The Mediterranean Prescription
When I was a young college student in New York, my father intro- duced me to a wise, older doctor named Dr. Peter Saita. He was a Sicilian internist who practiced in downtown Manhattan and over time became somewhat of a mentor to me. He used to tell me that being a doctor was the noblest profession, and it was he who inspired me to go to medical school. I kept up my relationship with him throughout medical school and would often accompany him to see patients. He would tell me, “The best thing I can do for my patients is to get them to stop smoking and to help them lose weight.” This was in the 1970s, when people didn’t really pay attention to these issues. He personally saw the connection between being overweight and poor health among his patients and took it upon himself to help those at risk. As a result, he developed a diet that he would describe briefly to his overweight patients, so easy to follow that he didn’t even have to write it down, that he saw work over and over. He handed this down to me, a newly graduated doctor, and I never forgot it—in part because I had so much respect for this man, but mostly because, as I eventually found again and again with my own patients, it worked.
Years ago as I was starting out as a physician, I tried to help patients lose weight in a more traditional way. I used to tell them how to eat healthily, would give them papers on nutrition, and would refer them to nutritionists, but they weren’t losing weight. In my frustration, I tried telling them about Dr. Saita’s diet. I said, “Why don’t you try this very simple diet?” They would come back to me for a follow-up telling me, “I tried the diet, but it’s difficult. I can’t stick to it.” I noticed that my American patients didn’t have the devotion to food that was found in the Italian culture I grew up in. When I told them the diet included all-you-can-eat fish and chicken entrées, they thought fish had to mean salmon or tuna, when there are so many kinds of fish out there. They also didn’t know how to cook it, nor did they have healthy, flavorful recipes for chicken. So I took the time to help them lose weight by writing recipes down on my prescription pad to get them started. I would say, “Look, it’s not hard. You just have to be creative. Here, try these,” and I’d scribble a couple of fish or chicken recipes down for them, based on my and my mother’s Sicilian recipes. And miraculously, my patients started losing weight. They couldn’t believe the easy and delicious meals they could eat while they were losing weight.
Initially, I would prescribe the diet to patients who had illnesses that had clear connections to being overweight, such as hypertension, type 2 diabetes (as opposed to type 1, which you’re born with), and sleep apnea. As my medical practice continued, however, it became apparent how much being overweight set the stage for untold numbers of illnesses and diseases, and how important it was to lose weight as preventive medicine.
My patient profile is no different from the patient population of doctors’ offices around the country. My new patients are coming in increasingly heavier, and the illnesses related to being overweight and obese are becoming much more frequent. The weight of Americans has been rising at an astonishing rate since the early 1960s due to a combination of diet, meal size, activity habits, genetics, and food industry and media influence. As most people know by now, either by reading statistics or by just glancing around themselves at a crowded location, around two-thirds of our citizens are either overweight or obese. And there appears to be every indication that this trend will continue. Not coincidentally, the United States is in the midst of major epidemics of heart disease, stroke, high blood pressure, cancer, type 2 diabetes, and hepatitis. These conditions are all clearly exacerbated, if not caused, by excess weight and are major causes of disability and death in this nation. They also account for a significant amount of our health care dollars.
The Shocking Statistics
nApproximately two out of three Americans are either overweight or obese (compared with fewer than one out of four in the early 1960s); around 127 million American adults are overweight, with 44–60 million of them obese, and 9 million severely obese.
nApproximately 15 percent of children ages six to nineteen are overweight or obese; this prevalence has nearly tripled in the past three decades.
nObesity may shorten life span by five to twenty years.
nObesity is currently associated with greater disease and poorer health-related quality of life than smoking, problem drinking, and poverty.
nThe World Bank has estimated the cost of obesity in the United States at 12 percent of the national health care budget, according to the Worldwatch Institute.
nThe leading causes of death in the United States are all exacerbated or caused by excess weight.
•Heart disease is the leading cause of death in the United States.
•Cancer is the second-leading cause.
•Stroke is the third-leading cause.
•Type 2 diabetes (95 percent of diabetics) is currently the sixth-ranking cause of death, and it recently became the fourth-leading cause of death in New York City. Type 2 diabetes also increases the risk of heart attack and stroke by two to four times and is the leading cause of blindness, fatal kidney disease, and lower extremity amputations.
In addition to helping people look better and feel better, which I am all for, it’s terribly important to reverse this trend of health problems in our country. People may be living longer due to advances in medication and health care management, but many diseases can be greatly improved or completely prevented without the use of drugs or surgical intervention. Take insulin resistance. Highly related to being overweight, it is a condition in which your body fails to respond properly to insulin. Around a fourth of Americans have it, unbeknownst to them, and it puts them at significant risk for developing full-blown diabetes. The first line of defense for this condition is—you guessed it—losing weight. Even a small percentage of weight loss can help appreciably. So, I am sure you want to know, how do you get there?
Let me tell you a little bit about the healthiest known diet in the world. In the 1950s, the role of diet in human health was a mystery. Most researchers accepted that there was a connection between diet and disease, but the nature of this connection was largely unstudied in human populations. In 1958, a young physician named Ancel Keys of the University of Minnesota, along with a team of international scientists, set out to understand one disease in particular, the disease that was killing more people around the world than any other: heart disease.
Animal studies had suggested that fats were to blame for heart disease, but there was only anecdotal evidence for humans. During World War II, for example, Keys had observed that heart disease rates plummeted in countries with shortages of meat and dairy products, both rich in saturated fats. In addition, when he and his wife had traveled around Europe and Africa measuring blood cholesterol levels in preliminary studies in the early 1950s, he noticed that affluent people, who were eating more meat and dairy products, had higher cholesterol and suffered more heart attacks than poorer people who could only afford limited amounts of those foods. Keys thus speculated that saturated fat might be the root of the problem and was responsible for increasing the risk of heart disease.
To test his hypothesis, Keys and his co-investigators looked at the diets, lifestyles, blood pressures, and blood cholesterol levels of more than twelve thousand healthy middle-aged men from Greece, Italy, Japan, Finland, the Netherlands, Yugoslavia, and the United States. For the first time, investigators were actually stationed in people’s homes to monitor what they were eating and sending samples back to their own laboratory for analysis, rather than relying on food-intake questionnaires. They then followed up after five, ten, fifteen, and twenty years. It came to be known as the Seven Countries Study, one of the greatest and most influential epidemiological studies of our time.
Ten years after the study began, men from east Finland were faring the worst: 28 percent of them had developed heart disease. It turns out the Finns were eating more saturated fat than almost anyone in the world—24 percent of their calories. That’s double what Americans eat now. The residents of the fishing villages that were studied in Japan ate the least fat overall and the least saturated fat. Only 5 percent of them developed heart disease—far better than the Finns. But it wasn’t the best. That honor went to the men from the Greek island of Crete. After ten years, only 2 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 Finns—30 to 40 percent of their total daily calories came from fat. The difference was that their intake of saturated fat was far lower. It was not, however, as low as that of the mostly rice-and-vegetables Japanese diet.
When the blood cholesterol of the Cretans was measured, they had the lowest levels of any group. This was a conundrum, because the investigators had been assuming that saturated fat from the diet played a principle role in one’s blood cholesterol level. How could the Cretans—who ate more saturated fat than the Japanese—be healthier than the Japanese, who ate hardly any saturated fat? This mystery was answered when it was learned that the kinds of unsaturated fats they were eating were also making a difference. The Cretans were getting nearly half of their fat from olive oil, a monounsaturated fat, and it created the best lipid profile for a human body that you could ask for. Keys thus established one of the most important pieces of knowledge we can arm ourselves with for good health: by monitoring the kinds of fat we eat, more so than the amount, we can minimize or prevent heart disease, the number one worldwide killer.
The Seven Countries Study also determined that rates of death from all causes, age for age, were among the lowest in the Mediterranean regions. The Seven Countries Study was essentially the launch for many studies to follow over the next several decades to try to elucidate what makes the Mediterranean diet so healthy, in addition to dramatically reducing heart disease. Currently it appears that concentrating on fresh, unprocessed food that was largely plant-based—along with some fish, olive oil, dairy, wine, and a little red meat—gave people of the Mediterranean the magic formula. Their diet had the best combination of fats, was high in complex carbohydrates and fiber, and was also rich in a combination of antioxidants, phytochemicals, vitamins, and minerals—the total effect of which cannot be duplicated with pills or supplements. These investigations have also taught us that, in addition to heart disease, the Mediterranean diet can help prevent obesity, heart attacks, cancer, arthritis, type 2 diabetes, hypertension, and the metabolic syndrome, among others.
In reading about Keys’s studies, I learned that his first destination, back in 1952, was the southern Italian town of Naples. He was drawn there because of the reports he’d heard that heart disease barely existed among Neapolitans. As it turned out, area doctors confirmed that their hospitals rarely had coronary patients; the only cases were seen at private clinics for the well-to-do. The men of the working class—who couldn’t afford the meats and dairy the upper classes could—had remarkably low cholesterol and almost no heart trouble. But the thing that struck me most about his experience was when he described the simple yet irresistible cuisine of the region:
The ordinary food of the common Neapolitans consisted of homemade minestrone/vegetable soup, pasta in endless variety, always freshly cooked, served with tomato sauce and a sprinkle of cheese, only occasionally enriched with some bits of meat, or served with a little local seafood without any cheese; a hearty dish of beans and macaroni; lots of whole-grain bread never more than a few hours from the oven and never served with any kind of spread; great quantities of fresh vegetables; a modest portion of meat or fish perhaps twice a week; red wine; always fresh fruit for dessert.
When Keys was asked years later to formulate a diet that might serve as a preventive against coronary heart disease, he could come up with nothing more suited for this purpose than the traditional working-class diet of early 1950s Naples. I realized with astonishment that he was talking about the diet I grew up on.
Sicily—an island off the southern coast of Italy and a place of dramatic beauty, history, and dazzlingly fresh and healthy cuisine—is the largest island in the Mediterranean. It’s also the island I lived on until the age of nine, when my family moved to America. I lived in a small, hilly town near the Mediterranean Sea called Castrofilippo. To me it’s the most beautiful place on earth—rugged, rocky, and colorful, with weather the most optimal in the world. Springtime occurs in February, and then there’s virtually no rain from May to September. We had an abundance of different varieties of fruits and vegetables because of this climate. In fact, there were very few if any grocery stores where you’d buy vegetables because everyone grew their own. What’s more, it was actually a necessity to eat a diet rich in vegetables, legumes, fruits, homemade whole-grain breads and pasta, and olive oil made from the olives of our own trees—even our wine was made from our own grapevines—because most people were poor and couldn’t afford to buy much, meat in particular; meat was considered to be a luxury. However, because of our proximity to the ocean, we always had fresh fish available to us. Perhaps partly because of our limited access to a vast selection of foods, such as the options Americans have at their disposal today, we made the most of what we had and paid a lot of attention to food preparation, flavor, and mealtimes.
It should be noted, however, that though the culture I grew up in ate the traditional Mediterranean diet, it’s not the case today. As my town as well as the rest of the Mediterranean became more affluent over the years, the diet of its inhabitants slowly became more Westernized, with more meats, dairy, and other sources of saturated fat entering into the diet, as well as refined grains. So even though the Mediterranean has historically been a healthy and lean region, it is not so anymore. Many more people there are carrying excess weight from their more Americanized diets—and American weight-related health problems have followed.
Because of the great benefits of the Mediterranean diet, I decided to adapt my weight-loss diet so that it could ease people into this exceptionally healthy way of eating. My goal was to take people from a rapid weight-loss phase with Mediterranean-style recipes into a maintenance plan in which they will be fully “eating Mediterranean.” I designed it so that in the first two weeks you should lose five to ten pounds if you follow the diet plan closely. For those who wish to lose more than that, they can continue on the Two-Week Weight Loss Stage. When you are reach, you can transition to the Maintenance Stage. I knew the plan had to be practical, livable, effortless, and most of all delicious, or no one would adopt it into their lives. Once I had the foundation, I took it upon myself to select the perfect recipes for the plan.
While I come from a family with a long tradition of cooking, I never cooked until I went to medical school. It began as a matter of necessity. The deal I had with my roommates was that I would cook and they would wash the dishes. They soon caught on that I was getting my mother to make the meatballs and sauce. I would heat up some pasta, throw the pre-made meatballs and sauce over the pasta, and then go into my bedroom to relax. My roommates were faintly annoyed, but they couldn’t resist the meals, so they let me continue for the whole first year of school. As time wore on, though, in the second and third years of medical school, I’d call my mother to get advice on how she made this or that. I began to keep her on the phone with me the whole time I was cooking. It was fun for me to cook and for us to bond in this way. And my roommates continued to do all the cleaning. At this point, they were so supportive of the deal that they started coming home early so we could all eat together.
Eventually I began cooking for family and countless friends as well, and it became a big part of my life. I love making and creating delicious dishes and then sharing them. Trying my recipes definitely seems to be my patients’ favorite part of my diet. It makes me feel great that they enjoy them so much and that they are taking pleasure in something I provided. In fact, it’s no surprise that the Mediterranean diet has demonstrated over and over in studies that because of its palatability, people are able to stick with it, much more so than other diets. You can eat Chicken Cacciatore, Grilled Shrimp with Thyme, Sweet-and-Sour Red Snapper, Halibut N.S.E.W. (potato halibut), Striped Bass Oreganato, Lentil Soup, and Pasta with Peas, Asparagus, and Tomato Sauce—now, that doesn’t sound like deprivation, does it?
I want to emphasize that it’s not just about the food, however. Part of the wonderful beneficial health effects from living in the Mediterranean just may be due to the lifestyle as well. During the postwar era, when the studies were done, Mediterraneans were physically active, had a slower pace of living, relied on and communed with family and friends, and—probably as a result of all of the above—had less stress. They had great reverence for the food on their table. I greatly encourage you to follow their course. Take the time to eat. Take the time to do what’s important in life, which is to make good food and share it with friends and family. These meals are highly nutritious for the whole family (anyone over the age of two), so prepare them to share. I truly believe this is one of the problems our country faces—we have deemphasized dinnertime with our families and the importance of food in our daily lives.
Mealtime should be a time to enjoy, gather, savor, and linger. Food should be a pleasure, not a forbidden, dreaded part of life ridden with anxiety and guilt. I have created delicious, easy-to-follow recipes as a starting point. My goal in helping you make a lasting change in weight and health was to make a plan that was desirable, pleasurable, simple, and maintainable, and I think I have done that. It cannot be a regimented, day-by-day rule book; it must be infinitely variable and flexible, able to adjust to a person’s cravings and degree of hunger, the contents of the refrigerator, or the offerings at whatever restaurant he or she winds up at. Moreover, in place of food that is mouth-watering and high in calories, there must be something healthy but equally mouth-watering and easy to attain, and that is what this book provides.
You can change your life if you follow my plan. You need to be at your best weight to be your best self, and I want to help you get there. In essence, when you become fit, you become able to free your mind from worrying about weight control and instead can concentrate on the things that matter most to you in life. First and foremost, you need to get rid of the idea of “keeping it off.” I think most people who feel they have excess pounds feel “overweight”—that is, like a normal-size person who is over his or her natural weight. “Keeping it off” implies you are a fat person struggling to maintain an unnaturally thin state. Instead, I will show you how to find your comfortable weight and stay there. Once you’ve reached your new set point, the reduction of your cravings and your new mind-set will make you feel as if you belong there, not that you’re fighting anything. The struggle is over. This book is not just a quick fix for the high school reunion; it’s a prescription for life.
From the Hardcover edition.