The Mediterranean Diet: The Good, The Overhyped

The Mediterranean Diet – Made in America

Warning against all fats- he became the cover boy for Time in 1961

Warning against all fats- he became the cover boy for Time in 1961

In January 1961, Ancel Keys was on Time magazine’s cover, and the article talked about diet and heart health, something new for the American public and most doctors. Prior to Keys, people considered heart disease to be simply a disease of aging, not a preventable disease of lifestyle and diet. Dr. Keys, a Ph.D. in physiology, was also known as the inventor of the wartime K-rations (K is for Keys). When my father, a World War II veteran, heard that the same person who developed K-rations invented a diet, his response was, “Well, that’s a diet I won’t have to worry about trying.”

Dr. Keys is the founder of the Mediterranean diet. He said, “My concern about diet as a public health problem began in the early 1950s in Naples, where we observed very low incidences of coronary heart disease associated with what we later came to call the ‘good Mediterranean diet.’ The heart of this diet is mainly vegetarian, and differs from American and northern European diets in that it is much lower in meat and dairy products, and uses fruit for dessert. These observations led to our subsequent research in the Seven Countries Study, in which we demonstrated that saturated fat is the major dietary villain. Today, the healthy Mediterranean diet is changing and coronary heart disease is no longer confined to medical textbooks. Our challenge is to persuade children to tell their parents to eat as Mediterraneans do.”

While in Italy, he noticed that the high consumption of fat in olive oil and a low incidence of heart disease. He came to the conclusion that not all fats were the same, and olive oil falls into what he described as a “good fat” category. Keys died at age one hundred, touting the benefits of the Mediterranean diet while living in Naples, Italy.

Keys’ evangelical teachings about the dangers of dietary fats affected recommendations about fats and saturated fats for over fifty years. It has been those assumptions he made that influenced the belief that saturated fat, and therefore red meat was bad. Some people blame the current epidemic of obesity on these principles – low fat and high sugar.

Keyes described the diet as, “Homemade minestrone, pasta of all varieties, with tomato sauce and a sprinkling of Parmesan, only occasionally enriched with a few pieces of meat or served with a small fish of the place; beans and macaroni; so much bread, never removed from the oven more than a few hours before being eaten, and nothing with which spread it; lots of fresh vegetables sprinkled with olive oil, a small portion of meat or fish maybe a couple of times a week, and always fresh fruit for dessert.”

Many think the Mediterranean diet is the foods that modern Italians, Greeks, or Spaniards eat. It isn’t. The diet is completely made up. No one ever ate that way.

Today’s Mediterranean diet is due to the efforts of K. Dun Gifford, who founded the non-profit corporation called Oldways after becoming interested in “traditional” foods. After organizing a symposium, in 1993 he developed the Mediterranean Diet Pyramid with the Harvard School of Public Health, where olive oil was the main fat, along with some wine drinking and minimal red meat.

At the base of the Mediterranean food pyramid, and the basis of the diet, are potatoes, breads, grains, beans, nuts, seeds, rice, couscous, and polenta (which, if you are from the southern United States, would mean grits). When they say whole grains, that is not defined—and while many food companies in the US want to slap the “made with whole grain” label on the food you buy, it is difficult to find any whole grains in the US—all of them have been milled.

Daily consumption would include fruits, beans, legumes, nuts, and vegetables, along with olive oil as the main fat, and some cheese and yogurt. (I suspect most yogurt currently sold in the United States labeled, as Greek yogurt, which has more sugar than ice cream, would not qualify in this diet.) In addition there would be weekly consumption of fish, poultry, and eggs, with red meat coming as a protein less than once a week.

A sample diet from the pyramid is below:


6 oz. Greek yogurt topped with ½ cup strawberries and 1 tsp. honey

1 slice whole-grain toast with half mashed avocado


1 whole-grain pita with 2 tbsp. hummus and stuffed with 1 cup fresh greens and 2 slices tomatoes

1 cup minestrone soup

1 medium orange

Water with 1 lemon wedge


1/8 cup sliced almonds

1/8-cup peanuts


3 oz. salmon topped with 1 tsp. tarragon and 1 tsp. mustard over

½ cup couscous, ½ cup zucchini, and 4 spears asparagus


½ cup arugula

½ cup baby spinach

1 tbsp. shaved Parmesan cheese

1 tbsp. vinaigrette dressing

5 oz. red wine (optional)


Small bunch grapes

½ cup lemon sorbet

This diet would be about 1,500 calories, with 29% coming from fat, 5% from saturated fat, and 50% from carbohydrates; 32 grams of fiber, 1,400 mg of sodium, 3,350 of potassium, a bit low in calcium for people over fifty at 418 grams, and 2.8 of vitamin B12.

It has no room for sugary drinks, no soda, no processed foods, and conforms to most common beliefs about a healthy diet.

I object to the small wine pour—only five ounces? That is homeopathy applied to wine. In Italy a five-ounce pour is called a tease.

Cardiovascular Health: Hype, Reality, and Statistics

Daily, there are reports touting the benefits of the Mediterranean diet with cardiovascular health. Some studies show a decrease in markers for heart disease; such as the decrease in LDL (the so-called bad cholesterol) and increase in HDL (which is the “good cholesterol”). A change in those markers does not mean there will be fewer cardiac events on this diet. Some of the plant-based diet enthusiasts note that the Mediterranean diet is not a low-fat diet, and make claims that a plant-based diet provides better heart health (this is why Patti chose to be plant based—she believed that fat was evil until she started eating it again, now she thinks butter is her personal savior).

You may have heard about the study reported in the New England Journal of Medicine, which the New York Times quoted as saying, “About thirty percent of heart attacks, strokes, and deaths from heart disease can be prevented in people at high risk if they switch to a Mediterranean diet rich in olive oil, nuts, beans, fish, fruits and vegetables, and even drink wine with meals, a large and rigorous new study has found.” Sadly, when the article was examined carefully, the authors did some statistical jockeying, lumping stroke deaths in with heart issues, which gave it a statistical significance. What the article did say was there was no reduction in heart attacks, no reduction in death from heart disease, and a small reduction in death from stroke. There was not a reduction in strokes or disability from stroke. Contrary to the press reports, this study didn’t show a reduction in heart attacks, heart failure, or even the number of strokes.

Extra virgin olive oil is one of the great gifts from the Mediterranean to the world. The most rigorous standards for what is labeled Extra Virgin Olive Oil come from the United States. So if you want great olive oil, buy American. Make sure the olive oil has a “Use by” date on it, and it comes in a darker bottle. Olive oil is good for about two years after bottling. No need to buy the expensive “made in Italy” olive oil, when you can get fresher, better, tastier olive oil here. Ironic – the Mediterranean diet is made in America, based on a lot of olive oil, and the best olive oil is made in America.

Weight Loss and the Mediterranean Diet

The diet gives you 1,500 kcal per day. It really was not a diet that was made for weight loss, and yet any reduction of caloric intake will result in some weight loss for those who are over nourished. It reigns in calories from processed foods, and decreases overall caloric intake while not restricting any particular group. In the long-term, maintaining that weight loss is proportional to adopting the diet, and the caloric intake as a lifestyle.

The Healthy Parts of the Mediterranean Diet

This is another diet that takes people to a wide variety of fruits and vegetables. Some would comment that this is another diet for upper middle class consumers who can shop in well-stocked supermarkets and don’t have to worry about the food deserts that exist in the United States or the world.

The base of the diet pyramid being grains means that it is in strict opposition to the Paleolithic diet. But where both Paleolithic and Mediterranean diets agree is lots of fruits and vegetables.

The diet was developed because the prevailing theory was that saturated fat (and hence red meat) was the enemy, so sources of protein come from fish, poultry, and vegetables. The occasional red meat tossed in once a month. For those who do not like red meat, because their gut bacteria have been changed, this is a fine diet to get protein and fat from.

Shortfalls in the Mediterranean Diet

Some have criticized the diet for falling short of sources of potassium, which is odd considering the major dietary sources of potassium are beans, leafy green vegetables, potatoes, yogurt, and salmon. In addition the leafy green vegetables, as the Paleolithic dieters will point out, provide a better bio-available form of calcium, and you do not need as much calcium because of that. Meaning, if you eat those four to six servings a day (and that is a lot of vegetables) there will be no reduction in calcium, even though the total calcium is less from those plants. That is, when the math about bioavailability is done you will have plenty of calcium in those diets. Sometimes nutritionists fall in love with their slide rulers (you have to be old to appreciate that), and neglect to add the bioavailability of the foods into their equations. The more conspiratorially minded people will note that the dairy industry has the ear of many nutritionists and emphasizes that dairy is, and should be, the primary source of calcium. Calcium is noted to be a “nutrient of concern,” meaning Americans don’t get enough of it.

Diabetes and the Mediterranean Diet

Studies have shown there is a reduction in diabetic markers, hemoglobin A1C while on the Mediterranean diet, so it is an appropriate diet for those who have diabetes. The difficulty is that with this diet there is an emphasis on grains, including pasta and breads, that can have a devastating effect on diabetes.

When in Sardinia, off the west coast of Italy, I asked for a bit of pasta with marinara sauce. What came out was a red tomato sauce, with amazing tomato flavor, but there were these chunks in it. The chunks were fish, langoustines, clams, and mussels—and then it hit me, the true meaning of a sauce of the sea (“marinara” – from marine) was a sauce for fish. For most of America it is a sauce you buy off the shelf that has some tomatoes and salt and pepper in it. The pasta was hand made, that day, not something dry that would survive the next nuclear attack.

I love this diet, and so does my fellow doctor-chef, John La Puma. John loves great wines, his prescription pad, like mine, are filled with recipes. By the way, the field of culinary medicine – invented by Dr. La Puma. He loves the joy of cooking and eating also and if you were his guest you would get a great Mediterranean meal (and more than 5 ounces of wine).

Dr. Terry Simpson About Dr. Terry Simpson
Dr. Terry Simpson received his undergraduate and graduate degrees from the University of Chicago where he spent several years in the Kovler Viral Oncology laboratories doing genetic engineering. He found he liked people more than petri dishes, and received his MD. Dr. Simpson, a renowned weight loss surgeon, is a leading advocate of culinary medicine. A frequent contributor to media outlets discussing health related topics and advances in medicine, he is also a proud dad, husband, author, cook, and surgeon “in that order.” For media inquiries, please visit