For 50 years–and longer–doctors have been telling us that what we eat is a key factor in determining our risk of having a heart attack or stroke.
The basic message, as Americans have interpreted it, is that foods high in fat should be avoided. Fat in the diet tends to increase serum cholesterol, which, in turn, leads to atherosclerosis–the development of fatty plaques in coronary arteries. When a clot develops in arteries that are narrowed by plaque, the result is usually a heart attack or stroke, sometimes fatal.
The message has never been as simple as avoid all fat, and, recently, it has been refined several times. The fats most likely to raise cholesterol and increase the risk of a heart attack are saturated fats and trans fats–mostly found in red meat, dairy products and processed foods.
Some fats, we now know, are actually beneficial to heart health when consumed in moderation. These include the fats in tree nuts and peanuts; the monounsaturated fats in olive oil, canola oil and avocados; and fatty fish such as salmon.
People in Mediterranean cultures follow a traditional diet that can hardly be called low fat. They have a high intake of olive oil, fruits, nuts, vegetables and cereals plus moderate amounts of fish and poultry. And they enjoy a glass or two of wine every day with meals. Compared to mainstream Americans, these people eat less red meat, dairy products, processed foods and sweets.
Large observational studies have found that people living in Mediterranean cultures have a lower than expected rate of heart disease. And, because the components of the diet make sense, the American Heart Association recognizes the Mediterranean diet as an option to the traditional reduced-fat diet, even though it has a fat content in the 30 to 35 percent range as opposed to 25 to 30 percent for the low-fat diet.
Med Diet Wins Head-to-Head
A Spanish study of about 7,500 men and women at risk of cardiovascular disease [New England Journal of Medicine, February 2013] recently compared the two diets head-to-head, and the Med diet came out the clear winner. It lowered the risk of heart attack, stroke and death from heart-related causes by 30 percent. Benefits of the Med diet were so clear that the study was halted after five years.
One of the first to object was Dr. Dean Ornish, the dean of low-fat diets, so to speak. The Dr. Dean Ornish Program for Reversing Heart Disease is based on a vegetarian diet that derives only 10 percent of total calories from fat along with moderate exercise and stress management.
Ornish and his colleagues have published a series of studies documenting the effectiveness of this program in reversing heart disease. One of these was a small study of 28 patients with coronary heart disease diagnosed through angiography. Of the 20 subjects who followed the Ornish diet, 82 percent showed significant regression of their atherosclerosis while 53 percent of the control group, who followed their regular diet, showed even greater progression of heart disease.
Ornish correctly noted that subjects in the low-fat arm of the Spanish study did not really eat low fat, as they were instructed to do. They reduced their fat intake from 39 to 37 percent of calories–far from the 30 percent recommended–and slightly higher than those on the Mediterranean diet. None of the subjects–either low fat or Mediterranean–showed a decrease in serum cholesterol.
Dr. Ornish believes strongly in his low-fat regimen, and it may actually come as a surprise to him that many Americans simply cannot or will not adhere to a diet that gets as little as 25 percent, let alone 10 percent, of calories from fat. Persons enrolling in Ornish’s program are highly motivated since their lives are on the line. Even so, about 30 percent quit within five years.
By comparison, the Mediterranean diet–with olive oil, roasted vegetables, beans, chick peas, fish, nuts and wine–is quite palatable, and subjects had no problem following it.
Med diet subjects in the Spanish study were discouraged from eating saturated and trans fats but encouraged to consume monounsaturated fats and omega-3 fatty acids. One arm was supplemented with additional extra-virgin olive oil and the other with nuts. The risk reduction was 30 percent for those consuming olive oil and 28 percent for those eating nuts–in both cases, far higher than those attempting to eat low fat.
The results confirmed earlier trials such as the Lyon Diet Heart Study. And an analysis involving 1.5 million healthy adults concluded that the Med diet is associated with a decreased risk of heart disease, cancer, Parkinson’s disease and Alzheimer’s dementia.
Compared to the Spartan fat-trimming recommendations of the past, it’s a whole diet approach that pays equal attention to foods you should eat as well as those you should limit. There is no question that the low-fat diet, if followed strictly enough, will result in reductions of total cholesterol and LDL (low density lipoprotein)–usually greater reductions than those achieved with the Med diet. Nevertheless, in terms of preventing fatal and non-fatal heart attacks and strokes, the whole diet approach has proved to be more effective.
With due respect to Dr. Ornish and his colleagues, the low-fat approach may be best suited to reversing heart disease, and the Med diet, more effective for prevention.
Except for the focus on healthy fats, the Mediterranean diet is not all that different from other heart healthy diets, including the DASH diet which has been shown to be effective in lowering and managing blood pressure.
You don’t have to pretend you are Italian or Greek to follow it, but you should commit yourself to eating more fruits and vegetables, whole grains, nuts, chick peas and beans.
• Try roasted vegetables drizzled with olive oil.
• Make your own salad dressing from olive oil mixed with vinegar or lemon.
• Use olive oil rather than butter for your bread.
• When you’re seasoning your food, go easy on the salt and focus instead on herbs and spices.
• Eat grilled or broiled fish two or three times a week; red meat, two or three times a month.
The whole diet approach encourages enjoyment of food with friends and family as a social occasion...along with a glass of red wine, if you wish. Friends, family, talking, laughter–that’s what good health is all about.
REFERENCES:
James E. Dalen, M.D., MPH, and Stephen Devries, M.D., FACC, “Diets to prevent coronary heart disease 1957-2013: what have we learned?” The American Journal of Medicine, May, 2014.
Ramon Estruch, M.D., Ph.D., “Primary prevention of cardiovascular disease with a Mediterranean diet,” NEJM, April 4, 2013.
Sandra Adamson Fryhofer, M.D., “Med diet vs low fat: And the winner is?” Medscape Medicine Matters, September 27, 2013.
Deborah Kotz, “Mediterranean diet vs. low-fat Ornish plan,” Boston Globe, April 15, 2013.
Gina Kolata, “Mediterranean diet shown to ward off heart attack and stroke,” New York Times, February 25, 2013.
“Low-fat, low-carb, or Mediterranean: which diet is right for you?” Harvard Health Publications Healthbeat, July 10, 2014.
Mayo Clinic Staff, “Nutrition and healthy eating,” MayoClinic.com, June 4, 2013.
Dean Ornish, “Does a Mediterranean diet really beat low-fat for heart health?” Huffington Post, February 25, 2013, updated April 27, 2013.
Honor Whiteman, “Mediterranean diet ‘better than low-fat diet’ for cardiovascular risk,” Medical News Today, August 31, 2014.
11/19/2014
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