How To Really Follow the Mediterranean Diet
Last week I offered up a little bit of background on the Mediterranean Diet, how the American researchers Leland Allbaugh and Ancel Keys “discovered” it and what it would take to get America on it.
But how can you follow the Mediterranean Diet? I mean really follow it as Allbaugh and Keys found it on the island of Crete? I’m not talking about ordering the souvlaki next time you go out for Greek. I’m talking about changing your eating pattern in a way that matches the habits of people that had some of the highest longevity and lowest rates of cancer and cardiovascular disease in the world.
In an attempt to try to offer some more concrete advice on this front, I went to Crete a couple years back to find out what exactly Cretans were eating when researchers found them in the peak of health. What I learned is that while much of the Cretan tradition can be vague, quixotic and even a little arbitrary, there are specific changes we can make to our American reality that can bring us more in line with the Mediterranean ideal.
1. Plenty of carbs but the right carbs
“This really is the base of the original Cretan diet,” so said the archaeologist Dimitra Mylona as she handed me a tough thick cracker in the dank cold chamber of a Minoan tomb a few miles outside the Cretan town of Rethymnon. For the last 20 years Mylona has been looking at skeletons of the early inhabitants of the island of Crete. What she concluded was that it was the twice baked barley bread or “rusks” that was the backbone of the diet. “You can see it in the teeth,” she told me, “they’re worn down from chewing on this hard stuff.” Whereas wheat was typically eaten by the upper classes, barley was the food of the commoners. This whole grain made for a bread that was slower to digest and less likely to cause the insulin spikes of white flour. This is largely attributable to the high amounts of soluble fiber contained in the grain — nearly twice that of whole wheat. “This has all sorts of benefits in terms appetite control and weight control,” David Katz founding director of Yale University’s Yale-Griffin Prevention Research Center, told me. Soluble fiber alters the time it requires to metabolize carbs and “smooths out” the digestion of sugars and lipids over time.
Many Americans think eating a sweetened version of Greek yogurt is “Mediterranean.” But some brands contain as much as 6 teaspoons of sugar per serving — similar to what you might find in a Twinkie.
In addition, the Cretan barley rusks were often milled together with carob seeds, an element that introduced high amounts of B-2, B-3, B-6, calcium, potassium and a host of other nutrients into a simple cracker. Carob also is a sweetener but with a very low glycemic index thus giving Cretans the impression of sweetness without the baggage of glucose.
All of this resulted in a population that Allbaugh observed were “slim-waisted, erect and able to withstand hunger during war and revolutions.”
Lesson: While ample carbohydrates were certainly part of the original Cretan diet the vast majority of those carbohydrates would have been from whole grains rich in soluble fiber. Meanwhile 90% of the grains Americans eat comes to us as processed white flour. You can follow the Cretan example by switching to 100% whole wheat bread products and trying to get at least one daily portion of non-wheat grains that are higher in soluble fiber like oats and barley.
2. Expand Your Fruit and Vegetable Repertoire
Under a canopy of 350-year-old olive trees just outside the city of Chaniá, another food- and gastronomy-focused archaeologist, Mariana Kavroulaki, explained that after the Minoan period of self-government ended around 1450 B.C, Cretan food habits were dictated by harsh socioeconomic conditions imposed by the island’s later colonizers.
Over the centuries, Crete was conquered and occupied again and again. The island’s overlords — Romans, Venetians, Ottomans — all used Crete as a giant plantation, sending the most highly prized agricultural products, like lemons, figs and raisins, abroad. As a result, Cretans had to eat whatever other foods were left.
But it turns out what was left had great nutritional benefits. Perhaps the greatest example are the wild field greens that women gathered in the winter and spring months, known as horta. Spicy and bitter, succulent and sour, horta encompass a broad array of more than 100 edible plants. Some, like purslane, contain high amounts of short-chain omega-3 fatty acids, which have been shown to help reduce blood pressure and cholesterol levels and lower the risk of heart disease and type 2 diabetes. Other greens, like dandelion, have antioxidants that may play a role in warding off cancer.
It’s largely because of the wide variety of horta that the Cretans enjoyed such longevity in general, according to Antonia Trichopoulou, M.D., Ph.D., a prolific Mediterranean diet researcher and president of the nonprofit Hellenic Health Foundation. A study she published in BMJ found that high consumption of plants (including greens, as well as onions, tomatoes, cabbage and eggplant) accounted for the largest reduction in early mortality risk compared to other beneficial aspects of the traditional Mediterranean diet, such as low meat consumption and liberal olive oil intake.
When it came to fruit, Allbaugh noted that the most-consumed items were grapes, pomegranates, and melons, all of which score an impressive 118 or higher on the Aggregate Nutrient Density Index (ANDI), a system that rates foods based on their nutrient content. Contrast that with the U.S., where our current top three fruits — apples, oranges and bananas — have ANDI scores of 53, 98 and 30, respectively.
The individual healthy components of the different fruits and vegetables Cretans ate was amplified by the sheer quantity they consumed — on average, 432 pounds of produce per person annually. Around that time, Americans were eating 323 pounds and today we get around 220. (These totals don’t include potatoes, which were — and are — popular with both groups.)
Lesson: The Cretans were models of plant-forward eating long before it was a thing in the U.S. (Author Michael Pollan’s oft-quoted maxim to eat “mostly plants” is, by his own admission, derived from the first Crete studies that went on to inspire our modern dietary guidelines.) So: up your produce intake. According to a meta-analysis in BMJ that looked at data from nearly 470,000 people, for every serving of fruits and vegetables consumed, the risk of dying from heart disease dropped by 4% and the odds of premature death from any cause fell by 5% (with a maximum benefit at about 5 servings a day). And go for variety. Despite the many types of produce available to us today, we often stick to the same ones, and not the most nutritious ones at that.
Michael Greger, M.D., author of How Not To Die suggests rotating as many different colorful fruits and vegetables through your diet as possible to get a broad range of vitamins and minerals. And, generally, the brighter or deeper the pigment — like that dark, leafy horta — the more phytonutrients the food will contain.
3. Good fat, not low fat
Another dozen miles up the road toward Crete’s western shore, stands the Olive Tree of Vouves. As big around as a station wagon and estimated at 3000+ years old it is an enduring testament to the fundamental role that olive oil has played in the Cretan diet. Indeed, when Keys made his observations he found as much as 40% of calories came from olive oil. Olive oil is, of course, a monounsaturated fat which, unlike the saturated fat in animal products, can lower LDL “bad” cholesterol boost and HDL good cholesterol. But since the foundational Mediterranean Diet studies we’ve learned much more about what olive oil might do. Emmanouil Karpadakis at the Terra Creta olive oil cooperative explained to me that Cretans were probably more likely to be consuming olives that were harvested when still green and richer in antioxidants. Yale’s David Katz zeroes in on this point noting that these greener olives would have contained high amounts of something called oleocanthal. Not only does this “highly bioactive anti-oxidant” seem to have “favorable effects on lipid profile and insulin” it also may have “potent effects on cell membrane health.” According to a 2018 study in the journal Endocrine, Metabolic & Immune Disorders all of these properties could help olive oil contribute “to lower the artherosclerotic burden” that we might accrue in our vascular systems as we age.
Lesson: Replace butter and saturated fats in your diet with monounsaturated fats like olive oil. Look for “early harvest” extra virgin olive oil that has been extracted from green unripe fruit for the highest amount of oleocanthal and other important anti-oxidants.
4. Ditch the meat, embrace the bean and the nut
Greeks often joke that in the rocky highlands of Crete “there are more goats than Greeks.” Goats were the first domestic animal the Minoans brought to Crete some 3000 years ago and are such a part of Cretan identity that the wild version of species, known as the “kri kri” is nationally protected. That the goat was so important to island animal husbandry illustrates another important point Keys and Allbaugh observed: meat in Cretan plates was lean and nutrient dense. Overall goat meat has less fat, less saturated fat, more iron, and about the same amount of protein per calorie compared to beef, pork, lamb and chicken.
But perhaps the more important point is that even this high quality meat was seldom on Cretan plates. According to Harvard’s Walter Willet the daily portion of red meat for a Cretan at the time amounted to a little over an ounce a day. What were Cretans using to supplement their protein needs? In the American interpretation of the Mediterranean diet chicken and fish make up the differential. But really when you dig into the Cretan data what you find is that beans and nuts were eaten nearly as frequently as animal meats. Together with the protein derived from whole grains, according to the Allbaugh study, plant-based proteins accounted for 64 percent of the 70.7 grams of protein consumed per person per day. Only 17.3 grams were of “animal origin”. Like whole grain barley, legumes and nuts, are concentrated sources of soluble fiber. This plus abundant micro-nutrients makes them a more nutritious alternative to meat which contains no dietary fiber whatsoever. The landmark 2013 PREDIMED dietary trial backs this up. In the study individuals who consumed three or more servings of nuts per week had a 39% lower mortality risk. Cretans themselves would do well to follow their own elders advice in this regard. In the last fifty years there has been a four-fold increase in meat consumption on Crete and now 86% of the population overweight or obese.
Lesson: While you probably won’t find goat in your supermarket, you can choose lean, grass fed meat. Eat it sparingly, no more than a few times per month. Make legumes and nuts your principal protein sources.
5. Beware “Mediterranean” foods that contains added sugar
After olive oil, the product in American supermarkets we most frequently associate with the Greek Mediterranean Diet is yogurt. And, indeed, as Allbaugh observed a large portion of the dairy consumed on Crete in the 1940s was in fermented form. Today even the most hardcore advocates for plant-based diets are fine with a little fermented milk. “Just try to find me a study that shows that yogurt hurts me!” the plant-based diet enthusiast Dr. Michael Gregor joked in a recent phone call. Yale’s David Katz takes it a step further noting “fermentation alters fatty acids and the novel fats found in yogurt and cheese may indeed have benefits for the microbiome.” Jacques Izard, a professor who studies the microbiome at the University of Nebraska further points out that fermentation also increases the bioavailability of proteins, and minerals like calcium.” But it’s extremely important to note that Cretans, unlike Americans, ate their yogurt plain. Meanwhile, flavored versions we eat today sometimes contain more than 6 teaspoons of sugar per serving — similar to that of a twinkie. This would not have flown in Allbaugh and Keys’s day. Allbaugh recorded a miniscule 12 calories per day from sugar or honey in the Cretan diet — less than a teaspoon a day. Americans currently get 367 calories worth of added sugar daily. Too much sugar in the diet has obvious implications for diabetes, but a 15-year-long study published in JAMA Internal Medicine found an association between added sugar and heart disease, as well. Those eating a diet high in these refined carbs (about 17 to 21% of daily calories) had a 38% greater risk of dying from heart disease than those who got just 8% of their calories from added sugar.
Lesson: Avoid added sugar even in healthy sounding foods.
6. Fast like your life (and afterlife) depended on it
When Allbaugh distilled the many interviews his team did over the course of his time in Crete, the grim statement that stands out from one of his subjects was, “We are hungry most of the time.” Overall intake was 2,547 calories per day — on par with average daily intake in the U.S. today. But many Cretans did backbreaking physical work every day that would necessitate much more than this. And indeed this is notable in the archive of Allbaugh’s work housed in the Rockefeller archives at Sleepy Hollow, New York. In the scores of photos I pored over while writing this article, the subjects were as Allbaugh described — slim-wasted and erect, even if they were a little severe in their gaze. The point here is in no way about starvation as a recommendation, but about a general pattern of not overeating.
Cretans also tended to spread their food out into six small meals, rather than sit down to three large ones, which many contemporary physicians recommend. A study in the Journal of the Academy of Nutrition and Dietetics found that people who ate at least six times a day had better overall diet quality and lower BMIs than those who ate less than four times daily. Other research has shown that small, frequent meals may improve cholesterol and insulin levels. Plus, Cretans observed a pattern of religious fasting that closely mirrors the 5:2 pattern of intermittent fasting that some research has shown can promote longevity and reduce blood sugar levels. In the Greek Orthodox calendar, both Wednesdays and Fridays are designated as fast days and there are also numerous religious holidays that require abstention.
LESSON: Keep calories in check and consider eating smaller, more frequent meals. You can also ask your doctor whether intermittent fasting might be right for you.
Will these six dietary lessons from Crete turn you into a slim-waisted, super fit individual free of heart disease and cancer and propel you headlong into a long, healthy old age? Well, it would be a start. There were many factors that contributed to long and healthy lives in the Crete of bygone days including strong family ties, relatively low stress levels and a penchant for dancing. But for the moment the easiest thing we can do to emulate the inhabitants of King Minos’s ancient island is to change how we eat. The rest, like the basis of so much traditional Greek yogurt, is culture.
An earlier version of this story appeared in Eating Well Magazine
More thoughts on food, health and the environment in The Climate Diet out from Penguin Press this month.