How many times have you heard nutritionists or other health professionals say a Mediterranean diet pattern is the healthiest way to eat? If I had to guess, I’d say too many to count! 

In case you aren’t familiar, the conventional definition of a Mediterranean diet is one that emphasizes: “cereals, vegetables, fruit, low-fat dairy products, olive oil, nuts, and wine in moderation, weekly intake of fish and legumes and limited meat consumption.” Health professionals champion it because of its emphasis on plant foods, monounsaturated fats, and seafood.

Now, I’m not here to say the Mediterranean diet is unhealthy – there are a lot of aspects to it that I support, especially when considering nutrition for pregnancy and fertility. 

However, the modern definition of the Mediterranean diet isn’t accurate. It over-generalizes the vast range of diet patterns in the region and excludes many food groups – some that are very nutrient-dense – that are traditional to people who live in the region. Plus, the research that first established the Mediterranean diet as the holy grail of nutrition was fraught with errors.

In this article, The Mediterranean Diet: A Western Construct, we will:

• Review the discrepancies between our understanding of the conventional versus traditional Mediterranean diet
• Share insight into the research methods that resulted in the western definition of the Mediterranean diet
• Provide my takeaways for incorporating aspects of a traditional Mediterranean diet into your life

 

The Mediterranean Diet: A Western Construct

Who defined the modern Mediterranean diet?

Let’s start with some history… The Mediterranean diet was first recognized as a healthy dietary pattern in the 1960s when it was observed that people from some regions of the Mediterranean had a lower prevalence of heart disease compared to Northern Europeans.

This research was conducted by Ancel Keys, who was trying to understand the association between dietary patterns and the rise of heart disease in the 1950s. To do this, Keys surveyed the dietary intake of people from many countries, though his report highlighted the findings from seven countries: Yugoslavia, Italy, Greece (specifically the islands of Crete and Corfu), Finland, Holland, Japan, and the USA. His famous “Seven Countries Study” presented his findings that areas with lower fat intake, especially saturated fat, had lower rates of heart disease. While there are a wide array of methodological problems with Keys research — that many other writers have thoroughly examined (see The Big Fat Surprise by Nina Tiecholz, for one) — for the purposes of this article, we’ll focus on the issues with his conclusions on the Mediterranean diet.

It was from the Seven Countries Study that the first definition of a singular Mediterranean diet arose. However, many researchers and historians take issue with the way his research was conducted. As noted by Dr. Karima Moyer-Nocchi, an Italian professor of culinary studies, in the book The Mediterranean Diet: – The Deconstruction of a Modern Mythology, Keys was inconsistent with his data gathering. She states, “only 3.9% of the participants were actually asked about their diet, that is 499 people out of the 12,700 who were subjected to lab tests. The data collecting methodology varied from location to location. Most records were based on the recall of a week’s food intake, in others just one day. In some locations, researchers went randomly to people’s homes at mealtime to collect aliquots, or amassed samples from the market, which were frozen and shipped to the US, in others, not. Genetic considerations, physical exercise, and smoking were not factored in.” 

In regards to the Italian population studied, Keys surveyed people from a rural area in southern Italy that had been hit hard by World War II. At the time, these communities had devastating food scarcity — and low meat intake — due to circumstance, not tradition. Local rates of malnutrition were widespread during that era. In Greece, some of the weeks when Keys’ research team visited the island of Crete was during Lent, during which most residents abstain from eating meat or dairy products for religious reasons.

What resulted was a dietary pattern that de-emphasized meat and showed a reliance on more inexpensive foods like grains. Keys concluded that the diet pattern from this region was lower in saturated fat and higher in plant foods. Keys named this diet pattern the “Mediterranean diet,” effectively over-generalizing the food intake from people in this region and touting that following this type of dietary pattern would lower cardiac measures of heart disease risk. 

From a research perspective, all of this is a big yikes! Keys’ methods were incredibly inconsistent, did not account for confounding factors, and made broad assumptions about an entire region (more on regional differences in the next section), leaving his association between a population’s diet intake and cardiac health unreliable. Yet, Keys was able to spread his message and have a great influence on the United State’s approach to nutrition for many years to follow. 

Since then, hundreds of studies have examined the Mediterranean diet, proposed certain criteria for what “counts” for or against adherence to this dietary pattern, and have attempted to correlate intake of such a diet to a variety of health outcomes. 

For example, studies often give extra points towards Mediterranean diet adherence when consumption of vegetables, legumes and nuts, potatoes, fruits, seeds, cereals, monounsaturated fat, and moderate alcohol is higher. Meanwhile, full-fat dairy products, meat, poultry, whole eggs, animal fat, and sweets count against participants’ scores. Of course, not all studies are in complete agreement on these parameters.

In Bach et al.’s review of adherence to Mediterranean diet scores, they note: 

“Mediterranean diet evaluation methods that utilize scorings are limited by subjectivity in the selection of scoring components, mostly conditioned by available data and by the study’s own objectives in assigning cut-off points and by the interpretation of the diet – disease relationship. The variability in choosing cut-off points in the score, and distributing the population into different intake groups according to the grade of adherence, may influence the interpretation of results. Also, the use of indexes and cut-off points by other authors is a limitation since the population in which the index is applied may differ from the population for which the index was originally designed. Furthermore, the majority of indexes do not really measure the adherence to a universal [Mediterranean Diet Pattern]  but rather to a specific pattern, based on the distribution of selected food groups in the same population. This makes international comparisons more difficult.”

Bach’s analysis looked at 9 Mediterranean diet scoring systems used in U.S. studies, studies almost universally awarded:

• better diet scores for fruit, vegetable, whole grain, and fish consumption
• neutral or negative scores for red meat and dairy products
• mixed scores for other food categories, such as wine/alcohol, poultry, starches, sugar, legumes, nuts, packaged food, coffee/eat, fried foods, etc.

This means that “adherence” to a Mediterranean diet can be wildly different from study to study. Even after reviewing 24 different Mediterranean diet scores, Bach et al. point out that there is still the need for a more precise and quantified definition of the Mediterranean diet.

What is the traditional Mediterranean diet? (Hint: there is more than one Mediterranean diet)

While Ancel Keys may have honed in on the specific dietary pattern of people in one part of Greece at one point in time, his definition of the Mediterranean diet doesn’t apply to all cultures living in the Mediterranean region.

There are 21 countries that border the Mediterranean sea, so the traditional Mediterranean diet isn’t just one dietary pattern. 

 

As you can imagine, the cuisine in Greece is different from Slovenia, Italy, Spain, Turkey, Albania, Morocco, Syria, and so on. Even within a country, there are significant regional differences in cuisine, such as greater seafood consumption in coastal communities relative to inland or high-altitude areas. 

One study interviewed over 100 people from the Mediterranean region and categorized the cuisine differences into four groups: Western, Adriatic, Eastern, and North African. While there were similarities between the groups, there also were notable differences. Below are the findings from this study, though I can imagine, even these are probably over-generalizations that don’t account for dietary differences between communities and families.

• Western group: Spain, France, Italy, and Malta.
  • Staples of the Western group include bread, rice, pasta and potatoes, with vegetables (especially tomatoes) and legumes 
  • Cheese is arguably the most important dairy product, with a stronger presence in the diet compared to other eating groups
  • Olive oil is consumed mainly in Italy and Spain, France consumes more butter, and Malta consumes more plant sources of fat
• Adriatic group: Croatia, Bosnia, and Albania.
  • A common dish from this group is bread or pita stuffed with meat or vegetables
  • Favorite vegetables are eggplant, okra, potatoes, pumpkin, cabbage, and grape leaves
  • Dairy is usually in the form of ricotta, cottage cheese, sour cream, and clotted cream 
  • Dried pulses and olive oil consumption is not as high as other countries in the Mediterranean region. 
• Eastern group: Greece, Lebanon, Cyprus, Turkey, and Egypt.
  • Herbs from this group are primarily dill, parsley, coriander, and oregano
  • Eggs and egg dishes are everyday ingredients 
  • Chicken and pastrami are commonly eaten, with pigeon popular in Egypt
  • Use of olive oil is high in Greece, yet uncommonly used in Egypt 
  • Sesame seeds are significant ingredients 
• North African group: Libya, Algeria, Morocco, and Tunisia.
  • Lamb is the most used meat in these countries
  • Eggs and egg dishes are sometimes had more than once a day
  • Couscous is a main grain, eaten more than rice
  • Buttermilk is a common drink; cheese is not important
  • Potato, pumpkin, chickpeas, and dates are very commonly used in cooking
  • Garlic is essential for Algerian and Tunisian cuisine, whereas fenugreek is mostly used in Libya as flour or seeds
  • Allspice and turmeric are common spices used in all countries from this region

As you can see, there are not only differences among the four groups outlined here, but also within those groups as well. Yet, all of these countries border the Mediterranean Sea, and could be classified as a “Mediterranean diet.” To lump all of these diets into one group is a wild oversimplification and a misrepresentation of traditional eating patterns. 

What’s the difference between the modern definition and traditional practices of the Mediterranean diet? 

Red meat, fish, and other proteins

One of the major issues with the conventional definition of the Mediterranean diet is the fact that red meat consumption is not necessarily low in many parts of the Mediterranean at all; rather, it is a daily staple for many. Take a look at some old cookbooks from Italy and you’ll see plenty of meat: cured pork (such as pancetta and salami), rich meat stews (such as osso buco), meatballs, and even a type of salami made with liver (mortadella di fegato). Yet, in the scientific community, “the emphasis is mainly made on plant-based foods, while the role of red meat in a traditional Mediterranean dietary pattern is to some extent overlooked.”

I did an informal poll on my Instagram stories and received hundreds of comments from people native to the Mediterranean region. Many reported frequent consumption of red meat with lunches and dinner. Intake of lamb and cured meats was very common both in modern intakes and dishes prepared by their elders. My followers reported that a lack of red meat was often a sign of financial hardship or a reflection of dietary practices to communities that live coastally (fishing communities). This supports the understanding that Keys’ survey of a group of people struggling to recover from the hardships of World War II would have resulted in lower meat consumption, purely out of a financial need to reduce food costs – not due to cultural traditions. 

Not to mention, fish and seafood are the primary non-vegetarian sources of protein promoted in the modern Mediterranean diet. While fish and seafood certainly have much to offer nutritionally, they are usually most accessible to people who live near the coast. This is wonderful for people who live near the water, but fish and seafood are not the only sources of nutrient-dense non-vegetarian proteins. Much can be obtained nutritionally from eating protein from other animal sources. 

Ultimately, my concern with the modern definition of the Mediterranean diet is that it places restrictions on the amount and type of protein that is best to consume. Protein is important, especially in pregnancy as protein requirements are higher than previously thought. Already 67% of 3rd trimester mothers in the U.S. are not hitting optimal protein intakes. I know my focus tends to be on pregnancy, but much of the protein research has suggested that our RDAs are set far too low population-wide. A dietary approach that encourages cutting back on protein when it’s likely our recommendations are too low gives me pause. 

Not to mention, protein-rich foods are also naturally rich in many micronutrients required in higher amounts during pregnancy such as B12, choline, zinc, iron, vitamin A, etc. When you meet your protein needs (assuming an omnivorous diet), you’re also likely to meet vitamin and mineral needs from food as well. Following a conventional approach to the Mediterranean diet may result in too much of a reduction or an omission altogether of nutrient-dense protein sources. 

Fats and oils in the Mediterranean; it’s not just olive oil

Another widespread assumption about diets in the Mediterranean is that olive oil is the primary dietary fat and that dietary fat as a whole is low. This, too, turns out to be a fabrication by Western researchers. Dr. Karima Moyer-Nocchi explains this clearly: 

“Contrary to the timeless myth of the ubiquitous use of olive oil, cured pork backfat and lard were the most commonly used fats in Italy and would remain so until the saturated fat advisory went mainstream.” 

It wasn’t until countries from the Mediterranean started mimicking the United States dietary guidelines that saturated fats were discouraged.

Even the concept that fat intake is traditionally low in the Mediterranean is not true. A traditional diet in Crete — one of the areas that Keys studied — was certainly not low in fat; an estimated 42% of calories were from fat. This contrasts to suggestions by Western researchers that this diet is low in saturated fat and has total fat ranging from 25–-35% of calories.

Western definitions of a Mediterranean diet also insinuate that only low-fat dairy products should be emphasized, out of fear of saturated fat intake contributing to cardiovascular disease risk. Yet butter, cheese, yogurt, milk, and cream are widely consumed throughout the Mediterranean (particularly in northern Italy). Butter was regarded as a healthy choice and the “shift from commodity to dietary disdain occurred in just two generations” as updated Italian nutrition guidelines were influenced by the West. Anecdotally, my Instagram followers who are from the Mediterranean region also frequently reported that dairy is a staple item in their traditional diet. 

While the concern regarding saturated fat intake comes from a good place, newer research shows that there is much more nuance to the impact of saturated fat intake on our bodies – context and source of fat certainly matter. A 2020 paper from the Journal of the American College of Cardiology on saturated fat and cardiovascular disease found that “there is no robust evidence that current population-wide arbitrary upper limits on saturated fat consumption in the United States will prevent CVD or reduce mortality.” Furthermore, they noted that saturated fat in the context of whole foods is not the same as isolated saturated fat in processed foods. Specifically, “Several foods relatively rich in SFAs, such as whole-fat dairy, dark chocolate, and unprocessed meat, are not associated with increased CVD or diabetes risk.”

My concern with the conventional Mediterranean diet’s gumption for low-fat dairy or reduced intake of dairy is similar to my concern for the push for less animal protein. Full-fat dairy is nutrient-dense and is important for obtaining fat-soluble nutrients necessary for making a baby – especially vitamin K2 and iodine. Plus you need fat to absorb nutrients from whole foods. Not to mention, fat is satisfying! Food not only tastes better with fat, but also leads to greater satiety. Diets low in fat are often replaced with processed foods high in refined carbohydrates or sugar.

What’s similar between the modern and traditional Mediterranean diet?

There are plenty of discrepancies between the modern and traditional definitions of the Mediterranean diet. However, those inconsistencies aside, what sets this dietary pattern apart from a typical Western diet is that it tends to focus on whole foods while minimizing processed foods. I’ve heard from people from many different cultures, yet a throughline in their reflections of their culture’s diet was a low intake of processed foods. 

In contrast to the standard American diet, the average American gets 58% of their calories from ultra-processed foods. Any dietary intervention trial that incorporates more whole foods, while displacing processed foods, will show beneficial results. There is promising research showing that a Mediterranean diet can help lower the risk of type 2 diabetes, heart disease, and certain cancers.

The Mediterranean diet – albeit the conventional or traditional version – is essentially a real-food diet. Regardless of the protein and full-fat dairy debate, the diet is based on real, whole foods, which I too support. Especially for pregnancy, reducing ultra-processed food intake is important for meeting nutrient needs and maintaining good blood sugar control. 

Can Red Meat be a Part of the Mediterranean Diet? Does a Mediterranean Diet Have to be High in Carbohydrates?

If your doctor or other healthcare professional has recommended the Mediterranean diet for you, yet you’re not so sure you want to cut out red meat, know that several studies have now tested out a Mediterranean-style diet that specifically includes red meat. These studies show that it can be healthfully incorporated without detrimental effects on cardiovascular health, even in amounts of red meat intakes typical in the average American diet. 

If you do consider following a Mediterranean-style diet, be mindful of the amount of carbohydrates you may be having. Many of the protein sources found in popular recipes for this diet plan are vegetarian (beans, lentils, chickpeas, etc.) and thus higher in carbohydrates. For women who have a lower carbohydrate tolerance (i.e., those with insulin resistance), having beans/legumes as a staple protein option can be a challenge for blood sugar management when they are combined with other carbohydrate sources at the same meal (such as whole grains, corn, potatoes, fruit, etc.). Animal sources of protein do not contain carbohydrates and thus make it much easier to create a balanced plate without an overwhelming amount of carbohydrates. 

It is a fallacy to think that a Mediterranean diet needs to be high in carbohydrates to be beneficial. In fact, some researchers have tested what they term a “Spanish ketogenic Mediterranean diet” on weight loss and cardiovascular health in overweight adults. This diet emphasizes fish as a protein source (not at the expense of other animal foods), olive oil, and ample amounts of green vegetables and salads as the primary source of carbohydrates (no grains or legumes). The diet was not calorically restricted in any way. After 12 weeks on this diet, participants’ weight dropped from an average of 238 to 208 pounds — a 30-pound difference. In addition, all cardiovascular parameters improved significantly, including lipid profile and blood pressure.

Summary: Final Thoughts on the Mediterranean Diet

Overall, I support a traditional Mediterranean diet, but have reservations about the origins and misinterpretation of this dietary pattern in the research. Ultimately, you can take the good parts of a conventional Mediterranean diet — fresh produce, olive oil, fish, and other unprocessed foods — while still embracing other dietary traditions of the region.

Most important of all is that you find a dietary pattern that makes sense for your region (what grows around you), is in line with your own family’s eating patterns/traditions, and that makes you feel good!

Now I’d love to hear from you in the comments below.

Are you (or your family) from the Mediterranean region? If so, what part? What is the traditional diet like in your region? How has it changed over time?

I’d love to learn more about your experience!

Until next time,

Lily

 

References

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