Models of Eating
Mediterranean (Greek & S.Italy) &
Asian (Japan) Food Patterns of the 1960's.
Mediterranean & Asian diet pyramids
were developed by Professor Walter Willet
and colleagues at Harvard University. They
the traditional food patterns in
the 1960s in Greece and Japan which have
been subsequently linked with longevity
and low rates of heart disease and cancer.
The evidence behind these pyramids originated
from the 7 countries study. Unlike other
pyramids/food guides, these pyramids indicate
frequency of servings (qualitative) across
a day, week and month. Red meat is recommended
a few times per month and fish weekly. Oils
are no longer at the top of the pyramid
because they are not severely restricted.
Also, legumes and nuts are separated from
vegetables and fruits and consumption is
This paper will review the evidence
regarding these cultural models of eating.
Diet Pyramid (Willet et
al. AJCN 1996)
Asian (Japanese) Diet Pyramid
7 countries Study 1960's.
Mediterranean diet which is currently promoted
as a model for 'good health' comes from
the Greek island of Crete and Southern Italy
around the 1960's when the prospective longitudinal
study (30 year mortality follow-up) began
as the 7 countries study. Since the 1960's,
the foods and dietary patterns of Greece
and Southern Italy have changed considerably
with the increased use of meat, dairy products,
polyunsaturated margarines and less olive
oil, legumes and nuts.
7 countries study instigated by Professor
Ancel Keys documented the diets of
middle-aged men aged 40-59 living
in Southern Italy, Greece (Crete, Corfu),
Yugoslavia, Finland, Netherlands, Japan
and US (about 70% of the men lived in rural
study showed clearly that populations who
ate the most saturated fat (Finland) had
the highest levels of blood cholesterol
and the most Coronary Heart Disease (CHD).
This study also awakened the interest that
the Cretan and Japanese diets may be related
to the lower incidence of CHD and colon,
prostate and breast cancer in these countries.
Cretan diet was one of the highest fat diets
in the study (40% energy as fat, but low
in saturated fat and high in monounsaturated
fat), but the Cretan Greeks eating it came
out with some of the lowest rates of CHD
and all-cause mortality and consequently
had the longest life expectancies in the
world at that time. They were even living
longer than mainland Greeks and the Japanese.
the first five years of the study there
were only two heart attacks in Crete and
one of these was the local town butcher.
The cohort from Finland had the highest
rates of CHD, being 30 times higher than
Crete even though they had a similar intake
of fat to the Cretans. However, most of
their fat was derived from cow's milk products
and was very high in saturated fat.
Cretan diet was also relatively low in carbohydrates
(45% energy) with most of the carbohydrates
consumed being of
low glycaemic index.
Even though the diet was high in
fat, it paradoxically had a low energy density
because of the large volume of plant foods
Cretan diet in the 1960's consisted of a
high intake of vegetables (360g/day i.e.
2-3 cups/day), especially green leafy types,
high intakes of
legumes (30g/day), nuts (30g/day),
fruit (460g/day i.e. 2-3 fruits /day) and
wholegrain cereals (450g/day i.e. 8 slices
were used as an integral part of meals,
not served ďon the side? Breads were made
by allowing dough to ferment slowly, resulting
in a lower glycaemic index. In contrast,
many breads we eat today use the rapid dough
fermentation procedure resulting in breads
with a higher glycaemic index.
also had moderate intakes of
fish (40g/day), alcohol (20g/day,
with meals i.e. 2 standard drinks/day) and
low intakes of
red/white meat (35g/day) and fermented
sheep/goats milk products (cheese/yoghurt
consumed weekly). Unfermented dairy products
i.e. fresh sheep/goats milk was reserved
for children. The average daily intakes
of these foods converted to the real-life
situation of weekly consumption, would be:
a 200g serving of fish twice a week, a 200g
serving of chicken/pork once a week,
a serving of lamb once a week or less, and
bean/lentil soups or casseroles about 2-3
times a week.
Cretan diet was also low in animal fats
(butter/margarine rarely eaten) and saturated
fat (8% energy), but high in total fat (40% energy) and monounsaturated
fat (25% energy) because the major source
of fat was olive oil (about 4 tablespoons/day),
which was nearly always consumed as 'extra
virgin' or the first pressing of the olive
and nearly always consumed with plant food.
was also high in omega-3 linolenic acid
(probably about 1% energy intake) due to
the high intake of nuts (especially walnuts),
wild greens (especially purslane) and legumes.
animals (sheep, goats, pigs, chickens) were
not always fed on grains (which is relatively
rich in n-6 fats), but were also allowed
to graze on wild plants and herbs, resulting
in fat deposits which were higher in n-3
fats. So the little meat they ate tended
to be leaner and the fat of these animals
was higher in n-3 fats and probably phytochemicals.
diet also had a favourable n-6: n-3 ratio
(<5:1) due to the absence of polyunsaturated
oils in the diet, the high intake of olive
oil and foods high in n-3 fatty acids (including
the 7 countries study, Cretan men had the
lowest incidences of CHD and cancer, followed
by Japan. Even though the fat content of
the two diets was very different (40% vs.
10% total energy respectively) both were
rich in omega-3 fatty acids (Simpoulos
Prostaglandins, Leukotrienes &
Ess Fatty Acids 1999; 60: 421-9). Cretan
men were found to have 3-fold higher intakes
of n-3 linolenic compared with the cohort
from the Netherlands and 21% lower intakes
of n-6 linoleic acid (Sandker et al. Eur
J Clin Nutr 1993; 47: 201-8).
Lyon Diet Heart Study 1980's & 90's.
evidence in support of the health benefits
of the Mediterranean diet has emerged recently
from Lyon in France, rural Greece and Melbourne
(see next section).
the Lyon Diet Heart Study 600 middle aged
Frenchmen who had suffered and survived
a heart attack were placed in two different
Prudent diet recommended
by the American Heart Association
There was no difference in the medications
or referral for invasive cardiac testing
between these groups.
groups had a similar content of fat (30%
energy) but group1 compared to group 2 had
a higher daily intakes of:
saturated fat (12% vs. 8% energy);
almost double the intake of n-6 linoleic
acid (5.3% vs. 3.6%);
one third of the intake of n-3 linolenic
acid (0.3% vs. 0.84%); a lower intake of
monounsaturated fats (10.8% vs. 12.9%);
lower intake of fruit (203g vs. 251 g),
bread (145g vs. 167g), legumes (10g vs.
20g), canola oil margarine (5g vs. 20g);
higher intakes of meat (60g vs. 40g)
and butter/cream (16g vs. 3g);
and similar intakes of fish (40g)
and oil (16g).
mimic the omega-3 content of the 1960's
Cretan diet, a canola oil margarine was
developed for the study, but subjects were
also encouraged to use olive oil. The study
was meant to last for 5 years, but after
looking at the rates of death, heart attacks
and angina it was stopped after 2 years
because of a marked difference between the
two groups. Within months of starting the
diets, plasma levels of vitamin C, E and
omega-3 linolenic acid (mainly from canola
oil) were higher and those of omega-6 lower
in the Mediterranean diet group. This group
had a 70% reduction in all cause mortality,
including heart attack and angina, compared
with people on the prudent diet. These differences
in mortality occurred despite similar levels
of blood lipids, blood pressure, body mass
index and smoking (~17% smokers) in the
two groups (De Lorgeril et al. Lancet 1994;
343: 1454-9; Circulation 1999; 99: 779-85).
4 years, overall death rates and cancer
deaths were respectively 56% (p=0.03) and
61% (p=0.05) lower among patients eating
the Mediterranean diet high in omega-3 linolenic
Lorgeril et al. Arch Inter Med 1998; 158:
other words, the protective effect of the
Mediterranean diet has been shown after
2 years and now 4 years, suggesting it is
not only effective but robust. The chances
of dying from a heart attack (and cancer)
were more than halved in those who had received
only a one-hourís instruction on the benefits
of eating a Mediterranean diet, especially
the increased intake of plant food, omega-3
linolenic acid (canola oil) and monounsaturated
fats (olive oil) and decreased intake of
saturated fats, linoleic acid, butter/cream
is particularly interesting about this study
is that it is possible to achieve positive
health benefits with relatively little dietary
education. Just learning about the diet
seemed to be enough to lead to major lifestyle
changes, whereas previously it has been
thought that dietary change is a complicated
process requiring major health educational
input. However, the magnitude of this effect,
and its robustness over time is enough to
suggest that this type of eating can be
promoted more widely.
diet and Survival in the Elderly in the
evidence in support of the Mediterranean
food pattern of the 1960s has come
three prospective cohort studies which described
the food habits of people aged 70
over in Greece (Trichopoulou, Kouris-Blazos
et al., BMJ 1995; 311 (7018): 1457-1460), Australia (Kouris-Blazos et al. Br J Nutr, 1999;
82: 57-61) and Denmark (Osler &
Schroll, Int J Epidem 1997; 26 (1): 155-9).
These cohorts were followed-up 5-6 years
later to ascertain survival status. The
Australian study included Greek-born and
Anglo-Celtic born elderly living
with food patterns consistent with the food
patterns found in Greece in the 1960s had
a reduced risk of death by about 50%, even
as late as 70 years and onwards. Smoking
male gender were not significant predictors
of mortality. The food pattern was defined
1) high consumption of vegetables;
2) high consumption of legumes;
consumption of fruits;
4) high consumption of cereals;
5) low consumption of dairy
6) low consumption of meat and meat
7) moderate ethanol consumption;
8) high monounsaturated: saturated fat
advantage if they
followed the entire food pattern, suggesting
synergy between food
groups. To read
the full text BMJ paper on the study in
Greece go to: http://www.bmj.com/cgi/content/full/311/7018/1457
traditional Greek diet has also been implicated
in protecting middle-aged and elderly Greek
migrants in Australia from fatal cardiovascular
disease (CVD), even though they appear to
have all the standard risk factors for CVD;
their blood pressure was found to be similar
to people born in Australia, their cholesterol
is similar, they are more overweight, and
yet they appear to be protected from heart
disease and diabetes complications. This
phenomenon has been described as a 'morbidity
mortality paradox' in Greek born-Australian
elderly (Kouris-Blazos et al. Aust J Nutr Diet 1999; 56 (2): 97-107) and as a 'Greek-migrant
paradox' in the middle-aged (Itsiopoulos
& O'Dea unpublished data).
phenomenon may be partly explained by the
olive oil in the diet, but it is probably
also related to their high intake of plant
foods and circulating blood levels of a
lot of protective
antioxidant phytochemicals that are absorbed
from fruit and vegetables with the help
of olive oil.
This is supported by recent evidence
emerging from a Monash University dietary
intervention study on Anglo-Australian middle-aged
diabetics (put on a traditional Cretan diet
for 3 months) and the epidemiological evidence
on 10,000 Melbourne Greek migrants "Health
not what you eat, its how you eat it"
(O'Dea 1999, ABC interview).
is now being hypothesised that the Mediterranean
is a very important component of maximising
the protection one derives from eating a
lot of vegetables combined with olive oil.
For example, the antioxidant lycopene in
better absorbed in the intestine
if the tomatoes are cooked; absorption is
even better if cooked with oil. This makes
sense, since these pigments are fat soluble.
The glycaemic index concept might
help further explain why the high fat low
carbohydrate Mediterranean diet, with all
the legumes and wholegrains, is healthy.
To listen to a "Health Report"
interview (conducted by Norman Swan) about
the Mediterranean diet, click
surely the Mediterranean diet does not have
a monopoly on eating well.
In the seven country study, the other
diet that came out with low heart disease
rates (but not strokes or stomach cancer)
was the Japanese diet high in carbohydrates
and low in fat - the exact opposite to the
This suggests that disparate food
patterns can result in comparable health
i.e. there is more than one ideal diet that
can lead to good health.
China or other Asian countries (India, Indonesia,
not included in the 7 countries-study
so we do not have comparable information
from the 1960's on these cuisines.
Japanese population of Kohama island have
the lowest incidence of CVD in Japan and
probably in the world. Their high intake
of omega-3 and omega-9 fats, low intakes
of omega-6 fats have been implicated in
providing cardioprotection. Their high intake
of n-3 fats is due to their use of canola
and soybean oils and high intake of fish
(Kagawa et al. J Nutr Sci Vitaminol 1982;
has been some debate about whether the Mediterranean
diet is preferable to the Japanese diet.
It does seem as though both of these diets
can be healthy. However,
Professor Willet has one word of caution
about the Asian diet
it tends to be very high in white rice,
and that may be something that is tolerated
by a population that is extremely lean and
active as traditional societies in Asia
have been. But when a society starts to
work in offices and drive cars instead of
working in the fields for many hours a day,
they will tend to develop more insulin resistance,
and in that case its pretty clear that we
can't tolerate high carbohydrate intake
nearly as well as a peasant farmer can ...
the total percentage of calories from fat
in the diet probably does not make too much
difference, if itís the right fat. But we
need to pay attention to the type of carbohydrate
in the diet, and try to minimise the highly
refined carbohydrates like white bread and
potatoes and instead use whole-grain, high-fibre
types of carbohydrates whenever we can.
We really have to recognise it's not that
carbohydrates are good and fats are all
bad, there's good and bad in both of them".
to Prof Frank Sacks of Harvard University,
both cultural models result in low blood
cholesterol (LDL cholesterol) levels. Both
a low fat and a high fat diet, low in saturates,
can reduce LDL cholesterol by 17%. However,
low fat high carbohydrate diets reduce the
'good' blood cholesterol (or HDL cholesterol)
by 18%, relative to the Mediterranean model.
relate this HDL effect to coronary incidence,
the low fat diet would predict a 16% increase
in coronary incidence in men and even more
in women. On the Mediterranean model there would be less change. In the short-term at least,
low fat diets also increase serum triglycerides
of the order of 25%. This would predict
an increase in coronary incidence of 16%
in women and 6% in men. Replacing one type
of fat with another does not affect triglyceride
On the low fat diet the benefits
of the decrease in LDL are nearly completely
offset by the negative impact of reduced
HDL and increased triglycerides, particularly
in women, and this actually predicts an
increase in coronary incidence.
These effects on blood lipids may
explain why the Greeks in the 7 countries
study had much lower death rates from CHD
than the Japanese.
shortfall of the traditional Cretan and
Japanese diets of the 1960's was the high
content of salt due to high intakes of olives,
bread, salted fish, pickles etc. Studies
have found a relationship between high salt
intakes in these countries and the high
rates of stroke and stomach cancer.
the low intake of meat and saturated fats,
moderate intake of alcohol (with food) and
high intake of unrefined cereals, legumes,
vegetables, monounsaturated fat, fish (especially
Japan) and fruit (especially Greece) is
believed to have contributed to their longevity
in the 1960's. However, the much higher
rates of stroke and stomach cancer in Japan
are thought to be linked with their much
lower intake of fruit, possibly fat and
higher intake of salty foods.
need to remember that traditional cuisines
are not necessarily perfect and can be improved.
For example, they evolved when there was
limited food availability and no refrigeration;
as a result certain foods/dishes developed
not be so good for ones
health e.g. salty
Walter Willet concludes in an article in
Science magazine (1994) that the evidence
is in favour of the traditional Greek diet
with respect to long-term safety.
Updated: March 28, 2001.