The Mediterranean (Med) diet is replete with fresh fruits, vegetables, nuts, wholegrains and olive oil, with moderate consumption of fish and chicken. Red meat, sweets and dairy products are eaten sparingly, though red wine is drunk in moderation with meals. Increasingly, it has become the “go-to" diet among doctors as research shows that it reduces the risk of a host of modern-day illnesses, including cancer, Alzheimer’s, Parkinson’s, cardiovascular disease, and the overall risk of premature death.

The diet is a relatively recent phenomenon, not a traditional diet of the region. It was first observed in Greece, Spain and Italy in the years immediately following World War II. It was a style of eating that emerged from war rationing but has since proved remarkably healthy compared to the global increase in consumption of fast foods loaded with sugar, red meat and refined carbohydrates.

And it doesn’t take much to adapt an Indian diet to a Mediterranean one.

In early April, an article in The New England Journal of Medicine headlined Primary Prevention of Cardiovascular Disease With a Mediterranean Diet described the results of a multicentre study in Spain, reawakening the discussion on the Mediterannean diet among researchers and clinicians alike. The study followed 7,447 Spaniards between the ages of 55 and 80 for nearly five years. Among the study participants, more than half (57%) were women and all were at high risk of heart disease. The risk was determined by including in the study people who were smokers, diabetic, or had three of the following conditions—hypertension, elevated LDL cholesterol levels, low levels of HDL, were overweight or obese, or had a history of premature heart disease. The study participants were randomly assigned a Med diet that had either nuts or extra virgin olive oil added to it or were recommended a low-fat diet that didn’t necessarily include olive oil or nuts. In each of the three groups—two Med diet groups and one control/low-fat diet group —nutritionists ran training sessions every quarter where adherence to the diet was determined with a self-administered questionnaire, followed by personalized advice. To figure out if the study participants were actually using the olive oil or eating the nuts, the researchers took urine and blood samples at random at the end of years 1, 3 and 5 to check for olive oil and nut metabolites.

Olive oil and walnuts, for instance, can be replaced with mustard oil, canola oil, almonds and cashew nuts.

Rachna Chhachhi, a Mumbai-based nutritional therapist, agrees with Dr Misra but says she has some concerns regarding the study design. “Study subjects being asked to consume olive oil or nuts doesn’t make sense, you cannot look at these things in silos. A more holistic approach is far more advisable."

The subjects on the low-fat diet had a daily intake of 37-39% fat while a typical low-fat diet is 15% fat—the low-fat group wasn’t low-fat at all, so it may not have been the best comparison.

Yet the fact that the Mediterranean diet works is not in question. Aashish Contractor, head of department, preventive cardiology and rehabilitation, Asian Heart Institute, Mumbai, says: “Though there are issues with the study design, the results of this study have served to reaffirm what we’ve known for a while. Mediterranean diets are cardio-protective but the more I learn, the more I believe in principles, not a diet. In India we can and should put emphasis on eating more fresh vegetables and fruits, for though we are largely a vegetarian society we don’t eat enough of those. Our grain intake should also tend towards the wholegrain. I have recommended these general eating principles for the past 10 years to my patients. And in my experience, along with exercise and medication, this diet works."

The Indian diet falls short on two main counts: First, we tend to eat a lot of processed grains (maida, white rice) and not enough vegetables; and second, the vegetables are almost always overcooked, whereas the ideal way to eat them is raw or lightly cooked to maintain their nutritional qualities. We also tend to skimp on fruits, and an increased consumption of fast food and processed meals that are high in saturated fats, simple sugars and low in fibre is taking its toll.

A systematic review of the studies and analysis on the effectiveness of the Med diet and other diets, like high-protein and low-carbohydrate, and their ability to manage type 2 diabetes was published in March in The American Journal of Clinical Nutrition. Jonathan Pinkney, professor of endocrinology and diabetes, Peninsula College of Medicine and Dentistry, Plymouth, UK, and colleagues found that the Med diet was the most effective in controlling glucose levels in the blood. And it leads to greater weight loss and a better lipid profile compared with a conventional diet, where the study participants didn’t change their usual way of eating.

What makes the Med diet special is that there is very little saturated fat (saturated fats are found in animal products such as butter, cheese, whole milk, ice cream, cream, and fatty meats) while there is an increased presence of unsaturated fats like monounsaturated fatty acid (Mufa) sources. Research shows that Mufa-rich oils can reduce total cholesterol levels in the blood, decrease levels of LDL, the “bad" cholesterol, and maintain or increase levels of HDL, the “good" cholesterol. The Med diet also has a high-fibre content from fruits, legumes and wholegrain cereals which slows digestion and prevents swings in blood sugar. This action improves insulin sensitivity and helps to keep type 2 diabetes in check. The micronutrients, antioxidants, vitamins and minerals that come from a diet rich in varieties of vegetables and fruits also help protect against cancer, heart disease and Alzheimer’s.

It is difficult to change what we eat. If we are to make changes and adhere to them, they need to be tailored to our individual tastes and habits. A one-size-fits-all approach is unlikely to work. Swati Bhardwaj, nutritionist and senior research officer, Diabetes Foundation (India), New Delhi, says that from the Indian dietary perspective, we don’t need to make too many changes to incorporate elements of the Med diet and reap its benefits.

The important shift that we need to make, apart from eating more fruits and raw vegetables, is to include Mufa-rich oils in our diet. The dietary recommendations don’t state how much, but say that total fat should be 25-35% of the calories. While olive oil is an excellent source of Mufa, other plant-based oils like safflower, sunflower, canola, mustard oil and peanut oil are Mufa-rich too. And so are avocados and nuts like almonds, cashews, macadamias and walnuts. Mufa-rich seeds include pumpkin, safflower, sesame, sunflower and watermelon seeds.

Sujata Kelkar Shetty, PhD, writes on public health issues and is a research scientist trained at the National Institutes of Health in Bethesda, US.

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