Diets From Around

The World
Food For a Healthy Planet 1
Monday 16th May 2016

Julia Steenkamp
B.Health Science (Nutrition & Dietetics)
Post Grad Dip Food Science
Master Social Change & Development (Food Security & Sustainable Rural Development)
You Are What You Eat

The Four Seasons, Guiseppe Arcimboldo, 1573

 Lecture Objectives
Mediterranean diet
History of Mediterranean Diet
Principles of Mediterranean Diet
A closer look at fatty acids
Studies on the Mediterranean diet & cardiovascular Health, overweight & obesity
Aspects of the Mediterranean diet that may explain its health benefits
More in depth look at:
Olive oil
Vegetables
Fish
Meat
French Diet
Principles of the French Diet
How the French Diet compares to Mediterranean Diet.
Health snapshot of the French population
Aspects of the French diet that may explain the French Paradox.
More in depth look at:
Eating frequency (3 meals v meals and snacks)
Portion control
Eating rate (slow versus fast)
Saturated Fat
Comparison between Mediterranean Diet & Healthy Eating Pyramid.
 Ancel Benjamin Keys (1904-2004)
Monsieur Cholesterol
American scientist
Extremely influential man
 Seven Countries Study

First major study to investigate diet and lifestyle risk factors for cardiovascular disease across
different countries over an extended period of time.

12,763 males, aged 40-59 years of age, enrolled in 16 cohorts, in seven countries.

Surveys on diet, lifestyle and health collected every 5-10 years.

 Seven Countries Study

Keys first observations:

Countries around Mediterranean: Long life.
Diets were:
High in:
Olive oil
Vegetables & fruit
Legumes
Fish
Moderate in:
Wholegrain breads and cereals
This way of eating was
Fermented dairy later termed the
Low in: Mediterranean Diet
Red meat
Sweets
Further investigations showed:
Low intakes of saturated fat and higher intakes of unsaturated fat.
Lower cholesterol levels
Lower rates of cardiovascular disease.
Birth of the Mediterranean Diet

Ancel keys became famous for:

1. Making the link between dietary choices and heart disease.

2. Establishing the Diet-Heart Hypothesis.

Saturated fat and dietary cholesterol increase serum cholesterol which can
cause plaque formation in the arteries which can narrow the arteries and
lead to heart disease.

3. Uncovering the secrets of the Mediterranean Diet.

Dietary Advice of Ancel Keys 1959

Source: Keys, A & Keys M, 1959. Eat Well and Stay Well. New York. Doubleday &
Company.
 Saturated & Unsaturated Fats
Fats are made up of combinations of fatty acids.

A fatty acid is a chain of carbons with a carboxyl group on one end.

Fatty acids can be saturated or unsaturated (mono or poly).

www.chemistry.stackexchange.com
 Saturated & Unsaturated Fats
Common Fatty Acids

Saturated:
Palmitic Acid (16:0)
Stearic Acid (18:0)

Monounsaturated:
Oleic Acid (18:1 n-9)

Polyunsaturated:
Omega 3 (essential fatty acids)
alpha Linolenic Acid (ALA) (18:3 n3)
Eicosapentaenoic Acid (EPA) (20:5 n3)
Docosahexanoic Acid (DHA) (22:6 n3)
Omega 6 (essential fatty acids)
Linoleic Acid (LA) (18:2 n6)
Fatty Acid Content of Common Foods
Why is this important?

Cardiovascular Disease (CDV) is

responsible for 33% of all deaths in
developed countries.

CVD is the leading cause of death in

Australia.

CVD kills one Australian every 12 minutes.

1.4 million Australians live with Coronary

Heart Disease.

28% of adult Australians are obese.

Australia has the 4th highest obesity rate in

the world!
 Mediterranean Diet
Cardiovascular Health & Obesity
Is the Mediterranean Diet the Solution?

Meta-analysis (Nordmann et al 2001)

Mediterranean Diet compared with Low Fat diet.
Lower body weight
Lower blood pressure
Lower fasting blood glucose levels
Lower total cholesterol
Lower C-reactive protein (inflammatory marker)

PREDIMED Study (Estruch et al 2013)

Randomized Trial in Spain (7445 subjects)
Mediterranean diet + extra nuts or olive oil compared to Low Fat diet.
Lower blood pressure
Lower fasting plasma glucose levels
Improved HDL:LDL cholesterol ratio
Lower C-reactive protein and other inflammatory markers.
 Mediterranean Diet
PREDIMED Study

Estruch et al (2013) Primary prevention of cardiovascular disease with a Mediterranean diet, The New England Journal of Medicine, 368:1279-1290
 Mediterranean Diet
PREDIMED Study

Estruch et al (2013) Primary prevention of cardiovascular disease with a Mediterranean diet, The New England Journal of Medicine, 368:1279-1290
 Mediterranean Diet
PREDIMED Study

Incidence of
stroke, heart
attack or death
from CVD.

Year

Estruch et al (2013) Primary prevention of cardiovascular disease with a Mediterranean diet, The New England Journal of Medicine, 368:1279-1290
 Principles of the Mediterranean Diet
1. Use olive oil as the main added fat.
2. Eat vegetables with every meal & include leafy
greens and tomatoes.
3. Include at least two legume meals per week.
4. Eat at least two serves of fish per week,
especially oily fish.
5. Eat meat less often.
6. Eat fresh fruit everyday.
7. Eat fermented dairy products everyday.
8. Choose wholegrain breads cereal products.
9. Consume wine in moderation & always with
meals.
10. Sweets for special occasions only.
Consume 60ml (3tbsp)/day
Include 100g leafy greens (1 cup cooked),
100g tomatoes (1 whole) and 300g of
other vegetables.
1 serve = 250g (1 cup cooked beans)
1 serve = 150-200g
Small portions only of beef, lamb, pork,
chicken.
Include fruit as a snack or as a dessert.
Eg yoghurt (cheese in moderation)
Eg Wholegrain sourdough
1-2 glasses per day and always with
meals.
Key Features of the Mediterranean Diet
Olive oil
60mls (3tbsp)/day

Karen ODea FFHP1 2014 adapted

from Itsiopoulos 2013.
 Olive Oil

Meta-analysis (Schwingshackl 2014)

42 studies
Olive oil consumption:
Decreased risk of death from cardiovascular disease by 12%
Decreased risk of heart attack by 9%
Decreased risk of stroke by 17%

Mechanism of action:
High in oleic acid (monounsaturated fatty acid)
Contains phenolic compounds (antioxidants)
Key Features of the Mediterranean Diet

Vegetables
1 cup of vegetables with every meal.
Include leafy greens and tomatoes.

Karen ODea FFHP1 2014 adapted

from Itsiopoulos 2013.
 Vegetables
Vegetables are a very important source of:
Vitamins
Antioxidants
Dietary Fibre

Meta-analysis (Luc Dauchet 2006)

9 studies
Risk of heart disease decreased by 4% for each additional serve of F+V
consumed.

Meta-analysis (He et al 2006)

8 studies
Consumption of 3-5 serves of F+V versus 5+ serves of F+V.
3-5 serves: relative risk of stroke 0.89 (compared to <3 serves)
5+ serves: relative risk of stroke 0.74 (compared to <3 serves)

Fruit and vegetables also preventative against various cancers.

 Key Features of the Mediterranean Diet
Fish
Include at least 2 fish meals/week.
(1 serve = 150-200g)
Include oily fish.

Omega 3 fatty acids (DHA &

EPA)

Karen ODea FFHP1 2014 adapted

from Itsiopoulos 2013.
 Fish

Meta-analysis (Whelton et al 2004)

14 cohort studies
Consumption of Fish 2 x week:
17% reduction in the incidence of death from cardiovascular disease.

Meta-analysis (He et al 2004)

13 cohort studies
Dose response
Consumption of fish 5 or more x week:
38% lower risk of death from cardiovascular disease.

Mechanism of action:
Decrease blood pressure
Decrease triglycerides
Decrease inflammation
Improve arterial and endothelial function
Reduce platelet aggregation (thin blood)
Key Features of the Mediterranean Diet
Meat
Eat meat LESS often and have smaller portions
Beef, lamb, pork, chicken.

Karen ODea FFHP1 2014 adapted

from Itsiopoulos 2013.
 Meat

Is red meat that bad???????

Micha et al 2010. Red and Processed Meat Consumption and Risk of
Incident Coronary Heart Disease, Stroke, and Diabetes Mellitus.
Circulation, vol 121.

Systematic review and meta-analysis

20 studies (17 cohort and 3 case control)
Looked at red meat consumption (unprocessed versus processed)

Red meat consumption (unprocessed) was not associated with risk of

CHD or diabetes.

Processed meat consumption was associated with a 42% increased risk

of CHD and a 19% increased risk of diabetes.
 Key Features of the Mediterranean Diet
Wine
Consume wine in moderation & always with meals.
1-2 glasses/day.

Resveratrol
(Phenolic compound/antioxidant)

Karen ODea FFHP1 2014 adapted

from Itsiopoulos 2013.
 Summary of Mediterranean Diet

Based on dietary patterns of people living in parts of Greece and Southern Italy
in the 1950s and 60s.

Based on principle that saturated fat, cholesterol and heart disease are
associated.

Largely plant based, with low-moderate meat consumption.

Encourages the intake of unsaturated oils from plant sources such as olive oil
and nuts as well as fish.

When compared to a low fat diet, shown to decrease stroke, heart attack and
death from cardiovascular disease.

Health effects are quite likely due to consumption of fruit and vegetables, olive
oil and fish..but are unlikely to be related to decreased red meat
consumption.
 Mireille Guiliano
Born in France in 1946
Author: French Women Dont Get Fat: The Secret of Eating For Pleasure.

A sliver of butter is pure pleasure and much better for you than pseudo-fat
substitutes like margarine, which should be tossed in the trash together with
Crisco. Eating is sensory, so eat with all five senses, and appreciate little
experiences (of small portions and three bites) which produce through
association and memory a gamut of emotions. Focus on the pleasurable ones
and evade the destructive ones".
 French Diet
Type of Food Food from all the food groups diet diversity
Plenty of red meat and fish
Good intake of fresh fruit and vegetables
Enjoy gourmet desserts and butter with their bread
Wine
Quality of Food High quality ingredients / minimally processed foods
Freshly baked bread
Gourmet cheese
Fresh fruit and vegetables
Quantity of Food Small portions

Frequency of Eating 3 meals per day (occasional small afternoon snack)

Pace of Eating Slow eating

Mindful eating
2 hour lunch
Social experience Mealtimes are shared with family and friends
Talking about food and enjoying the dining experience is
ingrained in the French culture.
Dieting / relationship Once you start counting it takes away from the joy of eating.
with food In America, you look at food as bad and guilty. In France, we
love food and we enjoy food; food is pleasure.
 French Diet

1996 survey, 837 French adults, habitual dietary intakes.

Only 15% derived less than 30% of energy from fat.

Only 4% derived less than 10% of energy from saturated

fat.

90% scored highly for diet diversity.

Drewnowski et al 1996
French Diet v Mediterranean Diet
One would assume that based on the research by
Ancel Keys and the Diet-Heart Hypothesis.the
French must have high levels of cardiovascular
disease and obesity and low life expectancy.
Health in France

OECD 2013, Health at a Glance: OECD

Indicators.
 Health in France

Death from Heart Disease Death from Stroke

OECD 2013, Health at a Glance: OECD

Indicators.
Health in France

OECD 2013, Health at a Glance: OECD

Indicators.
 Explaining the French Paradox
The French Paradox

People in France have one of the highest life expectancies in the world, with
comparatively low rates of lifestyle diseases such as obesity, cardiovascular
disease and diabetes. Yet, their intake of fat, in particular saturated fat, is well
above recommended levels and their cholesterol levels are amongst the highest
in the world.

Slow Eating Hunger/Satiety

Heart Disease Cues
Saturated Fat/Cholesterol -internal v external
Cause or Association

Mindful
Minimally Eating
Processed Foods
Meal Frequency

Wine
Portion
Fish Control
 Meal Frequency
French: 3 meals per day.

Is it better to eat 3 meals or 5-6 meals/day?

 Meal Frequency
Research shows:

Less meals associated with lower energy intake.

More frequent meals associated with higher energy intake.

However, frequent meals also associated with increased energy expenditure

(exercise).

Therefore, no conclusive evidence that 3 meals is better than 5-6 meals/day.

Recent research: Length of FASTING period

 Portion Control
French: Small portion sizes
Portion sizes in France are smaller (restaurants, supermarkets and cookbooks)
Attitude of moderation rather than abundance and quality rather than
quantity.

Its all about portion size

Portion control is more an art than a discipline
Contentment with most foods, in terms of taste, is to be found in the first few
bites

Rozin et al 2003
 Portion Control

Research shows:

Meta analysis (Zlatevska et al 2014)

When portion size is doubled, consumption increases by an average
35%.
This effect diminishes as the size gets larger and larger.

Restaurant study (Dilberti 2004)

Participants served either a small or a standard entre (same dish)
Large entre:
Consumption of entre increased by 43%.
Consumption of meal overall increased by 25%.
 Slow Eating
French: Eat meals slowly

Eat. Eat well. Eat slowly.

 Slow Eating
Research shows:

Controlled Trial 2004

35 normal weight and 35 overweight subjects
Same meal
Eating slowly significantly lowered the energy consumption for the
normal weight subjects, but not for the overweight subjects.

Systematic review and meta analysis 2014

22 studies
Slower eating rate was associated with lower energy intake in
comparison to faster eating rate.

Population Study 2011

Nationwide population survey in New Zealand
2,500 women
Speed of eating (self reported) was significantly associated with
higher BMI.
Shah et al 2004 & Robinson et al 2014 & Leong 2011.
 Saturated Fat
Some researchers believe that the French Paradox was never a paradox at all
 Saturated Fat
Willet W (2012). Dietary Fats and Coronary Heart Disease (Review) J. Intern.
Med. 272:13-24.

Total fat is not important.

Trans fatty acids are clearly no good for heart health and should be
eliminated.
Replacing saturated fat with unsaturated fat can decrease rates of CHD.
Replacing saturated fat with carbohydrate has no effect on rates of CHD.
 Summary of French Diet
The French have a very high life expectancy as well as low rates of
cardiovascular disease and obesity.

The French consume a diet that contains plenty of meat, cream and butter.

The French consume more total fat and more saturated fat than current
recommendations.

Explanations for this French Paradox are:

Eating 3 meals/day, eating small portions, eating slowly and enjoying the
eating experience
Consuming wine, fish and minimally processed foods

Some argue that there is no French Paradox. Saturated fat may not be the bad
guy it was once thought.
 Recommendations
Enjoy a wide variety of nutritious foods everyday with foods from all the food groups.

Enjoy plenty of fish, olive oil, vegetables (and red wine?) as part of a healthy diet.

Try to limit highly processed foods and consume mainly minimally processed foods.

Concentrate on the benefit of the WHOLE food and the WHOLE diet rather than the
nutrients and calories that each food does/does not contain.

Consume either 3 meals a day or more frequent meals depending on how active you
are.

Make sure your portions are not too big.

Try to eat slowly and take time to enjoy your meal.

If you choose to consume alcohol, 1-2 glasses of red wine per day may be beneficial to
heart health.