Going Mediterranean.

He's a shepherd or small farmer, a beekeeper or fisherman, or a tender of olives or vines. He walks to work daily and labors in the soft light of his Greek Isle.

His midday, main meal is of eggplant, with large mushrooms, crisp vegetables, and country bread dipped in golden olive oil. Once a week there is a bit of lamb. Once a week there is chicken. Twice a week there is fish fresh from the sea. Other meals are hot dishes of legumes seasoned with meats and condiments.

The main dish is followed by a tangy salad, then by dates, Turkish sweets, nuts, or fresh fruits. A sharp local wine completes the meal.

--Henry Blackburn, M.D. University of Minnesota Co-Investigator, Seven Countries Study All that delicious food and wine and the lowest heart attack risk and lowest death rate in the Western world. What was it about peasants living on the Greek island of Crete in the 1960s that made them so healthy?

A small number of researchers, a slew of cookbook authors, and a few industries are betting that it was the olive oil and other foods they ate instead of a diet rich in meat, cheese, and butter.

Welcome to the marketing of the Mediterranean Diet.

What causes heart disease? In 1958, Ancel Keys of the University of Minnesota and an international team of scientists set out to see. Animal studies had suggested that fats were to blame, but "there was only anecdotal evidence about the role of diet" in humans, remembers coinvestigator Henry Blackburn.

During World War II, for example, heart disease rates plummeted in countries with shortages of meat and dairy products.

And when Keys and his wife traveled around Europe and Africa in the 1950s measuring blood cholesterol levels, they noticed that affluent people, who were eating more meat and dairy, were more likely to have high cholesterol and suffer heart attacks than poor people.

In Naples, Keys was taken to dinner at the Rotary Club. "The pasta was loaded with meat sauce and everyone added heaps of parmesan cheese," he recalls. "Roast beef was the main course. Dessert was a choice of ice cream or rich pastry."

Could a diet rich in saturated fat lead to heart disease? At the time, the notion was radical.

GOIN' TO THE COUNTRIES

Keys assembled a research team that looked at the diets, lifestyles, and blood cholesterol levels of more than 12,000 healthy middle-aged men in Finland, Greece, Italy, Japan, the Netherlands, the United States, and Yugoslavia.(1)

The participants in the Seven Countries Study ranged from 2,000 U.S. and 750 Italian railroad workers to 500 faculty members of the University of Belgrade to 1,000 residents of two fishing villages in Japan.

After five, ten, 15, and 20 years, Keys counted how many people had--or had died of--heart disease.

After ten years, the 775 men from east Finland fared the worst--28 percent of them had developed heart disease. The Finns were eating more saturated fat (mostly from cheese and butter) than almost anyone else in the world--24 percent of their calories. That's double what Americans now eat.

The 1,000 Japanese residents of the fishing villages of Tanushimaru and Ushibuka ate the least fat (nine percent of calories) and saturated fat (three percent of calories). Five percent of them had developed heart disease. That was far better than the Finns.

But it wasn't the best.

That honor went to the 655 men from the Greek island of Crete. After ten years, two percent of them had developed heart disease, and none of them had died.

Amazingly, the Cretans were eating about as much total fat as the artery-clogged east Finns. True, their intake of saturated fat was far lower (about eight percent of calories), but it wasn't as low as that of the mostly-rice-and-vegetables Japanese diet (see "Dueling Diets," p.7).

Dueling Diets

In the 1960s, the Greeks (not just the Cretans) and Japanese were eating much less saturated fat than the less-healthy Americans.

[CHART OMITTED]

The Greeks and Japanese of the 1960s ate more bread, beans, grains, fish, and alcohol than the Americans. (Note: the graph shows ounces of "pure" alcohol. A typical serving of wine, beer, or liquor contains one-third to one-half ounce of pure alcohol.)

[CHART OMITTED]

CRETAN EATIN'

You've heard about it on the news. You may have a copy of one of the cookbooks or the pyramid.

From kitchens in Milwaukee to trendy New York and L.A. bistros, the Mediterranean Diet is hot. The olive oil's flowing and the feta cheese is crumbling like there's no tomorrow. The foods of southern France and southern Italy are being touted as Roto-Rooters for your arteries.

Of course, many of those dishes aren't what the healthy Cretan peasants were eating back in the 50s and 60s.

"Their diet was dominated by olive oil and [whole-grain] bread--the two alone accounting for 50 to over 60 percent of their total calories," remembers Ancel Keys. It was also rich in beans and fresh fruits and vegetables. Meat--even poultry--was infrequent. So was sugar and most dairy.

That's a far cry from drenching your salad with olive oil instead of blue cheese dressing. Or from making the "Broad Beans with Sausages and Mint" in Diane Seed's Mediterranean Dishes cook-book.

"I do think there is a risk in making any traditional diet gentrified," says Walter Willett, chair of the Department of Nutrition at the Harvard School of Public Health. "The usual tendency is to pick out the meat dishes which might be eaten only on holidays and special occasions and treat that as the norm."

When you get right down to it, the Cretan diet was near-vegetarian. "It's not a diet that most Americans would find very easy to adopt," says Marion Nestle of New York University, who co-chaired (with Willett) the 1993 International Conference on the Diets of the Mediterranean.

HIT THE BOTTLE?

Let's say you could kiss goodbye the burgers and fries, the chicken salad sandwiches, the double cheese pizzas, and the chocolate-iced cakes. That would eliminate a good chunk of artery-clogging saturated fat. But how would you replace most of those missing calories?

You could hit the bottle (olive oil, that is) and go the high-fat Mediterranean route. Or you could turn towards the low-fat Orient by loading up on carbohydrates like rice, breads, cereals, beans, and pasta.

Is one healthier than the other? It depends on who you are.

* Heart Disease. Olive oil is rich in monounsaturated fat, "which appears to raise blood levels of HDL," explains researcher Scott Grundy of the University of Texas Health Sciences Center in Dallas. HDL ("good") cholesterol seems to protect people against heart disease, perhaps by ferrying cholesterol away from the arteries and out of the body.

Low-fat, high-carbohydrate diets, on the other hand, can lower HDL. Does that mean low-fat diets lose the HDL battle? It's not quite that simple.

"If I put you on a pure vegetarian, low-fat, high-carbohydrate diet, your HDL is going to fall," explains William Castelli, director of the Framingham Heart Study in Massachusetts. "But your LDL ['bad' cholesterol] will fall far faster, and your ratio of total cholesterol to HDL will actually improve.

"If you look around the world, countries that have very low heart attack rates [like China and Japan] actually have lower HDLs than we do. But they have very much lower LDLs, too, so their ratios are better."

Of course, looking at entire populations obscures differences between people. If your genes predispose you to low HDL, a diet that gets, say, only 15 percent of calories from fat could make things worse.

"An extra-low-fat diet will, in many people, elevate triglyceride levels, which lowers HDL levels," says Alice Lichtenstein, a heart disease researcher at Tufts University in Boston.

But, she adds, an extra-low-fat diet may make things better for someone who has a tendency to put on weight. "What frequently happens when overweight people drastically cut the fat content of their diet is that they lose weight." And that raises their HDL.

* Cancer. The Greeks and Japanese were not only less likely candidates for heart disease, they also were (and are) less likely to get breast, colon, and prostate cancer (see "Have a Heart"). What's more, a recent study from Spain found that women who consumed the most olive oil were a third less likely to develop breast cancer than women who ate the least olive oil.(2)

Have a Heart

In the 1960s, far more Americans died of heart disease and cancer than Greeks and Japanese. (The Greek rate isn't zero because it includes more than just Crete.) While the death rate from heart disease in the U.S. has fallen steadily in recent years, it's still the highest of the three.

[CHART OMITTED]

And unlike large amounts of high-polyunsaturated oils like corn, soy, and safflower, olive oil doesn't promote tumors in animals. Of course, animal studies may not be relevant to humans.

It's just not clear whether it's the olive oil or the fruits and vegetables in the Mediterranean diet that's protective. Either way, both the Mediterranean and low-fat diets seem to lower the risk of cancer.

* Diabetes. Diabetics tend to have low HDL ("good") cholesterol. Anything that raises HDL cuts their risk of heart disease--which is the leading cause of death among diabetics. And, compared to a low-fat diet, a diet rich in monounsaturated fats like olive oil raises HDL.

What's more, monos may also lower blood sugar levels in diabetics.(3)

But a high-mono diet may be a double-edged sword. Eight out of ten diabetics are overweight. Many would no longer be diabetic if they could lose their bellies.

For the overweight, eating more fat--any kind of fat--can be disastrous. And, if it made them fatter, a high-fat diet wouldn't even raise their HDL.

In fact, the risk of gaining weight is the most controversial part of the Mediterranean Diet.

WEIGHT A MINUTE

"You can't recommend high-fat diets," says pioneering heart disease researcher Mark Hegsted of Harvard Medical School's New England Primate Center. "Americans eating high-fat diets would put on weight."

That makes sense. While no one has done a longterm study to test whether people gain more weight on a high-fat diet, there is lots of animal evidence.

"Rats get fatter with high-fat diets than with low-fat diets," says James Hill of the University of Colorado Health Sciences Center in Denver.

But what about the healthy men on Crete back in the 1960s? They weren't overweight, and they lived on olive oil.

"The Cretans were leading a very active life," explains researcher Henry Blackburn. "They burned 3,500 to 5,000 calories a day." That's about twice what sedentary Americans burn.

Of course, since the 1960s, the Cretans--like the rest of the world--have shifted towards an "affluent" diet. And guess what? As the meat, cheese, and butter have gone up, so has their weight...and their heart disease and cancer rates.

DOES FAT MAKE YOU FAT?

Not all researchers agree that fatty foods make you fat.

"Clearly, body fatness is an enormous and increasing health problem," says Harvard's Walter Willett. "[But] it is very clear that...[dietary] fat is not an important determinant of body fatness. The reason is that it is also easy to get fat on a high-carbohydrate diet if physical activity is low."

Willett says that he is "not hesitant about consuming a diet that is 35 to 40 percent of calories from fat, as long as those fat calories are mainly from monounsaturates" like olive oil.

Willett's argument stems largely from four studies in which people ate low-fat diets for at least a year. On average, they lost only about two pounds.(4)

But others argue that those studies weren't a fair test of the slimming capacity of low-fat diets. "They were not explicitly weight-loss studies," explains Lawrence Kushi of the University of Minnesota. Had the volunteers actually made an effort to shed some pounds, they might have had greater success.

What's more, several studies have found that while obese people don't eat more calories than lean people, they do get more of their calories from fat.(5) Still, that's not proof that fatty foods make fatty people.

"There's just no evidence that's going to say one way or the other," says researcher James Hill. And given the spread of obesity in the U.S., it doesn't make sense to recommend a high-fat diet until we're sure that it won't expand the national waistline.

The American Heart Association agrees. "Because of the high fat content of the Mediterranean Diet," it says, "adopting it may increase the risk of obesity."

Even the Med Diet promoters acknowledge the risk.

"If you're active and don't have a weight problem and you're eating a diet that's very high in fruits and vegetables and monounsaturated fats, it may not matter what the total fat level in your diet is," says Greg Drescher, co-founder of the Oldways Preservation & Exchange Trust, a non-profit group that's pushing the Mediterranean Diet (see p.9).

"On the other hand," he concedes, "if you're prone to weight gain, it might matter."

THE BOTTOM LINE

* For most people, the healthiest diet is a low-fat one that's full of grains, fruits, vegetables, and beans and that uses olive oil as the main source of fat (see pages 8 and 9).

* If you are slim and have low HDL ("good") cholesterol, a diet rich in monounsaturated fat (like olive oil) may protect your heart.

* If you have a tendency to gain weight, a diet rich in monounsaturated fat may make you fatter, which can raise your risk of heart disease.

(1)Seven Countries: A Multivariate Analysis of Death and Coronary Heart Disease (Harvard University Press, Cambridge, 1980).

(2)International Journal of Cancer 58: 774, 1994.

(3)Journal of the American Medical Association 271: 1421, 1994.

(4)Science 264: 532, 1994.

(5)American Journal of Clinical Nutrition 47: 406, 995, 1988.