The Mediterranean Diet: What Your Heart Desires with Julia Zumpano, RD

Podcast Transcript

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host. Why do some people on this planet live longer than others? It's a question that brought together researchers from around the world in the 1950s. Their goal in what became known as the Seven Country Study was to explore possible connections between diet and heart disease. That project introduced us all to what's known as the Mediterranean diet. Today, we're going to look at that eating plan, which serves as the bedrock for heart healthy living. Registered dietitian Julia Zumpano is here to walk us through the foods and the general rules of the Mediterranean diet. She's one of the many experts at Cleveland Clinic who pop into our weekly podcast just to help us live a little healthier. So with that, let's see what your heart desires for your next meal.

Julia, welcome back to the podcast. Always a treat to have you on with us.

Julia Zumpano:

Thank you so much for having me again, John.

John Horton:

One of the things, and I know we've talked about this a lot, is just the word diet, and people hear it and they think it's some sort of short-term calorie cutting, got to lose some pounds to fit into an outfit thing, but it's much different than that in your world, right?

Julia Zumpano:

Yeah, well, it certainly can have that description. It can be a short-term plan, a diet can be short term, but I like to look at it from a lifestyle way of eating versus a diet. A lot of people do feel that the description that you provided about a diet is true. They think of it as a beginning and an end, and they have a goal in mind. And once that goal is attained, the diet's done or the goal is never attained, then the diet just kind of goes on the wayside. So they just kind of start to incorporate their normal eating habits and all those properties are then lost. I think that's where we're doing false service to the American public and the nation about talking about diets that have these short-term benefits. We really need to talk about a lifestyle of eating. I do feel that there are certain diets that need to be followed for certain short periods of time to gain a certain benefit, but then, there's a lifestyle after that that needs to be maintained.

John Horton:

Well, and that's what we're talking about today, the ultimate kind of lifestyle diet, which is the Mediterranean diet. Before we get into a bunch of specifics as to what you eat on this plan, let's talk about why it's deemed so healthy and what kind of benefits you get out of it.

Julia Zumpano:

Sure. There's been several clinical studies proving the benefits of the Mediterranean diet. What it does, it looks at the countries around the Mediterranean. They did a seven-country study and they looked at all these countries and how they ate and noticed that there was a theme around the countries that lived around the Mediterranean Sea and that they ate very similar foods and they had a lot less health problems.

John Horton:

What sort of health problems are we talking about, then? Let's kind of roll through some of the biggies there that it was going to help with.

Julia Zumpano:

Cardiovascular disease and then, certainly, they had some boosts and longevity. So it's more longevity and heart disease related is what we found. So really more of a cardio-protective benefit to their style of eating.

John Horton:

And then I saw other things, lower risk of dementia, cancer risk down, gut health, weight control. I mean, all of that kind of gets tied into that form of eating?

Julia Zumpano:

Yeah, it does because the Mediterranean diet has been lumped into more of an anti-inflammatory diet as well. So when we talk about the properties of what a Mediterranean diet is, it's very similar to the properties of what can support the suppression of inflammation. And a lot of those disease states, if not all of them, are a byproduct of inflammation.

John Horton:

Let's talk about inflammation for a minute because I think in most people, you think about inflammation and it's when you sprain your ankle and it swells up. But the reality is that you have little bits of inflammation that go on all the time within your body when even if you just don't eat right or something happens. What's going on there?

Julia Zumpano:

The inflammatory processes is where you create chemicals in the body that are trying to fight off this inflammation. So your body's kind of fighting against this foreign form of substance that might be in your body that's causing the inflammation, which we know there are tons of substances that cause inflammation in our world. From our diet and from the air we breathe and the products we put on our skin and the water that we drink, they can all create all levels of forms of toxicity in our body that then our body fights again, and that creates inflammation in our body, in our cells, and inside our body and our organs. And that inflammation eventually leads to disease.

John Horton:

That's just such a fascinating concept because you just don't think when you eat something, it's going to make your arteries swell or some inflammation come in. But the truth is, if you put garbage in your body, that's how it reacts.

Julia Zumpano:

Right. It's fighting to get it out. So we want foods that it's only going to support its growth, it's going to support the cell protection, it's going to create those anti-inflammatory chemicals and enzymes and things to start working to suppress the inflammation and protect your cells, protect your organs, protect your entire system.

John Horton:

Well, let's talk about those foods because that was the next on our list as we were going to go through this. If you're on the Mediterranean diet or that's how you're choosing to live, that's going to be your lifestyle choice, what sorts of food are you going to be putting on your plate?

Julia Zumpano:

Foundationally, the Mediterranean diet has abundant amount of fruits and vegetables. So really, that's kind of key. And we know that all varieties of different fruits and vegetables have a variety of different antioxidants, phytochemicals, phytonutrients, some more than others, but they all provide some. And the variety is the key because you're going to get then a variety of those benefits. So fruits and vegetables for sure.

John Horton:

So mix it up. You want a little color on your plate. Those fruits and vegetables all seem to add that little splash.

Julia Zumpano:

Right. All different colors, all different varieties. Trying something new every week is what I usually challenge my patients to do. We have fruits and vegetables, grains. If you are going to choose grains, they're whole grains, minimally processed. Things like oats and quinoa, barley. So grains, brown and wild rice, avoiding any refined products; so refined flour-based products; so white bread, white rice, crackers, pretzels, bakery items, et cetera.

John Horton:

When you talk about whole grains versus those refined ones, what's happening in that process that makes the whole grain so much better than something that's a little more refined and been through the processing?

Julia Zumpano:

Sure. We know all those nutrients are found in the whole grain. Once we start to strip the outside layers of that grain, once we start to add chemicals to it, extract things from it, fortify it, we're killing off all those wonderful properties that it already maintains. We know antioxidants can be killed by heat. So by making this wonderful grain being processed, we've pretty much killed all the nutritional benefit of it. And then we go and add it back in. That's what we call enriched flour because we've killed it off.

John Horton:

It's just not as enriched as what you might think.

Julia Zumpano:

No, definitely not as enriched as what you think.

John Horton:

Let's keep shopping. What else should we be looking for?

Julia Zumpano:

Fish is a foundational source of protein in the Mediterranean diet. Again, it's very easy to have fish around the Mediterranean. It's the most abundant source of protein. It is a little harder to instill that in Ohio specifically, but when you don't live around a body of freshwater, that's readily available. So fish is the primary source of protein.

John Horton:

Are there certain fishes you should look for?

Julia Zumpano:

Yeah, so great question. Fish high in omega-3 have been shown to suppress that inflammation even further. Omega-3 fatty fish are things like salmon and herring, tuna, mackerel, sardines, sea bass, those are good sources of omega-3. All fish can play a good role, so could be good sources of protein, but if you're looking for specifically the fish high in omega-3 to suppress the inflammation, you want to go that route.

John Horton:

OK. And you said fish should be kind of the main protein in the Mediterranean diet, correct?

Julia Zumpano: 

Yeah, we recommend fish about three days a week, three meals a week of fish.

John Horton:

What should you use on those other four days?

Julia Zumpano:

So again, great question, poultry, skinless poultry would be the second preferred choice of protein. And then, getting your other sources of protein from plant-based sources, like grains and beans and nuts are the other great sources of protein. Legumes are another foundational part of the Mediterranean diet. Legumes include dried beans and lentils. Any kind of bean, they all provide great benefit, and variability here is again key. Using some beans on a salad instead of putting meat on it or having a bean soup. Hummus is a great dip that has the properties of protein and fiber and the benefits of having legumes in your diet. And then nuts, we know nuts are definitely integral part of the Mediterranean diet.

Most of the nuts that are used in the Mediterranean are things like walnuts and almonds and hazelnuts. Those are wonderful things to include on a regular basis, but if you don't favor those, all nuts can be included. What I just recommend is trying to incorporate the Mediterranean-style nuts more often. So if you do favor more like peanuts or cashews, trying to mix in the other nuts is key. And then, nuts are great, but you want to be careful with portion because they can add up calories very quickly.

John Horton:

Do they really add that much protein? Because it's almost hard to believe that you can substitute in legumes and nuts and have it be a full substitute for beef, but I mean, it sounds like it can work that way.

Julia Zumpano:

It can. You have to look at portion and volume and what other foods you're eating. So when you look at volume, an ounce of meat has about 7 grams of protein. You would have to eat a half a cup of beans to get that much protein. So volume by volume, it doesn't necessarily match. You do have to eat more legumes to get in the amount of protein you would in beef or lean source of flesh meats or fish. But incorporating some of that plant protein in combination with eating things like fish and poultry, you certainly can meet your protein needs. You can still eat egg whites and Greek yogurt. Those are great sources of protein as well. It's just a matter of getting a good variety of sources of protein and noting the fact that although beans and legumes may not be as high in protein when you compare volume as meat, but they have a lot of other benefits that the meat may not have.

John Horton:

Since we're talking about meat and you had mentioned eggs and dairy and things like that, I mean, those are obviously really big items in a lot of people's, on their shopping list. Is there a place for those within the Mediterranean diet?

Julia Zumpano:

Yes, absolutely. Things like yogurt can be encouraged daily on the Mediterranean diet. We do suggest more of a Greek style yogurt or plain yogurt. Something that's not packed with a lot of sugar. Lower fat varieties, so skim or 0 percent fat, 1 percent or 2 percent fat would be fine. You just want to avoid the full fat varieties of that. But yeah, yogurt and milk is acceptable, again, in moderation. Cheese is the one that I think we really encourage limitation. Cheese, the recommendation on the Mediterranean diet is about 3 to 4 ounces of cheese a week. That does not come out to be a lot. Most people eat about 3 to 4 ounces of cheese a day. We want to avoid all processed cheeses again because they are not leading us to healthy outcomes that we want to choose more mild or lighter cheeses. Something like a feta cheese or a fresh mozzarella, a ricotta or goat cheese, very, very light cheeses. And then, again, still limiting the portion of that.

John Horton:

What about baked goods and things like that? We like to delve into that every so often. Is there room for that in there also?

Julia Zumpano:

Sure. Commercial baked goods are avoided. There's really not much room for commercial baked goods. Special occasions once a year fine, but on a regular weekly basis, no. But if you want something baked, it is encouraged you bake at home so you can adjust and include healthier ingredients. Certainly you can make a banana bread or some cookies or something with the acceptable ingredients. Using things like whole grain flour, healthier oils, using more egg whites, reducing the sugar, maybe using honey or using some fruit to sweeten. So making adjustments to help that baked good be more nutrient-dense.

John Horton:

You had mentioned the healthier oils, too. It seems like the one that always comes up with the Mediterranean diet is olive oil. What's so magical about that?

Julia Zumpano:

Yeah, so an olive oil has a ton of antioxidant properties. We know antioxidants protect our cells from damage, so that can really help suppress things like cancer and heart disease, et cetera. And then there's a lot of polyphenols in olive oil that has been shown to be protective from a cholesterol standpoint, a blood pressure standpoint, a lot of proven benefits to extra virgin olive oil.

One thing that commonly comes up when you're following a diet or an eating plan is that it can be bland. In the Mediterranean, they use olive oil very freely and very generously, and it does provide a lot of great flavor to the food that they're eating. We found that even though they're using it so generously, there have not been negative health benefits.

John Horton:

Wow!

Julia Zumpano:

That's another really key factor of the Mediterranean diet. We found that this kind of oil that adds so much flavor to our foods, it doesn't have negative health outcomes, where we've always kind of focused on low fat when it comes to heart health, and it's very refreshing to know that we don't necessarily need to focus on that when using olive oil, extra virgin olive oil.

John Horton:

Just going through this whole list with you, what really strikes me is just how accessible all these foods are. I mean, this isn't some kind of wild exotic list of items that you need to go get. These are all things that we're familiar with, that you see, that you probably buy when you're out, but it's just a matter, it sounds like I'm focusing on eating them a little more and putting together certain plates.

Julia Zumpano:

Absolutely. I think that's what is the saving grace of the Mediterranean diet. It's why people can follow it, for so many centuries and decades of families following the style of eating is because it really just does focus on whole foods that we all know, we all see, they're accessible to everyone. Some fish may be less accessible to some people than others, but just seafood in general is accessible to most people. Poultry is accessible to most people, nuts. All of these things are so accessible and there's so much variety within each category of the food that you can find something you enjoy in each category and start there and then start to get a little bit more adventurous and starting to try different types of fish or vegetables or fruit or grains or whatever it might be. But there's almost something that everyone can enjoy in each category. Really, it just focuses on filling up your diet and your plate with these single-ingredient foods that have so much nutritional benefit, and really decreasing all the junk and snack foods that we're eating.

John Horton:

It just seems more natural and it's not going to rule out a ton of different stuff other than, like you said, that really processed, just the stuff that we know deep down is probably bad for us.

Julia Zumpano:

Sure, sure. Red meat can be included in moderation in the Mediterranean diet. We usually recommend red meat only about one meal a week, and that red meat is classified as beef, pork, veal and lamb. Now, if you have pretty progressive heart disease, I'd say probably consume less than that. But if you're just protecting your heart and doing it for overall heart health, red meat can be included in moderation.

John Horton:

Well, Julia, we always, on this podcast, one of the things we pride ourselves on are giving people some actionable tips that they can use, if they want to follow the Mediterranean diet and take this advice. What sort of adjustments would you have to make or what sort of tips would you give someone who wanted to start on this eating plan?

Julia Zumpano:

I would start with trying to incorporate a fruit or a vegetable with every meal. That would be the first step. So every time you sit down, see if you have a fruit or a vegetable, and ideally progressing to having one of each.

John Horton:

I think people don't do that enough. I mean, that's what you must see as a dietitian I'd imagine.

Julia Zumpano:

Yeah. That is one of the biggest problems is just an adequate intake of vegetables more so than fruit, but both are fairly inadequate. That would be a very good first step. And then, finding which of those fruits and vegetables you enjoy and continuing to consume them throughout the day, multiple times a day. The hope is that you eventually start to decrease the amount of refined grain and processed protein or meats that you're eating and then, incorporate more into fresh meats and fish and then, minimally processed grains.

John Horton:

When eating more of those vegetables, too, I'd imagine during the day, they're filling, so that will help just with the desire to binge snack and reach for those chips and the pretzels and all the other things that we just grab when you get the grumbellies around three o'clock.

Julia Zumpano:

Absolutely. I think that's one of the biggest pitfalls that most people fall into is that they are hungry and they tend to grab a snack food. That's not going to fill them, not going to provide them any nutrition, but going to provide them with a ton of extra calories, a ton of extra fat, ton of extra sodium that's not leading to their health goals, whether it be lowering your blood pressure, cholesterol or losing weight.

So we are getting in a habit of just grabbing the wrong food instead of filling our day with fruits and vegetables, which can be so much more filling, so much more satisfying, provides so many more nutrients and antioxidants that are just going to support the whole picture. Not to mention the fact that they're extremely low in calories, low in, if any, sodium, low in fat, if any fat, and have natural sugars, no added sugars. So many benefits there. That would be really the integral first step would be incorporating a fruit and a vegetable with every meal.

John Horton:

What about as far as getting used to fish. I know a lot of people have some strong opinions on eating fish. How do you get past that?

Julia Zumpano:

That is a tough one to get past. I generally recommend starting with a very mild fish, a very, very mild fish, and maybe starting at a restaurant when you're going out to eat. It's usually prepared the best way. So trying that, maybe incorporating fish more when you're eating out and then trying to find what kind of fish you like and how you like it prepared. And then, experimenting a little bit there at home, starting with whatever fish you already know you do like, whether it's shellfish or white fish or salmon, whatever it is, just trying to incorporate that on a regular basis. Even canned tuna can be included. You just want to be careful with sodium and mercury, but there's certainly ways around that when you're purchasing canned tuna. But that's another great way to just kind of get your feet wet.

Don't look at it from, OK, all of a sudden I have to make fish my primary source of protein. That's, I think, the worst way of looking at it. We want to just start slowly. Let me try to have fish every Friday, let's start there and I'm going to try different kinds and see what I like. I would encourage that with fruits and vegetables. That's why I said try to add one or the other each time you eat and then, eventually progress.

John Horton:

This all seems to go back to the very first thing we were talking about, which is the concept of a diet as not a forced eating style for this time, but as a lifestyle and a lot of different choices, but you're just making them in a big picture sort of way.

Julia Zumpano:

I really think that when you try something once and you don't like it, I think you should definitely give it another try. Fish can be tough. Sometimes, it can be not prepared properly or wasn't stored properly, so it can have that fishy taste that can really turn people off. That's happened to me, I've definitely had a piece of fish, I'm like, oh, I'm going to give fish a break for a little bit. And that's OK, but just going back to it and trying again. I would say that again with anything new that you try, whether it's hummus or a quinoa or a different kind of vegetable or fruit or one that you don't.

Just, again, keeping a very open mind and trying it again or trying a different kind or a new way of preparing it and seeing if you can incorporate it more regularly and finding a way that you can enjoy it. Because the key is to find enjoyment out of food. No one wants to be told to eat a bunch of foods that they don't enjoy. That's never going to be sustainable, and it's not realistic. There's so much variety and so many options in the Mediterranean diet, it's just a matter of finding what you like as a part of the Mediterranean diet and instilling those on a regular basis.

John Horton:

When we're talking about fish, too, I take it we should try to stay away from fried fish. There's other ways to prepare it that we need to look at there.

Julia Zumpano:

Yeah, definitely deep-fried and breaded fish, you want to try to avoid.

John Horton:

Deep fried never seems to be the healthy answer to anything.

Julia Zumpano:

No, but I do think that there's something to be said with pan fried fish. I think it adds a nice crispy flavor on the outside, just really minimizing. You don't want to cook in high levels of heat with extra virgin olive oil anyhow, so you'd have to use more of a refined olive oil if you're going to cook in a pan in high heat. But I usually say turn the heat down, use the least amount of oil you can, kind of coat the pan and put a lid and just kind of get that crispiness without over frying or overcooking it.

I think using a little bit of pan frying is totally acceptable. If you even want to bread it, there's some whole grain breadcrumbs you can use. Some people use flax seeds. There's ground up like almond flour you can use to bread it. There's certainly ways that you can incorporate some of that flavor without having the full-flooded, typical deep-fried breaded fish. You can try to make it home. I say that for anything in the Mediterranean diet, and that's where that baked goods comes in. That full store bought poundcake. You can try to find something that you can make at home that can give you that same benefit and pleasure without having so many unhealthy ingredients in there.

John Horton:

See, this one was so great. The Mediterranean diet seems like it offers just about everything you would want. You have to look for different ways to get it and then, just kind of experiment with the food and have some fun while you're doing it.

Julia Zumpano:

Yeah, definitely experiment with it. And it is more fun if you do it with a group or with a partner. So trying to navigate this on your own can be challenging. So if you can recruit a family member or friend or try to see how you can incorporate this in your social network, too, can be really helpful. And then, you can bounce ideas off and share recipes. That can be really helpful, too.

John Horton:

Well, you have certainly filled our plate with just a ton of helpful information today. Anything else you would like to add about the Mediterranean diet?

Julia Zumpano:

Not really. Just knowing that it has so many positive benefits, that any small step toward the Mediterranean diet is a step in the right direction.

John Horton:

All right. Well, that sums it up perfectly. Julia, thank you so much for being here and can't wait for you to come back.

Julia Zumpano:

Thank you so much for having me.

John Horton:

There's a reason why the Mediterranean diet grabs so much attention. It works. Decades of research show how this eating plan can help you live longer and healthier. So give it a try. Your heart will love you for it. Till next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.