For nearly five years a great many Americans have been convinced that all they have to do to guarantee their good health is to eat what the people of the Mediterranean basin eat. So enchanted have they become with the concept that four international scientific conferences have been devoted to the subject. It may seem rather American, but even though those conferences were all concerned with the dietary habits of the Mediterranean, they took place at Harvard University in Boston, in Hawaii and in San Francisco.

The latest of these conferences, the International Conference on the Diets of the Mediterranean and the World Conference on Wine and Health, recently concluded in San Francisco. According to the findings presented at both, excellent health, increased longevity and an abundance of the simple pleasures of life are all readily available. All that has to be done is to fall in line with America's newest love affair - "the Mediterranean Diet".

The first hint that such a dietary pattern existed came about in the 1950s, when researchers from Harvard University's School of Nutrition became curious about why men and women on the islands of Crete and Sicily (many of whom lived well into their eighties), had one of the lowest rates of heart disease and cancer in the world. They also noted a remarkably low rate of heart disease in other nations around the Mediterranean. In 1959, for example, the coronary heart disease death rate for American men between the ages of 55 - 59 was eight times that of Greek men of the same age (748 per 100,000 for Americans versus 95 per 100,000 for Greeks). Other diseases such as breast and colon cancer were also lower in the Mediterranean region, and in Greece and southern Italy life expectancy was about four years longer than in the United States or Northern Europe.

During more than fifteen years of research studies, epidemiologists, those researchers who study large populations of people to identify "risk factors" for diseases, eliminated one factor after the other. Finally, in 1964, the researchers began to focus on what they identified as the "traditional Mediterranean diet". Among other factors they noted was that the core of the tradition- al Mediterranean cuisine of the 50s and 60s was an abundance of fruits and vegetables as well as large quantities of bread, pasta, couscous, rice and other grains. Legumes ad nuts were also eaten frequently. The overall diet included very little meat and only moderate amounts of fish, poultry and dairy products. Sweets played a small role in the dining habits of the people and fruits were the main form of dessert. Although each of these factors was important, the two most conspicuous features of the Mediterranean diet were the fact that olive oil accounted for as much as 40% of all of the fat consumed by most Mediterranean people and that they consumed wine with nearly every meal. In addition to asking whether Mediterranean eating habits could reduce the risk of heart disease and if so, what elements of the cuisine might be most effective.

At the recent San Francisco conferences, medical specialists, nutritionists and epidemiologists presented the latest scientific data supporting the dietary guidelines of what is now known as the "Optimal Traditional Mediterranean Diet Pyramid". Even though the pyramid (shown in the accompanying illustration) consists of nine levels, each representing the stress to be placed on various elements of the diet, the major focus at the recent conferences was on olive oil, nuts and wine. Considering the titles and integrity of the researchers who presented papers, one is almost embarrassed to point out that three of the major sponsors of the conferences were the American Wine Institute, The International Olive Oil Council and the International Nut Council.

Professor Walter Willet, Chairman of the Department of Nutrition at Harvard's School of Public Health, is one of America's leading advocates of increasing the use of olives and olive oil in the daily diet. According to Willet, olives and olive oil lower levels of LDL, which is considered the harmful or "bad" cholesterol because it contributes to the buildup of fatty deposits in the arteries, thereby raising the risk of heart disease. Olive oil also helps the body maintain the level of HDL, the "good" cholesterol which removes such deposits. According to Willet, olive oil also contains high quantities of antioxidants, today's nutritional miracle, and these are also thought to ward of heart disease. Perhaps best of all, according to Dr. R. Curtis Ellison, Professor of Medicine and Public Health at Boston University, antioxidants can also prevent various cancers by neutralizing volatile chemicals that drift in the bloodstream. Left unchecked, these molecules can damage cells and lead to the growth of tumors. Thus, conclude both Willett and Ellison, those who eat olive oil and nuts, both of which are high in antioxidants, have a reduced risk of both heart attack and cancer.

Even Israeli researchers have been working on the "olive oil connection". Professor Elliot Berry of the Nutrition Department of the Hadassah Faculty of Medicine at Hebrew university, for example, has recently published findings that "demonstrated that olive oil reduces negative blood-cholesterol levels and protects the body from cholesterol oxidation which causes coronary heart disease". As to the consumption of wine, the other major factor singled out for special attention at the conferences, the pyramid suggests that a moderate level of alcohol consumption, especially of red wine, also raises the HDL level and also lowers the risk of heart disease and reduces overall mortal- ity. Andrew Waterhouse and Edwin Frankel, both of the University of California at Davis concur that wine is a richer source of antioxidants than either olive oil, most fruits and vegetables or Vitamin E.

"The good news about all of this", says Dr Elisabeth Helsing, a regional director of the World health Organization which has officially endorsed the pyramid, "is that olive oil adds charm to food and wine adds charm to life". The problem, she continues, is that there remains a good deal of confusion as to precisely what the impact of each of the elements in the pyramid has on longevity and health.

There are other problems as well. Some point out, for example, that advocating a diet in which nearly 40% of the calories we take in comes from olive oil is problematic. Olive oil is pure 100% fat, and fat, no matter what its positive effects may be, fat is also public health enemy number one. In fact, some say the ideal fat intake should be no more than 10% of our daily intake. Dr. Helsing also says that simply adding olive oil to an existing diet that already includes a large amount of animal fat may actually negate the beneficial effects of olive oil. In addition, since all fats, including olive oil have 9 calories per gram, it is import- ant not to overdo them for if the Mediterranean diet results in significant weight gain, the value of the diet is undermined, for that would increase other risk factors, including high blood pressure and diabetes.

Others object to the pyramid, claiming that it has never been truly representative of the Mediterranean diet. Respected cook- book writer Claudia Roden, on a recent visit to Israel even questioned whether there has even ever been a typical Mediterranean diet, saying that "the only things that one really finds in common with the eating habits of the people of the Mediterranean nations are olive oil and hard physical work". Ironically, it is writers and scientists who have their roots in the Mediterranean (like Roden, who grew up in Cairo), who raise the strongest objections to the concept of the diet. Roden chuckles, for example, at data that would have us believe that the people of the Mediterranean ate very few sweets. "Just think", Roden says, "of the enormous amounts of baklava and other pastries drenched in honey and sugary syrup".

Professor Dimitrios Trichopoulps, a native Greek and now chairman of the department of epdemiology at Harvard's School of Public Health, points out that the studies of 34 Cretan men in 1964 and 52 Sicilians in 1968 "are based on far too small a number of participants on which to justify the con- cept of the Mediterranean diet". Dr Antonia Trichopoulou of the Athens School of Public Health goes even further, indicating that "not only were the numbers of people chosen to be studied extremely small, but they were also a very select population whose diet evolved out of poverty and hardship". Both also question the wisdom of including wine as part of the basic diet, pointing out that many of the residents of the Medi- terranean basin are Moslems and thus consume virtually no wine whatever.

Whether the Mediterranean diet is applicable to those living anywhere, even in the Mediterranean, in the 1990s is also open to question. Professor of Anthropology Dwight Heath of Brown University says that because of differences in temperament and traditions, there is a more fundamental problem in applying the diet to our times. "We simply do not and cannot live in their world", says Heath, who points out that the people in the study not only ate healthy foods, but engaged in robust physical activity every day, took a daily siesta, sat down with their families twice daily for prolonged meals, and had strong, inter- locking support systems between families, neighbors and friends.

Professor Walter Belasco of the University of Maryland goes even further when he claims, that although "we can spend an hour or two of exercise every day to make up for the eight to ten hours we are not plowing the fields, and try to duplicate a few other aspects of the way Cretan and Sicilian people lived in the 1950s and 60s, we would have to slow ourselves down and duplicate the family structure of the time. Belasco also feels that there are several aspects of the life of the people studied that we might not want especially to import, "especially their tyrannical patriarchal society, the sometimes terrible poverty and the environmental degradation that typified life in Crete and Sicily nearly 50 years ago".

Other unresolved controversies center about the suggestion to reduce the input of dairy products (which many consider necessary to prevent osteoporosis in old age); the advocacy of wine for women (while it may lower the risk of heart disease, some research indicates that even moderate consumption of wine increase the risk of breast cancer); and the very low reliance on sea fish (which are rich in Omega 3 fatty acids which are also suggested to be helpful in preventing heart disease). Another reservation is that the diet is based mostly on preventing heart disease and is not concerned enough with the relationship of diet to cancer and other diseases. Dr Elisabeth Helsig reminds people that "we all have to die of something after all, and what we should be concerned about is premature death". Helsing also says that she would "prefer cardiac death to any other form or mortality. I just don't want it to be premature".

The consumption of cheeses is an issue of special sensitivity. Although the pyramid suggests eating only a minimal amount of cheeses, Prof Serge Renaud , one of the originators of the pyramid claims that cheese is actually good for us, and points out that in France, Italy and Switzerland, nations with the lowest rates of heart disease in Europe, the people are the highest consumers of cheese. (The French eat 22 kilos per person per year). Although Renaud agrees that the consumption of other high fat dairy products should be reduced, he argues that calcium- rich cheeses actually neutralize fat by combining with it so that both are excreted rather than absorbed. Renaud explains this by claiming that the chemical process involved in the ripening of cheese makes cheese as different from milk as wine is from grape juice.

Although the Mediterranean Diet may not be the cure for every- thing that ails us, even its most vocal opponents concur that there is a good deal of wisdom inherent in the pyramid. Nearly every- body agrees, for example that we should eat less red meat. While Dr Willet and several others feel that it should be forbidden completely, most take a more moderate approach and agree with food writer Paula Wolfert who says that "people like the taste of meat and once they can afford it, they simply don't want to give it up". Ironically, Wolfert points out, even the people in Crete and Sicily now eat far more meat than when the original studies were carried out and in both places meat is stuffed into every vegetable and is so much a part of every casserole of beans or rice that sometimes the vegetables or legumes become the least important ingredient in those dishes.

There is broad agreement on other things as well. In addition to reducing red meat consumption, the amount of saturated fats we consume should also be reduced; there should be a major shift towards foods from plant sources; and that olive oil, fruits, vegetables, legumes, whole wheat and nuts are valuable sources of antioxidants, all of which prevent the buildup of fat deposits on the walls of the arteries. A survey of many of those presenting paperse at the conference also disclosed that nearly all agreed that even moderate amounts of exercise, if carried out regularly together with intelligent dining patterns, can improve our health.

There is no question that diet and life style play a vital role in the prevention of many diseases. The Mediterranean Diet may or may not point the way to good health but, as the charismatic Dr. Willet himself points out, "perhaps the question we should be asking ourselves is how, almost two millennia ago, the ancient Greeks managed to eat a delicious diet as healthful as any we now know in the world".

The Mediterranean Diet As Perceived In A Mediterranean Nation

Israeli medical specialists and nutritionists are enthusiastic but far more moderate than their American colleagues in their reactions to the concept of the Mediterranean Diet. Even though his own research findings indicate a critically important role for olive oil in the daily diet, Professor Elliot Berry suggests eating only two tablespoons daily (on salads, but not in cooking). He also feels that of the 30% recommended fat component of the regular diet, half should be olive oil, and the rest of polyunsaturated and animal fats such as dairy products, poultry or meat. "Mortality rates", says Berry, "are affected by many other factors", and with regard to the Mediterranean Diet, he feels it is too early to reach final conclusions about long-term life styles. Dr Olga Raz senior nutritionist at Tel Aviv's Ichilov Hospital, feels much the same and adds that although "the pyramid can serve as a general guideline, one has to think of an entire life style, one that includes factors such as exercise and stress management, and not merely of one or two dietary factors". Dr Raz also points out that studies of the Mediterranean diet have ignored factors of genetics and, because of the bias in sampling techniques, are far more applicable to men than women.

Each of the nutritionists and medical sources consulted agreed that Israelis are far from adhering to the rigid guidelines suggested in the pyramid. On the whole, Israelis consume about 3 ½ times as much red meat, 4 times as many eggs and 6 times as much dairy products as recommended and even though they consume far more olive oil than Americans, Israelis use only about half the amount recommended by the outlines of The Mediterranean diet. Israelis also consume nearly 35% more saturated fats (which encourage the development of "bad" cholesterol) than we should and, even though the Mediterranean diet calls for the use of minimal amounts of refined sugar, we gain 10% or more of our calories from sweets and sweetened beverages.

In other major departures from the requirements of the diet which calls for the use of fresh fruits, vegetables and other food produce, Israelis rely more heavily than the population of any other Mediterranean nation on tinned, frozen and preserved produce, many of which contain preservatives and other additives that the diet forbids and although we eat enough bread, we tend to eat breads made from refined flour and not whole-wheat flour as suggested by the pyramid. Although Israelis do not drink as much wine as recommended, they do eat (primarily because of the existence of humous) plenty of beans, peas, lentils and other legumes.

© Daniel Rogov