Palmiro Giansante, standing at the stove, shook his head sadly.
"Too many cakes," he said. "And too much Coca Cola." This, in sum, is what's wrong with the American diet.
Giansante, 53, has never been to the United States. Except for two years in London, where he studied English (and met the Englishwoman who would become his wife), he has lived all his life in Citta Sant'Angelo, a quiet hill-town in the central Italian region of Abruzzo. But his youngest daughter, Gabriela, recently spent a month as an exchange student in Grosse Pointe, Michigan.
"It was too much even for her," the elder Giansante said. Not the shopping malls, so much, or the SUVs, or even the lake-effect snow. The diet. Fast food. Processed food. Junk food. In the adjoining dining room, Gabriela wrinkled her 16-year-old nose at the thought of it. "In Italy," she said, "one bottle of Coca Cola will last a teenager two or three days."
In Italy, her father echoed, or at least in this part of Italy, the food is fresh, its preparation simple. Vegetables are a major component of the meal. Dessert is likely to be fighi e albicocce—figs and apricots picked from the trees in the side yard.
It isn't much like what you see in an American Italian restaurant.
Let's face it: We Americans love Italian food, maybe more than anybody except Italians themselves. It started with pizza, which conquered New York shortly after World War II. Progressed to spaghetti and meatballs, ravioli, lasagna. In the golden age still dawning, we have learned to savor an endless variety of regional dishes, from polenta to porchetta to zuppa de pesce.
In recent years, too, we've been hearing the unbelievable—that this food we love is good for us. This Mediterranean diet, rich in olive oil, tomatoes, pasta, can protect us against heart disease and cancer. Our infatuation bodes well for our health.
Alas, something is lost in the translation. A simple dish of pasta is ladled with enough heavy cream to cramp your stomach. A pizza is paved with five kinds of meat, and four of cheese. We've taken the not-insubstantial fat content already present in Mediterranean food, and we've biggie-sized it, with a side of fries. Not exactly what the dietitians have in mind.
In the interest of international public health, then, my friend Palmiro had agreed to let me in on his Mediterranean diet. Standing next to him in his tiny kitchen as he prepared his family's mid-day meal, I was starting to absorb some of the essentials.
Olive oil went into the pot. Followed by a few tablespoons of diced onion. Of carrot. Potato. Green pepper. Celery, stalk and leaves. Rosmarino. Already, the waft of aromas was making me feel faint.
These were the elements of a basic meatless sauce, Palmiro explained: a take-off point for pasta e patate, pasta e fagioli, pasta e ceci, and any number of other variations. "In winter," he said, "you can add a bit of bacon." Today, a warm day in July, he was adding chopped tomato and boiled chicory, a green similar to dandelion. After the simmering, he would stir in cooked rice, then sprinkle the mix with some Parmesan cheese .
Three days later, in Rome, Francesco Branca described a similar diet to a classroom full of Penn State nutrition students.
The setting was the Istituto Nazionale di Ricerca per gli Alimenti e la Nutrizione—roughly, the Italian Institute of Nutrition—on the outskirts of the city. The students were participants in the first Penn State International Program in Nutrition. Map in hand, IPN director Claudia Probart, an associate professor of nutrition, had led her charges by Metro and then by crowded bus to this sprawling pale-brick campus, far from the tourist hordes. The cool dark of the classroom was a welcome relief from the baking afternoon sun.
Branca, a senior researcher at the center, described the daily food intake of the rural population of the southernmost regions of Italy, circa 1960. "The basis of this diet," he said, "was cereals." Over 55 percent of daily food was made from grain—pasta and bread. About 20 percent was fresh fruits and vegetables. Only four percent was accounted for by meat, fish, and eggs. Fat made up about 10 percent, most of that added in the form of olive oil.
Above all, Branca stressed, it was a diet semplice—the simple agrarian fare of a sunny, impoverished region. It was born of necessity, and coupled, of necessity, with lots of physical exercise: plowing and harvesting and tending after sheep. It also included a modicum of red wine.
This, Branca said, is the basis of the diet that was formalized in a food pyramid developed by the Oldways Trust, an American nutrition think-tank, in 1995. This is the diet that for 50 years has been linked with increased longevity and the lowest rates of cancer and heart disease in the world. The one that has been cautiously endorsed for heart patients as a suitable alternative to boiled chicken breast and poached fish.
This diet was "discovered"—as far as Americans are concerned—in the early 1950s, by Ancel Keys, the same University of Minnesota physiologist who developed the war-time Army meal packs that became known as K-rations. "At the time," Branca said, "there was an epidemic of cardiovascular disease in the U.S., so scientists from there tried to look at other diets." Impressed by low rates of heart attack reported from southern Europe, Keys went to Naples, Italy, and to the Greek island of Crete, and studied the diets of fishermen and peasant farmers.
A subsequent long-term investigation, known as the Seven Countries study and conducted with populations in Italy, Greece, Japan, The Netherlands, Finland, the United States, and Yugoslavia, confirmed Keys's early hunch: that there was an undeniable link between the rate of heart disease in a given population and that population's consumption of saturated fat. Heart disease and saturated fat were both low in Japan, Greece, and southern Italy, where almost all dietary fat was unsaturated, i.e., olive oil, heart disease dropped off the chart.
Keys, with a flair for popularizing, immediately started to tout this "Mediterranean diet." In 1959 he and his wife, Margaret, published Eat Well and Stay Well, arguably the first "heart-healthy" diet book, and Ancel Keys made the cover of Time. "Americans have Sunday dinner every day," he scolded. His then-revolutionary advice: Eat fresh, eat light, cut back saturated fats, and get plenty of exercise.
Penny Kris-Etherton, now a distinguished professor of nutrition at Penn State, was a graduate student at Minnesota while Keys was winding up his long career there. "The Seven Countries study," she remembers, "got people very interested in looking beyond total fat, at other dietary factors. Clearly, there was something else going on." Twenty-five years later, Kris-Etherton and her colleagues are still working to pin down exactly what that something is.
One widely publicized focus has been antioxidants, compounds that protect the body against free radicals and other highly reactive molecules that can damage cells. Some of these molecules are produced as part of the body's immune-response system, others are a byproduct of the oxygen we breathe. Still others are triggered by environmental pollutants.
Ideally, these reactive oxygen species are tied up by antioxidants, which we ingest in certain nutrients: vitamin C, beta-carotene, vitamin E, and others. But when reactive species become too numerous and damage control fails, bad things happen. Oxidizing of lipoproteins in the blood is the beginning of atherosclerosis. Oxidative changes to DNA can trigger mutagenesis and cancer. Tissue damage caused by oxidative stress leads to rheumatoid arthritis, inflammatory bowel disease, and other degenerative diseases.
By now it's common knowledge that the fresh fruits and vegetables that are the mainstays of any real Mediterranean diet are shot through with antioxidants. Leafy green vegetables, broccoli, and peppers, are all full of beta-carotene, whose consumption has been linked to lowered risks of heart disease and lung cancer. Leafy greens and citrus fruits are also rich in vitamin C, a powerful protector against a host of ills. And tomatoes are one of the few common dietary sources of lycopene, a recently discovered carotenoid that may protect against several types of cancers.
Red wine, another Mediterranean fixture, is abundant in antioxidant compounds called polyphenols. Recent studies suggest that drinking a glass of red wine with dinner may help to reduce arterial plaque and lower cholesterol. One phenol, trans-resveratrol, has been shown to have anti-cancer properties in mice.
Then there's olive oil, the foundation of traditional Mediterranean cooking. In addition to being a mono-unsaturated replacement for artery-clogging animal fat, olive oil (unlike other vegetable oils) is rich in phenol compounds, and also a source of vitamin E.
It's one thing, however, to note a link between the dietary presence of these compounds and lowered rates of disease. To pin down precisely how antioxidants work in the body is something else. Catharine Ross, who holds the Dorothy Foehr Huck chair in nutrition at Penn State, is well-acquainted with the complexities of nutrient metabolism. For 25 years she has been tracing out the intricacies of vitamin A, linking basic biochemistry to dietary studies.
"There's been substantial progress," she says. Not a little of it has involved identifying the complicating factors that scare off easy answers. "What we know now is that nutrients can take different forms, some of which the body can use more readily than others," Ross says. Olive oil, for example, contains less total vitamin E, or tocopherol, than corn oil does. "But the type it has—alpha-tocopherol—is the type the body prefers for transfer and delivery to tissue."
Bioavailability is another entanglement. There's a difference, Ross explains, between the amount of a given nutrient consumed and the percentage of that nutrient that is actually "available" to be taken up in the bloodstream or gut. That percentage depends on the nutrient source: food vs. supplement, raw vs. cooked. It can vary, in some instances, from person to person.
Finally, "These compounds don't act in isolation," Ross says. "They react with one another, protect
one another. Vitamin C, for example, is important in its own right as a powerful antioxidant, but it also helps to keep the overall cellular chemistry in a less oxidized state." Lycopene, whose individual benefit, Ross says, "is debatable," has recently been shown to work in combination with lutein to protect against prostate cancer.
"I think the leap from foods to individual nutrients has in some cases been premature," she concludes. "It's a balance of all of these antioxidants that makes for healthy cellular biochemistry. The lack of any one of them can be detrimental."
Another major focus of nutrtition research since the Seven Countries study has been on dietary fat. Keys's pioneering work made a clear distinction between bad fats and good ones: the hard or saturated fats in butter and meat versus the unsaturated, plant-derived fats that constitute seed and vegetable oils. Replacing the former with the latter, he argued, is good for the heart.
Chemically, fatty acids are long chains of hydrocarbons with a carboxylic acid group (COOH) at one end. In saturated fats, all the carbon atoms in the chain are saturated with hydrogen. In unsaturated, one or more carbon atoms is double-bonded, and a corresponding number of hydrogen atoms is missing. One double bond makes a monounsaturated fat. More than one is polyunsaturated.
That full complement of hydrogen makes the molecule stable: That's why saturated fats are solid at room temperature. That's also why saturated fats (and "hydrogenated" oils, to which hydrogen has been added to prevent rancidity) contribute to the "bad" LDL cholesterol, the kind that promotes waxy arterial plaque.
Unsaturated fats, on the other hand, seem to inhibit this sticky build-up. The monounsaturated variety lower blood cholesterol. Polyunsaturated fats, in addition to lowering cholesterol, provide essential omega-3 fatty acids, which improve heart function and reduce risk of blood clotting and stroke.
All fats, however, are calorically dense. Eating too much can cause obesity, which raises the risk for high blood-pressure, diabetes, and a host of other ills. Traditionally, then, dietitians have been strict about total dietary fat. To some dieters, one of the attractions of the Mediterranean diet is that it is somewhat less concerned about total fat, and more concerned with improving the ratio of good fat (unsaturated) to bad (saturated). That means a healthy Mediterranean diet might actually be a bit higher in total fat than a "traditional" low-fat diet. But not necessarily, says Penny Kris-Etherton. "The thing to remember is there is not just one Mediterranean diet," she says. "On Crete and Corfu, Ancel Keys found fat content as high as 40 percent. But in Italy, it was only about 24 percent." Lowering total fat is still a desirable goal, Kris-Etherton stresses. Even more important, however, is to replace saturated with unsaturated wherever possible.
A widely reported study conducted in Lyon, France, in 1994 dramatically illustrates the point. In Lyon, a group of cardiac patients—people who had already had heart attacks—were placed on a "Mediterranean-type" diet: fish instead of meat, unsaturated fat (including both canola oil and olive oil), lots of fruits and vegetables and legumes. The results were so dramatic that the five-year trial was stopped after less than three years: These patients experienced a 70 percent drop in second heart attacks and other heart-related problems.
"It was an amazing clinical trial," Kris-Etherton says. "For a diet to have such a powerful effect, especially when you consider that the control group was getting a reasonably good diet, is just amazing."
The Lyon Diet Heart study, she says, was a direct catalyst for the American Heart Association's subsequent (qualified) endorsement of the Mediterranean diet. What it doesn't prove, however, is precisely which constituents of the Mediterranean diet are beneficial. "Is it one food? I don't think so," Kris-Etherton says. "There are lots of things that differentiate the Mediterranean diet from what we tend to eat. So now we have to do some sleuthing."
"It may not be only the chemical compounds in these foods that account for their benefits," said Claudia Probart. We were sitting at a sidewalk table outside a small neighborhood restaurant near the famous Piazza Navona in Rome.
"Where and how foods are grown and processed, how they are utilized in the diet—these things may tell part of the story," Probart said. A recent study comparing tomatoes grown in Glasgow, Scotland, with those grown in Naples, she pointed out, showed that the latter had higher lycopene content. And tomatoes grown in the field have turned up more lycopene than those grown in tight grids for ease of collection, Francesco Branca had said earlier. In both cases, the difference may relate to the amount of total sunlight plants receive.
Italian cooking famously relies on fresh, local ingredients, another nutritional plus. The daily open-air markets, prominent in every city, teem with buyers, collecting produce picked this morning for the family meal this afternoon. "Antioxidants have a shelf life," as Catharine Ross says. "A produce-and-consume system like the Italian one is inherently better than a produce-store-consume-later system, in terms of preserving nutrients."
The effect of eating patterns on the body's metabolism may also be important. "We used to think this didn't matter," Kris-Etherton says. "Now, I'm wondering." As is Ross: "Mediterranean peoples traditionally eat a very light breakfast and a hearty mid-day meal, followed by activity," she says. "They're not going to bed on potato chips. How much do these health benefits have to do with patterns of glucose release?"
But Probart's argument at the restaurant went still further. In Italy, she was saying, eating well, i.e., healthfully, involves factors far beyond food.
"Take a look around. Here we sit in a piazza—an outdoor living space, really an ideal space for eating. For people." Indeed, the scale of the space, its dimensions, sight-lines, acoustics, all acknowledged that taking a meal is more than taking in nutrients: It's an opportunity for enjoyment—and for interaction.
In such a relaxing, atmospheric setting, it was easy to spot the Americans. They were rolling their eyes, holding their breath, glancing at their watches. We're done eating, their body language was screaming. What are we doing still sitting here? All around them, Italians were engaged in spirited after-dinner conversations. The waiters floating at the periphery seemed oblivious, but weren't, quite. You have paid for the privilege, their neglect was saying. Why would you want to rush off?
Sheer enjoyment, as much as red wine, has been cited as a reason for the so-called French Paradox, whereby millions of French people can indulge with seeming impunity in a diet clotted with duck fat, butter, and pastry. Italians, too, know how to enjoy the experience of eating. Before and after dinner, many still engage in the passagiata, a leisurely, sociable stroll around the neighborhood—a chance at once to chat, to stretch your legs, and to be seen. Especially in the provincial towns, grandmothers and granddaughters meander arm in arm; men hold walking conversations; teenage boys stride along unselfconsciously, their arms slung companionably across each other's shoulders.
"I think it may well be the way Italian families sit together and talk over their meals, the fact that three generations are eating dinner together, that may be the catalyst that allows these chemicals to work in the body," Probart said. There's some evidence to support this view. A famous study conducted in the 1960s in Roseto, Pennsylvania, a small town populated almost entirely by Italian immigrants, found that in spite of a high prevalence of smoking and a diet heavy in saturated fat (steaks and sausages, in the land of opportunity, had gradually become affordable), the town had a remarkably low incidence of heart disease. This fact was attributed to the closeness of the community and the persistence of communal rituals. "People are nourished by other people," wrote physician and co-author Stewart Wolf.
If you're really going to understand the Mediterranean diet, Probart believes, all of these factors—biochemical, psychological, social—must be taken into account. "That's why we absolutely must bring students to the source," she said.
Almost as soon as they arrived in Rome, she had assigned her charges to get out and experience the social dimension of Italian eating first-hand. "I asked them to plunge in," she said, "since it's easy to be intimidated. I had them write narrative sketches of their encounters in restaurants and shops. I want them to take notice of the cultural differences, to see that this is a different way of eating."
Field trips helped the students pick up local flavor. On a week-long excursion north to Emilia Romagna, one of Italy's breadbasket regions, they visited a factory that makes Parmigiano Reggiano cheese, and another that produces prosciutto, the prize ham of Parma. The authenticity of both products, they learned, is tightly enforced by Italian law. Closer to Rome, they toured a cooperative farm that produces cheese from sheep's milk and a winery that supplies the Vatican. "Quality is important to the Italian," one student wrote admiringly.
They even got a taste of Italian culture. Part of her aim, Probart told me, had been to help her students see nutrition in various contexts, art as well as science. To accomplish this, she collaborated with Romolo Martemucci, an associate professor of architecture at Penn State, and a native Roman. For the past 12 years Martemucci has run Sede di Roma, a small center in a grand palazzo near the Pantheon, where all Penn State architecture and landscape architecture students are required to spend at least a semester. That morning he had given the nutrition students a walking tour, tracing a route through several neighborhoods and 2000 years of Roman history. The architecture of Italy, Martemucci argued, is one of the vital contexts that gives Italian food its meaning.
Palmiro Giansante's kitchen in Abruzzo takes up a corner of a house that was built in the 16th century. Its single window looks out on a valley far below, snugly quilted with green and gold fields and red tiled roofs. The majestic white cap of the Gran Sasso is visible most days in the far distance.
The idyllic setting begs a question. There being, apparently, no "magic bullet," the health effects of the Mediterranean diet being apparently related to a gathering of influences, even an entire "way of eating," how much, then, of this diet—and its effects—can be successfully transplanted? How much should be transplanted?
"Even in Italy things are changing," Probart had said, back in Rome. The alimentari and other traditional food shops are still protected by Roman ordinance, but convenience is gaining fast. There's a giant subterranean supermarket at one of the downtown Metro stops, complete with processed foods and Muzak. Fast-food shops are on the rise. The Mediterranean diet that Americans are starting to embrace is a diet many younger Italians have long since abandoned.
It began back in the 1970s, according to Francesco Branca of the Nutrition Institute, when Italy's economic boom opened the country to influences from northern Europe and the U.S. "With changes in lifestyle, advances in food-preservation technology, and increased imports, diet patterns changed drastically." The intake of cereal-based foods fell off, while dietary protein increased and fats almost doubled.
This "westernization" hasn't been all bad, Branca acknowledged: Italians today get more vitamin A and C and more fresh fruit than their parents did, especially in the northern part of the country, where the growing season is relatively short. With improved transportation and the building of greenhouses, he added, per capita tomato consumption since 1960 has actually doubled. But the big increase in dietary fat, combined with a drop-off in physical activity, he said, has led to a rise in obesity. (Even so, obesity rates in Italy remain lower than those in the U.S.)
What Branca calls "the Italian paradox" is this: Despite the jump in both fat and fatness, there's been no rise in heart disease. "In fact, there has been a decrease since 1960 in cardiovascular mortality." More consumption of antioxidants and better medical screening, he speculated, may be parts of the answer.
In fact, since the late 1980s, many Italians have turned back to healthier eating, Branca said, as a result of nutritional campaigns and the promotion of dietary guidelines. "There is a new culture of health," he said. And a renewed interest, too, in protecting the Italian tradition of eating well: The Slow Food movement, conceived by an Italian journalist in 1986 as a bulwark against global hamburger hegemony, now has some 60,000 members worldwide.
In places like Abruzzo, it sometimes seems like the old ways never left. In L'Aquila, a bustling small city in the mountains, well-dressed businessmen pocket their cell phones and tuck into a traditional multi-course lunch at a local ostaria. Not far from there, in the nearly abandoned hilltop village of Castrovalva, an old woman in kerchiefed head puts up her winter's tomatoes the same way her grandmother did: Capped bottles of the red pulp bob in a boiling cauldron over a wood fire. A young product engineer working for the Italian branch of Procter & Gamble and living in the coastal city of Pescara preserves tomatoes the same old way.
Branca, for his part, doesn't want to go back to the diet of 1960. "In terms of human health," he said, "it's better to have tomatoes available year round to everyone, than only a few available only sometimes"—even if the quality isn't quite as good. ("I find frozen vegetables perfectly acceptable," he noted.) "This way of eating depends on having the time and opportunity to buy small quantities of food, freshly picked, and prepare things from scratch," Probart acknowledged. "Now that women are working you see changes."
Still, there are aspects of Mediterranean tradition that might readily be adapted, to positive effect. A balanced, varied diet, moderate consumption, physical activity: These things are not beyond our reach, Ross suggests. They are part of what Kris-Etherton calls "a consistent pattern of healthy living."
And what about the sheer pleasure of eating? Can we modern, Western folk find a way to make honest enjoyment a part of the equation? "Think about it," Probart said. "What is the American equivalent of buon appetito?"
Read A Better Tomato the sidebar to Dieting Italian Style
Claudia K. Probart, Ph.D., is associate professor of nutrition in the College of Health and Human Development, 5D Henderson Building, University Park, PA 16802; 814-865-7054; email@example.com. Penny M. Kris-Etherton, Ph.D., is distinguished professor of nutrition, 271 South Henderson, University Park; 863-2923; firstname.lastname@example.org. A. Catharine Ross, Ph.D., is Dorothy Foehr Huck professor of nutrition, 126 South Henderson; 865-4721; email@example.com. Romolo Martemucci, M.S.Urb.Des., is associate professor of architecture in the College of Arts and Architecture and director of Penn State's Sede di Roma, 206 Engineering Unit C; 865-9535; firstname.lastname@example.org.
For more information about the International Program in Nutrition, check the web at http://nutr88.hhdev.psu.edu/italy/welcome.html.