So goes the nursery rhyme allegedly referencing the unfortunate King Charles I and his wife Henrietta Maria’s tastes.1 But which of them would have lived longer if there hadn’t been a revolution and a beheading? This used to be an easy question to answer: most of us would have bet on fat-loving Mrs Sprat, aka the Queen, for an early grave. In the past fifty years, with changing views on fat, improved breeding, genetic testing and butchery techniques the levels of fat in all cuts of meat have dropped by up to 30 per cent in countries like the UK. But should we avoid these fatty cuts, or is this yet another myth?
After my health scare on the top of the mountain and my relatively lucky escape from more serious problems, I felt it was time to re-evaluate my lifestyle and see what I might change. I wanted to reduce my risk of future strokes and heart disease while still trying to enjoy a normal life for however long I had. I was desperate to come off, if possible, my two blood-pressure medications. I knew that exercise can reduce blood pressure, so I started doing more cycling at weekends, took up swimming and some gentle running round the park.
I thought then about improving my diet. My father having died suddenly of a heart attack at fifty-seven, since I share half his genes, put me in a high-risk category, and I wanted to try and avoid that genetic fate. My cardiologist tested my blood for other risk factors and said that my cholesterol levels at around 5 mmol/l indicated no cause for concern (the average levels in the UK are around 6 mmol/l). More importantly, I had a reasonably good blood lipid (LDL/HDL) profile. All the same, I should still try to reduce it further, which would further lower my risk of heart disease. He advised me also to reduce my salt intake. My penchant for salty nuts aside, I thought this would be fairly easy, but I knew that for many people salt reduction has only a minor effect on blood pressure, and I wanted to do more.
I decided I needed a more radical change – a diet makeover. I had reached a point in my life when I really wanted to know more about the food I was eating. After fifty-odd years of meat eating I would try going vegetarian – well, nearly. I would give up meat, but I didn’t want to give up seafood, for a couple of reasons. I couldn’t find anything scientifically wrong with it, and I was about to spend several months on my own on sabbatical in Barcelona surrounded by some of the best seafood in the world.
To improve my heart chances I thought I would also give up eggs and dairy (milk, cheese and yoghurt). I had briefly read The China Study, which suggests that all the fats and calories in dairy and even the proteins are bad for us. I thought about giving up alcohol, but only for a few seconds. I reassured myself that most of the studies showed a benefit for the heart of a mild intake, especially of red wine.
So I started my no-meat-or-dairy challenge. This was the first time I had attempted such a strict regime. To my surprise, avoiding meat was pretty easy, apart from the odd tempting tapas with jamón ibérico, and I managed to continue for several years – until getting down seriously to writing this book, at least. What I hadn’t bargained for was how hard it was for me to give up cheese. Having a glass of Rioja without Manchego left a gaping hole in my pleasure centres, and the thought of never again tasting a nice Parmigiano or fresh Brie was too much to bear. My short-lived semi-vegan phase ended about six weeks later when I couldn’t find anything to eat in an American airport – if it didn’t have ham or turkey in it, it was covered in something bright orange they called cheese. I was so hungry that I gave in and bought a cheese pizza slice.
After four months of my pescatarian and (mostly) low-dairy experiment I had lost a bit of weight (about 4 kg) and felt virtuous and healthier. My raised blood pressure had come down a little (by about 10 per cent) and I was able to stop taking one of the tablets and reduce the other (amlodipine) to the lowest dose. My blood cholesterol had also gone down by 15 per cent to around 4.2 mmol/l, and my HDL/LDL ratio had improved. But were these benefits solely due to my low-fat and low-animal-protein diet, or to something else?
One interesting consequence of suddenly becoming vegetarian was having to deal politely with the baffled and sometimes outraged reactions of friends. More significantly, for the first time in my life I had to think carefully about what I put in my mouth. Those of us without major religious, cultural or health foibles are probably used to accepting most food put in front of us. At parties or functions I now found myself declining most of the appetisers offered, either because they had some real or processed meat or, just as often, because I couldn’t make out the ingredients. The act of making decisions delayed the reactive eating impulse, and seemed to ensure that fewer unwanted calories ended up inside me.
By cutting out meat in general I was not just reducing unsaturated and saturated fats and protein in the meat itself, but by default I was cutting out most unhealthy processed foods that contain lots of added salt, sugar and fat. The other helpful side effect was that I was eating far more fruit and vegetables than ever before, and was discovering that I liked pulses and many other vegetables I had never heard of. I was becoming more adventurous when ordering food in restaurants, whereas in the past I might just have had a steak, chips and salad. As my diet changed and diversified I realised that making a small rule about, say, meat can have a major impact – if you can stick to it. As meat in some form is found in most savoury processed and frozen foods, I found I rarely used the microwave and was relying more on fresh food. Clearly, changing your diet is about much more than just excluding one arbitrary villain: it is about all the other compensatory changes you make.
Virtually all fatty foods are a mixture of unsaturated and saturated fat – technical terms that refer to the number of chemical bonds each fatty acid has to prevent it being saturated with hydrogen. Plant and vegetable oils like canola (rape seed) and olive oil, nuts and avocados, all contain large amounts of unsaturated fats. Meat is mainly made up of water (75 per cent) and protein, which we discuss in depth later, and a lot of fat, both saturated and unsaturated. Levels vary, of course, depending on the types of meat and the cuts.
In nearly all countries overall meat consumption has increased steadily since 1961, doubling in Europe by 2003 although still far behind US levels.2 In developed countries although red meat eating predominates, increasingly people are switching to white meat (chicken and turkey), which usually has less fat. In the UK between 1991 and 2012 meat eating increased slightly, most of it due to a 37 per cent increase in poultry consumption.3 The difference between white and red meat is more than skin-deep. Red meat is red because of the protein myoglobin in the specialised muscle fibres that are good for endurance, whereas chicken muscles lack myoglobin, which explains why you may see them making a quick dash across the road but not running marathons.
These sprinting chickens contain less total fat and the lowest proportion of saturated fat – two-thirds of their fat is unsaturated – compared to a roughly equal proportion of unsaturated and saturated fats in beef, pork and lamb. There is wide variation, depending on where on the animal the meat is cut from; some cuts of lean pork are similar to chicken, and minced beef and sausages can contain over 10 per cent saturated fat. The 20 per cent increase in deaths from heart disease associated with meat eating was thought to be due to the amount of cholesterol and saturated fat in meats that caused the disease in the first place. This ignores the large amount of unsaturated fat in meat, and as we saw earlier the most recent meta-analysis studies of saturated-fat contents in food have now cast major doubts over fat being the real cause. Importantly, the massive global experiment of replacing the total fat component of our diet with extra (mainly highly refined) carbs in recent decades has turned out to be a total health disaster.4 5
It is worth now taking a closer look at the different types of fat in meat and at what our ancestors ate.
Ancestral steaks
Hunter-gatherers around the world vary in the amount of meat they eat. In the tropics it is only 30 per cent, while the rest is made up of plants. We now tend to assume that eating lean meat is natural and healthy and that most people will sensibly discard the visible surrounding fat. However, our ancestors probably did exactly the opposite. Weston Price, an eccentric and energetic dentist practising in the US in the early 1900s, dedicated twenty-five years of his life to travelling the world to record the diets of isolated populations. He travelled from Alaska to Africa to find people untouched by ‘modern degeneration’, by which he was referring to diets and lifestyle. This was a concept that was hugely popular at the time and exemplified by vegetarians like lapsed Adventist John Harvey Kellogg, the inventor of Corn Flakes, who also promoted sexual abstinence, yoghurt enemas and other bizarre treatments.
What Price (and his long-suffering wife) found on his tour was a total absence of modern disease in tribes that ate traditional food. One characteristic of these primitive tribes was their love of the fatty cuts of meat and the vital organs – liver, kidneys, heart, as well as the intestines.6 He even witnessed Native Americans giving away the lean game meat to their dogs – exactly the opposite to modern Western behaviour. Inhabiting a very different landscape, Inuits have few plant sources and so seek out the skin of whales and caribou liver, which when eaten raw contain their only source of vitamin C. In the past our bodies and our traditions recognised which edible animal parts held the key nutrients. We may prefer fatty foods for this evolutionary reason.
One important message here is that strong links undoubtedly exist between how you and your brain interact with food and how your microbiome functions. People that really enjoy their food may actually, via their brains, be able to both make themselves feel happier and stimulate their microbes. As noted in an earlier chapter, cultures like those of the French and the Mediterranean countries love their food and food traditions, and they still spend far more time eating and talking about food than the Anglo-Saxons. And their strong food culture tells them that whatever their grandmothers ate is generally good for them, and they continue learning to cook and prepare the same meals.
Unsurprisingly, they were relatively well protected by these food traditions from overreacting when, for example, ‘expert advice’ from the US on the evils of high-fat dairy foods emerged in the 1970s and 80s. These countries simply went on eating their healthy yoghurt and high-fat cheeses and meats. They are probably better off as a result, as they didn’t replace the fat with refined carbohydrates. This contrasts sharply with most Americans and Brits, who with little or no common food culture reacted to the next wave of erroneous advice in a state of considerable stress. So not only do they make bad choices about the best diets for them and their families, by swapping real foods like meat and fresh cheese for margarine and processed-cheese pizza, but the associated stress and guilt may have adversely affected their microbes and their health.
Greasy foreign food
When the dictator General Franco in the late 1960s decided to open up parts of southern Spain to mass tourism, he relaxed the strict bikini laws and built hotels to attract Britons. The first tourists went on package holidays to Torremolinos on the sunny south coast and loved it. But they were shocked by the food they were served – ‘chicken and chips floating in a lake of greasy oil or covered in garlic – revolting’.
By contrast they saw their own British food such as fish and chips fried in batter as healthy and wholesome, and couldn’t wait to get back to their traditional full-English fry-up. The canny local Spanish hoteliers and their cooks soon adapted to the millions of British tourists arriving annually. Rising to the challenge, they provided ‘English Breakfasts and Fish and Chips just like at home’, with the addition of cold beer twenty-four hours a day but without too much visible ‘unhealthy’ olive oil.
Mediterranean countries have been making and using olive oil since at least 4000 bc, and it is part of the practice of most ancient religions. Spain produces 40 per cent of the world’s olive oil, followed by Italy and Greece, but the Greeks are apparently still the biggest users, at 24 litres per person per year in 2010 compared to 14 in Spain and 13 in Italy. For Greeks to be drinking nearly half a litre a week seems quite hard to believe, unless they still use it for washing and on their hair. The cynical but more likely explanation is that they may be reselling it to the Italians on the black market.
In the UK its use has been increasing. In 1990 only 7 million litres were imported, whereas in 2014 the figure had risen to over 60 million, but outside trendy areas of the country this is still a drop in the ocean. Like Americans, Brits consume less than 1 litre per person per year – the same as the Greeks use in a fortnight. One tablespoon of olive oil contains plenty of energy: about 120 calories and 13 grams of fat, which should be very fattening.
For non-Mediterranean countries that were dictating to the rest of the world what a healthy diet should contain, the possibility that olive oil had some health benefits rather than being scorned as a cheap lubricant or hair oil came about only gradually. The idea of adding a few spoonfuls daily to the American diet was actually discreetly included in the US food pyramid in 1995, although most Americans took no notice.7
Ancel Keys and his original researchers were surprised that the Cretans not only had the lowest rates of heart disease besides Japan, but also scored much better than northern Greece in this department. The studies of Cretan fishermen revealed that in the 1950s and 1960s they were consuming huge quantities of olive oil, making up about 40 per cent of their daily calories, as well as using it in the form of cheap soap. The story went that they would even drink it neat for breakfast. When I asked some of my Greek colleagues they said they had never personally witnessed this but it was quite likely – for instance when, at dawn, the poor shepherd or fisherman wanted a quick cheap hit of calories to last him the day. I tried this for breakfast for a few days, but wouldn’t recommend it on an empty stomach.
The problem facing Keys’s researchers was that a southern Greek diet was so different from a British or American one that it was hard to know what to pinpoint. They initially assumed that the benefit of the diet came merely from reducing the saturated-fat levels by eating much less meat and dairy than they did, and that olive oil was fairly neutral. As more became known about fats, the possibility that some could be beneficial as well as harmful slowly took hold.
Olive oil – the fatty miracle drink
Once again, we see how scientists seem driven to ignore the big picture and try to find the single magic ingredient that makes people healthy or sick. Dissecting diets and even simple foods into their important key components is a complex area that has generally eluded the nutrition community, and work done in this area has generally been misguided. Even something like pure olive oil is made up of several sub-fractions of different fatty acids that vary in length and structure. The main fatty acid is oleic acid, a mono-unsaturated fat with double bonds, and it constitutes up to 80 per cent of high-quality oil. However, olive oil also contains palmitic (saturated fat) and linoleic fatty acids (polyunsaturated fat) plus hundreds of other compounds including around thirty phenol compounds. Finding out which are crucial is not easy.
Olive oil’s properties may also change with heating or frying, and proponents of other ‘better’ oils have criticised olive oil for having a low frying temperature and producing certain ‘toxic chemicals’ when overheated or burnt. This is another example of the field routinely picking on a few chemicals out of thousands and assigning some ‘deadly’ or ‘health-giving’ theoretical properties to them – usually way out of the natural context. In fact, there is no good data to show that cooking with olive oil is actually harmful or has different properties for health than when consumed cold.
Olive oil comes in three main types: expensive high-quality extra virgin olive oil, which has less than 0.8 per cent acidity, indicating its freshness and quality, plus a strong, sometimes slightly bitter taste. This comes from the rapid first pressing of the olive – which is sometimes performed at cold temperatures and marketed as ‘cold-pressed’. Virgin olive oil is a grade lower, possessing higher acidity and still some taste; then finally there’s regular olive oil. This last is made industrially by refining the leftovers and is cheap and normally tasteless, but may be given some flavour by mixing with a small amount of extra virgin oil. We now know there are huge differences between the health properties of the types, and most of the Italian and Greek oil produced now is extra virgin. Good-quality extra virgin olive oil contains the greatest amounts of the chemicals known as polyphenols, which have special properties and probably account for much of its health benefits. The low-grade oils used in spreads and processed foods probably have no equivalent advantages.
The Mediterranean diet: the proof of the pudding
With all the controversy over including fat in the diet and blood cholesterol, one fact remains. Namely, that people living in Mediterranean countries have consistently lower rates of heart disease and stroke than northern Europeans and Americans. This is primarily because of their diet and not some fluke of genetics. The Mediterranean diet has many current variants but for this discussion I refer to it as the traditional dietary pattern found in the olive-growing areas of Greece and southern Italy in the late 1950s and early 1960s.
The main characteristics of this diet are a high consumption of whole grains, legumes, other vegetables, nuts and fruits; a relatively high fat consumption (up to 40 per cent of total energy intake), mostly from mono-unsaturated fatty acids (MUFA, providing up to 20 per cent of energy) mainly from olive oil; moderate to high fish consumption; poultry and dairy products (usually as yoghurt or cheese) consumed in moderate amounts; low consumption of red meats, processed meats and other meat products; and moderate alcohol intake, usually in the form of red wine with meals.
As with our discussion of the French paradox, there are many possible explanations for the differences in the incidence of heart disease in the Med. It used to be thought that the sunshine just made people more cheerful and that this translated into less stress and a healthier heart. Sadly, the truth is somewhat different, and the people reporting to be happiest and most content are the Scandinavians: the pragmatic Danes, who in particular have low expectations in this regard, regularly come top of most polls. In fact, the sunny Mediterranean countries tend to be the most miserable and discontented, thus knocking that theory on the head. As we discussed, I believe regular consumption of traditional dairy products – cheese and yoghurt – is one important factor. The other key ingredient dividing northern and southern Europe is of course olive oil.
A group of Spanish researchers set up a unique and ambitious project called PREDIMED in the early 2000s to see if the many observational studies suggesting the Mediterranean diet was beneficial could be proven in a proper gold-standard clinical trial lasting years. The initial idea was ‘to try to return these at-risk Spanish patients back to an average diet their parents would have had in the 1960s’. The researchers collected 7,500 volunteers from across Spain, all in their sixties and at high risk of heart disease. They allocated them randomly into one of three dietary groups, and all were given regular advice and support to help them stick to their diets.
The comparison diet group were to take a low-fat diet as recommended by most nutritionists, and advised to reduce the proportion of fat they ate as calories – which in Spain was already quite high, at close to 40 per cent. They were told to avoid meat, olive oil, nuts, snacks, dairy (unless low-fat) and to eat more fish, fruit, whole grains and vegetables. The control group were given extra (non-edible) kitchen accessories as incentives.
The Mediterranean diet groups, on the other hand, were told to eat more fish, vegetables and fruit but to continue dairy, white meat, nuts and olive oil and drink wine. These groups were further divided into two subgroups, one given 30 grams of extra mixed nuts to eat per day, and the other given an extra bottle of extra virgin olive oil each week to cook and eat with, to tempt them to consume four tablespoons a day. The study was originally designed to compare the rates of heart disease and diabetes between the groups and to run for ten years.
All went smoothly for four and a half years, until an independent committee stopped the trial. This had been set up for patient safety, to protect the volunteers from carrying on with an arm of the study that was clearly detrimental to health. The committee announced their findings in the New England Journal of Medicine in 2013. It was a knock-out blow for the high-fat diverse diet advocates and against the low-fat traditionalists.8 Both Mediterranean diet groups with high fat consumption had 30 per cent fewer heart attacks and fewer strokes, as well as improved lipid and cholesterol levels and blood pressure. Although both Mediterranean diet groups did well versus those on low-fat diets, the extra-olive-oil group did even better than the extra-nut group at preventing diabetes and in respect of several other parameters.
The diet study was not designed to make the high-heart-risk participants lose weight, and we know that on average most sixty-year-olds continue to gain some weight. But participating in any kind of a trial is usually beneficial for health, and the low-fat group receiving regular dietary advice and support gained only a kilo over five years. The nut group did slightly better and lost a small fraction, but unexpectedly the olive-oil users lost over a kilo and, more importantly, reduced their waist measurements, suggesting they had lost more visceral fat.
Although the trial had directly tested only extra virgin olive oil, they also recorded data on the use of cheaper varieties. These low-quality products had no obvious beneficial effect on the heart or diabetes risk, which explained some of the previous conflicting olive oil results that didn’t account for this quality factor.9 10
Until recently the benefits of polyphenols in olive oil were thought to come mainly from its antioxidant properties whereby they mop up any excess cell-damaging chemicals and have a calming anti-inflammatory effect. Other studies show that olive oil can somehow switch off the genes (possibly by epigenetics) responsible for much of the inflammation in the blood vessels that leads to heart disease.11 But research suggests a much greater role for our microbes. Over 80 per cent of the fatty acids and nutrients from olive oil reaches the colon before full digestion and comes into contact with our microbes. Here the microbes feed on the rich mix of fatty acids and polyphenols and break them down into smaller by-products, and at this point several interesting things happen.
Some of the compounds produced act as antioxidants, then use the polyphenols as fuel to produce a range of even smaller bits of fat – short-chain fatty acids. These compounds are more interesting than their name suggests, signalling to the body to lower harmful lipid levels and telling the immune system what to do next. Polyphenols actively encourage some microbes to flourish, such as lactobacilli that mop up and bind fat/lipid particles and clear them from the blood. They also prevent unwanted microbes from colonising our guts. This reduces the incidence of infection from bugs like E. coli that can cause diarrhoea, H. pylori that can cause stomach ulcers, and other bugs that cause pneumonia and tooth decay. Even the build-up of unhealthy atheromatous plaque in our arteries is due in part to abnormal and mysterious microbial activity in the damaged blood vessel – and polyphenols are likely to help reduce this too.12
The PREDIMED study was a major landmark in medical studies of diet, and the first to definitely show the beneficial effect of a sustainable diet on health. It clearly demonstrates that extra virgin olive oil and nuts taken regularly on top of a basic Mediterranean diet reduces the incidence of disease and early death. It is the only diet that has produced this high degree of evidence; observational or short-term studies only suggest changes in markers of risk. Most nuts have fat as their major component (49 per cent for almonds), which accounts for their calories. The types of fat vary, but only about 10 per cent is saturated and the rest poly- and mono-unsaturated. That the nut diet performed nearly as well as the olive-oil diet suggests they have similar mechanisms of action on our microbes. This makes sense because nuts, in addition to fat, contain a wide range of other nutrients such as proteins and fibre as well as polyphenols similar to those found in the extra virgin olive oil. (We discuss nuts in more detail later.)
In fact polyphenols are found in a number of other Mediterranean foods: in many brightly coloured vegetables and fruits such as berries, in cocoa nut, some green and black teas, turmeric and red wine. The fact that we are more attracted to these foods visually may have an evolutionary basis. Selecting healthy foods on the basis of colour (counting colories) rather than calories makes a lot of sense. Sadly, we still know little about how many of these polyphenols are biologically active or affect our gut microbes.
One study looked at different types of sofrito (the tomato-based sauce containing onion, garlic and olive oil that is used across the Mediterranean) and found, amazingly, at least forty different types of polyphenols.13 It is likely that each ingredient on its own may not work particularly well without the others. Once you ferment these fruits and vegetables as pickles or alcohol, the number of polyphenols produced can increase exponentially. The universal use of extra virgin olive oil may be the crucial catalyst for bringing out the benefits of all of them.
Olive oil may have benefits over other oils because the complex juice comes from the whole fruit rather than just the seed, and this may be a general principle that applies more widely. It also means that its extraction is much simpler and doesn’t require chemicals or solvents. So far its proven benefits extend to reducing heart disease and diabetes and possibly helping weight loss, but it has been claimed also to alleviate arthritis via its anti-inflammatory effects. More far-fetched are the assertions that it is a cure for baldness, increases testosterone and boosts male libido – Greek and Italian women may contest these claims, of course.
Olive oil is therefore the poster boy of the new diet order, dispelling for ever the myth that eating saturated fat is bad for you. Full-fat yoghurt and real cheese should come off the ‘banned’ foods list, unless you only eat it as frozen pizza. Picky Jack Sprat who ate no fat may well have died before nutrient-rich Mrs Sprat. Microbes are behind many of the health benefits, and offering us probiotics is a good first attempt by companies to give us as supplements a few helpful microbes. These few species don’t work for everyone – we are all unique in this respect – but there can be no doubt that the diverse, real, fresh foods from the Mediterranean are what we should be trying to eat more of.