Is Italy's "Mediterranean Diet" a Myth?

By Dr. Ralph Moss
from Newsletter

I recently returned from a trip to Italy during which I spoke at a conference in Rome and visited with several prominent Italian scientists. I will have more to say about the work of these scientists in weeks to come. Today, however, I want to comment on what I feel are some popular misconceptions about the Italian life style and its impact on health.

There is a widespread opinion that Italians are a people in excellent health because they follow something called the "Mediterranean Diet." This image of Italy as a mainly vegetarian Garden of Eden is sadly out of touch with present-day reality. Italian life is very definitely not a pasta sauce commercial!

The concept of the Mediterranean Diet stems from the work of Ancel Keys, PhD, of the School of Public Health, University of Minnesota, Minneapolis (Keys 1985, Keys 1986, Kromhout 1989). In the early 1960s, Prof. Keys concluded that people residing in countries bordering the Mediterranean Sea lived healthier and longer lives than those who resided in northern Europe, the United States and Japan. He thought this was because their diets centered around plant-based nutrients, with animal proteins playing only a peripheral role. Olive oil provided healthful monosaturated fats (as opposed to the harmful fats in dairy products). The result, he said, was a lower incidence of heart disease, diabetes, obesity and some cancers.

While there may be some truth to that view, we must recognize that diet and life style are changing in Italy as well as across Europe as a whole. So too is the incidence of chronic diseases, including cancer. If Keys' theory were the whole story we would expect to see much less cancer in Italy than in northern climes. However, according to the authoritative Globocan 2000 database, there is actually a considerable amount of cancer in Italy. In a country with a population of around 58,000,000, the annual cancer incidence among men is 141,000 and among women 120,000 - a total annual cancer incidence of approximately 261,000, and an annual cancer death rate of 156,000. Expressed another way, this works out to an overall cancer incidence rate of 0.45% per year. The cancer death rate is 0.27% of the population.

By contrast, the United States has a total population of around 276,000,000. The estimated cancer incidence is 1,334,000. Thus, the incidence rate is 0.48%. The estimated number of cancer deaths in America is 557,000. Thus, last year about 0.20% of the population died of cancer. Looked at in broad strokes, Italy has a slightly lower incidence rate than the US but a slightly higher death rate. Although one could certainly refine these figures in various ways (such as by adjusting them to the age of the affected populations), it is obvious cancer is as large a public health problem in Italy as it is in the United States.

The Italian Cuisine

Let us next look at some life style factors that may either contribute to, or hinder, the development of cancer. Italian cuisine is certainly among the tastiest in the world, but from a health point of view I give it mixed reviews. A typical Italian breakfast consists of strong caffeinated coffee and some sort of sweet pastry. Admittedly, this "sweet roll" may be the best-tasting croissant you've had in your life, but such a breakfast offers little more than refined carbohydrates by way of nutrition. The average day is also punctuated with periodic breaks for espresso or cappuccino. Sometimes it seems that the country runs on caffeine! Coffee is so ubiquitous that the current Health Minister, Raffaelo Costa, gained fame by campaigning against "la cappuccino pausa" (i.e., the prolonged coffee break) among government bureaucrats. I'm not saying that coffee consumption is directly linked to cancer. But it does take the place of more healthful beverages, including black and green tea, fruit juice or even antioxidant-rich cocoa.

You can certainly get memorable and healthful lunches in Italy's many restaurants. And in some parts of Italy workers still go home for a leisurely lunch and siesta, as their forebears did. But today two-thirds of Italians live in cities and, by my observation, the lunch of urban working people is apt to be a variant on the classic ham-and-cheese sandwich. Again, I am not faulting the tastiness of the food. An Italian "ham sandwich" might be made with delicious prosciutto or mortadella combined with one of Italy's 500 famous cheeses. But no matter how you slice it, ham and cheese is still processed food that is high in saturated fats and in potentially carcinogenic preservatives. Worse, it usually comes on a white-bread 'panino' (roll) which, however crusty and delicious, is almost totally devoid of fiber, antioxidants or other micronutrients.

According to the European Prospective Investigation of Cancer (EPIC), a massive study of modern European food consumption, "…diet patterns including regular consumption of processed meat are associated with a higher risk of colorectal and stomach cancers, while diets high in fish, fiber, fruits and vegetables are associated with a reduction in the risk of these and upper aero-digestive tract cancers" (Blanchard 2003). This helps to explain the high rates of cancer in Italy.

An Italian dinner is likely to be the most nutrient-dense meal of the day. Certainly in restaurants one is more likely to find fresh vegetables and salads, beans and fish than in the US. Those ancient saving graces of Italian agriculture, the olive and the vine, come to the rescue once again. Olive oil, high in monounsaturates, is among the healthier kinds of fat. And Italy's famous red wines contain significant amounts of a powerful anticancer constituent called resveratrol. In the south of Italy, especially, one gets prodigious quantities of freshly-made tomato sauce, a rich source of the antioxidant lycopene. With good food, you can have fun and maintain robust health at the same time.

On the other hand, dinner these days for the busy Italian is increasingly likely to be a Big Mac and an order of fries washed down by a large Coke at the local McDonalds restaurant. That provides a total of 1430 calories and 53 grams of fat-with a minimum of micronutrients of any kind. There are presently 290 McDonalds in Italy, giving Italy the dubious distinction of being eighth in the world in terms of total number of McDonalds outlets - albeit far behind the US, with its astonishing 12,804 McDonalds. The damage is still reparable…but I fear for the future.

A propos of the rise of junk food, I witnessed an interesting scene in the town of Orvieto, where I had stopped to visit the famous cathedral. I was having lunch at a charming restaurant that served the "cucina tipica" (authentic cuisine) of the region. At the table next to me was an Italian family on holiday. The mother, father and grandmother were slowly relishing and commenting on the antipasti and other well-prepared traditional dishes, as they sipped a delicious Umbrian wine. But their young son squirmed as he waited for his special order, distracting himself with a hand-held video game. Finally, the waiter brought him his order-pale French fried potatoes with ketchup and a Coke! The parents were then able to relax, gratified that their son's attention was finally focused on a meal he would enjoy.

Many Italians deplore this erosion of their three thousand-year-old traditions and are nostalgic for a return to the former ways. Not long ago a commercial was released on Italian television that showed a mother and child shopping for food. They carefully chose their produce from local vendors' stalls, as well as from fruit trees and chicken coops in the Sienese countryside. The only problem was that this was an advertisement for a supermarket chain! Award-winning filmmakers are now crafting commercials that exploit a vision of the old ways in order to sell the new high-pressure culture. They brag about how they impose themselves as symbols of home, family, and harmony among individuals and the world that surrounds them, according to a website that vigorously promotes such image manipulation. (Sagone 2004)

Meanwhile, according to a 1997 CNN report, "The tradition of multiple course meals and the overall healthy eating habits of Italians are being threatened by the modern convenience of fast food…. Convincing young Italians that popular fast foods are not always the best foods for them is expected to be difficult. Especially when many food traditions take time, something people don't seem to have a lot of." (Skiff 1997). Seven years later, the problem only seems to be getting worse.

The fact is that in this era of globalization we need not only to fight bad food habits, but also actively to preserve and strengthen good ones. Italy has a lot to offer in terms of its fabulous food traditions. Some strong points of the Italian diet include varied salads and antipasti, carefully cooked vegetables, luscious fruits, fresh tomato sauce, succulent fish, and wine, especially red wine (imbibed in moderation, of course). Perhaps even more important than these culinary virtues is the reverence paid to the rituals surrounding the breaking of bread. The tradition of gathering together and sharing unhurried time around the table is one that does much to bind together family and friends, and it was a joy that I was lucky enough to share with my colleagues and their families in various cities along the length of the Italian peninsula.

The human family needs to find its way back to these modest but intense pleasures that promote the enjoyment of life not just at the level of biochemistry but at the social level as well. If we don't take steps to reclaim this culinary and social heritage, we run the risk of going down together in a morass of fatty burgers, pallid fries, and super-sized syrupy drinks.

Note from Chet: Be sure to sign up for Dr. Moss's excellent newsletter at his website.


Kromhout D, Keys A, Aravanis C, et al. Food consumption patterns in the 1960s in seven countries. Am J Clin Nutr. 1989 May;49(5):889-94.

Keys A, Menotti A, Karvonen MJ, et al. The diet and 15-year death rate in the seven countries study. Am J Epidemiol. 1986 Dec;124(6):903-15.

Keys A, Aravanis C, Blackburn H, et al. Serum cholesterol and cancer mortality in the Seven Countries Study. Am J Epidemiol. 1985 Jun;121(6):870-83.

Skiff, Jennifer. Fast food threatens Italian healthy eating and traditions, CNN, January 29, 1997.

La pausa Cappuccino

Sagone, Salvatore: Locations for Commercials.

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