injury for healthy men and women, drink no more than 10 standard drinks per week and no more than four standard drinks on any one day. The less you choose to drink, the lower your risk of alcohol-related harm. For some people not drinking at all is the safest option.”

Can we still enjoy some red meat and at what level?
The traditional Mediterranean diet included low quantities of red meat due to less availability of meat and a reliance on plant foods in this peasant eating style in post World War II times. Red meat was consumed about once per month and often during festive occasions, and people relied more on wild meats such as wild rabbits or birds.

Nowadays in the modernised Mediterranean diet, red meat is consumed one or twice a week and in small portions. Examples include small portions of lean beef or lamb or pork in a casserole (80g per person), with plenty of vegetables and legumes to add more plant protein, or on a skewer with vegetables to bulk it out. Choosing free range meat or chicken or eggs is a better choice as the fatty acid profile will be healthier due to the diet consumed by the animals such as seeds and wild grasses and herbs.

High blood pressure is a known enemy and contributor of disease. Can a Mediterranean diet help those who are taking high blood pressure medication?
The heart protective effects of a Mediterranean diet are understood to be due to the positive effects on reducing the risk factors associated with heart disease such as obesity, blood fats and blood pressure. In studies specifically looking at blood pressure, the most researched diets are the Dietary Approaches to Stop Hypertension (DASH Diet) and the Mediterranean diet. The DASH diet is similar to the Mediterranean diet but is lower in salt and uses low-fat dairy foods. The Mediterranean diet is easier to follow over the long term and can easily be incorporated into everyday life by following the 10 principles above. The Mediterranean diet’s effects on lowering blood pressure is attributed to the rich source of minerals such as potassium from fresh fruits and vegetables and wholegrains which are important in blood pressure control. Although some foods in the Mediterranean diet are quite salty, such as olives and feta cheese, there can be very little salt added due to the extensive use of herbs and lemon juice and vinegar in salads and with vegetables instead of salt, and the low use of processed foods and ingredients which have a lot of hidden salt.

I love the line in your book, “The Mediterranean diet is not just a diet but a way of life”. In what way do you think our lifestyle improves with a Mediterranean diet?

The Mediterranean diet was heritage listed in 2013 for its positive impact on the health of populations around the Mediterranean. It is described as a set of skills, knowledge, rituals, symbols and traditions of growing your own food, preparing and cooking, conserving food, and particularly sharing foods and eating together. The Functional Mediterranean diet pyramid includes at its base an image of people enjoying slow eating around a large table, focusing on seasonal produce, traditions with conviviality.

We can easily adopt some of these principles by making time to grow some of our own foods, even in pots on the kitchen windowsill, preparing foods together with family, and enjoying meals with family and friends whenever possible. In this way we are more conscious of what we are eating (mindful eating) and spending more time socialising and being outdoors, which improves not only heart health but mental health and wellbeing.

My mouth was watering reading the delicious recipes in the book. Do you have a favourite?
I have a number of favourite recipes that I make regularly, depending on how much time I have to cook. During the week I love to make the spicy green bean casserole with a rich tomato sauce and sweet potato and borlotti beans. On weekends when I have more time, I love to make Vegetarian Moussaka – a modified version of the traditional lamb mince moussaka. The recipe makes a lot of serves, so plenty of leftovers for the next day.

And please tell us that you are sometimes a little ‘naughty’?
Yes, of course, I am human after all! When I feel like something sweet, I go for a small portion of dark chocolate or a scoop of creamy Italian ice cream – my favourite flavour is pistachio.

The Heart Health Guide, published by Pan Macmillan, is available at all good bookshops.

Are you convinced of the benefits of the Mediterranean diet? Do you follow the guidelines or will you now?

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