Seven Countries Study
1958 professor Ancel Keys, director of the Laboratory
of Physiological Hygiene at the University of
Minnesota School of Public Health, launched
the Seven Countries Study. For more
than a decade Professor Keys, with the help of
an international team of specialists, studied
the diet, lifestyle and incidence of coronary
heart disease among 12,763 randomly selected middle-aged
men from seven countries: the United States, Japan,
Italy, Greece, the Netherlands, Finland and Yugoslavia.
all the research was analyzed, a clear and predictable
pattern emerged. In the Mediterranean and Asian
regions of the world (Greece, Japan and southern
Italy)where vegetables, grains, fruits,
beans and fish took center stageheart disease
was found to be rare. But in those countries where
people filled their plates with red meat, cheese
and other foods high in saturated fatsuch
as in the United States and Finlandthe rates
of heart disease were found to be very high.
Professor Keys' research convinced him that diet
played the primary role in the onset of coronary
heart disease. But, after so many years of research,
he had come to realize that food may not be the
only factor involved. Professor Keys also observed
that Mediterranean and Asian peoples were physically
active, family ties were strong, and the pace
of life was leisurely. Keys concluded that although
diet was the single most important factor, it
was a combination of dietary and lifestyle factors
that were responsible for the remarkably low rates
of heart disease in Mediterranean and Asian regions.
of the surprising findings of the Seven Countries
Study was that people living on the Greek island
of Crete consumed up to 40 percent of their calories
from fat, yet they had the lowest rate of heart
disease and the highest average life expectancy
in the world (along with Japan). However, Professor
Keys found that unlike the saturated fat that
was prevalent in American and Finnish diets, the
majority of the fat in the Cretan diet came from
olive oil and fish which are rich in unsaturated
fats. Keys concluded that although saturated fat
can be harmful to your health, unsaturated fats
can have positive health benefits.
D, Keys A, Aravanis C, et al. Food consumption
patterns in the 1960s in seven countries. American
Journal of Clinical Nutrition (1989) 49:889-894.
A. Seven countries: a multivariate analysis of
death and coronary heart disease. London: Harvard
University Press, 1980.
A. Mediterranean diet and public health: personal
reflections. American Journal of Clinical Nutrition
The China-Cornell-Oxford Project (China Study)
China-Cornell-Oxford Project (also known as
the China Study), conducted by Cornell University
in the United States, Oxford University in England,
and the Chinese Academy of Preventative Medicine,
was launched in 1983. The study, which focused
on China, was massive in it's proportions. Dozens
of researchers were involved, led by T. Colin
Campbell, Ph.D., professor of nutritional biochemistry
at Cornell University. Between 1983 and 1990 researchers
traveled across the far reaches of Chinafrom
the southern coastal regions to the Gobi desertstudying
the dietary practices and disease rates among
10,200 Chinese men and women.
make the study as comprehensive and thorough as
possible, Dr. Campbell and his colleagues collected
every conceivable piece of information they could
about their subjects. They found that a rural
Chinese diet was the same diet that had been eaten
in China for thousands of years. It was rich in
plant-based foods such as rice and vegetables,
low in animal foods and contained around three
times more fiber than an average Western diet.
The rates of heart disease and breast cancer in
these areas was also found to be many times lower
than in Western society, as was prostate cancer
and osteoporosis. Obesity was also very rare.
when further research was conducted on Chinese
populations living outside of rural areas, it
was a different story. It was found that the diet
in many urban areas of China was a lot more Westernizedwith
far more animal food consumption at the expense
of traditional dietary staples like rice and vegetables.
was also found that the urban Chinese who had
abandoned their traditional diet had much higher
rates of common Western ailments than their rural
cousinsincluding heart disease, breast cancer
and prostate cancer. And obesity, which was rarely
seen in rural Chinese populations, was found to
be common among those Chinese eating a Westernized
the years of painstaking research were completed
in 1990, The China Study had generated the largest
database in the world on the multiple causes of
disease. And the findings of the study were clear:
"In the final analysis," reported Dr.
Campbell, "we have strong evidence from this
and other studies that nutrition becomes the controlling
factor in the development of chronic degenerative
China Study was hailed as a great success. Dr.
Mark Hegsted, professor emeritus of nutrition
at Harvard School of Public Health called it "a
very, very important studyunique and well
done." The New York Times dubbed it
the "Grand Prix of epidemiology," and
went on to describe it as "the most comprehensive
large study ever undertaken of the relationship
between diet and the risk of developing disease
. . . tantalizing findings."
TC, Junshi C. Diet and chronic degenerative diseases:
perspectives from China. American Journal of
Clinical Nutrition (1994) 59(suppl):1153S-61S.
TC, et al. China: from diseases of poverty to
diseases of affluence: Policy implications of
the empidemiological transition. Ecol Food
Nutr (1992) 27:133-144.
The Lyon Diet Heart Study
1988 Michel de Lorgeril, M.D., from the University
of Saint-Etienne in France, teamed up with researchers
from the French National Center for Health Research
to investigate the protective effects of a Mediterranean
diet. In what became known as the Lyon Diet
Heart Study, researchers randomly divided
605 male and female heart attack survivors into
two groups. One group was advised to eat the standard
"prudent" low-fat diet suggested for
heart patients. The other half were advised to
eat a Mediterranean-style diet, complete with
plenty of vegetables, fruits, grains, beans and
olive oil, small amounts of red meat, moderate
amounts of fish and poultry, and wine with meals.
Instead of butter they were advised to use a canola
the study was originally scheduled to last for
five years, after only two years researchers were
so astounded by the differences in the two groups
that the study was abruptly ended for ethical
reasons. It was found that those following the
Mediterranean-style diet had a 70 percent lower
death rate compared to those following the prudent
low-fat diet. In a follow-up report the researchers
also discovered that cancer rates among the Mediterranean
group were 61 percent lower than those of the
results were spectacular and of unexpected magnitude,"
reported Serge Renaud, Ph.D. from the French National
Center for Health Research, Bordeaux, who helped
initiate the study. "The protective effects
of the diet began to occur within two months of
fact, the results of the Lyon Diet Heart Studyresults
that hadn't been seen in any other diet, drug
or medical procedurewere deemed so important
that they were published in three prestigious
medical journals, the American Journal of Clinical
Nutrition, the Lancet and the Journal
of the American College of Cardiology.
S, de Lorgeril M, Delaye J, Guidollet J, Jacquard
F, Mamelle N, Martin JL, Monjaud I, Salen P, Toubol
P: Cretan Mediterranean diet for prevention of
coronary heart disease. American Journal of
Clinical Nutrition (1995) Jun;61(6 Suppl):1360S-1367S.
Lorgeril M, Renaud S, Mamelle N. Mediterranean
Diet, Traditional Risk Factors, and the Rate of
Cardiovascular Complications after Myocardial
Infarction: Final Report of the Lyon Diet Heart
Study. Circulation (1999) 99(6):779-785.
The GISSI-Prevenzione Study
positive results of the Lyon Diet Heart Study
were duplicated recently by the GISSI-Prevenzione
Study, a large-scale clinical trial organized
by the Italian National Association of Hospital
Cardiologists which evaluated the long-term changes
in dietary habits of a group of Italian heart
participants were divided into five categories
according to how much of their diet consisted
of vegetables, fruit, fish, olive oil and butter.
The number of patient deaths in each category
was noted over the duration of the study.
Compared to those who most followed traditional
dietary practices, those who consumed the most
butter had a 2.6 times greater risk of dying within
42 months after their heart attack. "A significantly
lower risk of death was associated with eating
more Mediterranean-style foods and fewer foods
containing saturated fats, such as butter,"
reported Roberto Marchioli M.D., who helped co-ordinate
Investigators. Results of the GISSI-Prevenzione
trial. Lancet (1999) 354:447-455.
Asian Diet and Breast Cancer
the mid-1990s researchers from the University
of California recruited 25 breast cancer survivors
to determine the merits of an Asian-style diet
in reducing the risk of breast cancer re-occurrence.
The study participants were placed on an Asian-style
diet rich in vegetables and grains, low in red
meat and saturated fat but rich in omega-3 fat
from fish oil, and their progress was noted.
the three-month study there was no re-occurrence
of breast cancer in any of the subjects and the
researchers also found that the breast fat composition
of the women had bio-chemically changed in response
to the diet. In fact, levels of healthy omega-3
in the breast had increased by 40 percent. "My
colleagues and I have shown that at least one
aspect of human breast composition in American
women can be altered to approximate the breast
composition of women in certain Asian and European
in those countries, the incidence
of breast cancer is much lower than it is here,"
reported John Glaspy, M.D., director of the University
of California Oncology Center and lead author
of the study. Dr. Glaspy was also surprised at
how fast the healthy changes in the breast had
occurred: "I think it shows that not only
are you what you eat, you are what you ate very
researchers also noted that the Asian-style diet
promoted better cardiovascular health as well
as weight loss.
D, Capone S, Wang H-J, Heber D, Lill M, Chap L,
Glaspy JA. Dietary modulation of omega 3/omega
6 polyunsatruated fatty acid ratios in patients
with breast cancer. Journal of the National
Cancer Institute (1997) 89:1123.
Mediterranean Diet and Weight Loss
Mediterranean-style diet can help you lose weight
and maintain that loss according to a study by
researchers at Brigham and Women's Hospital and
Harvard Medical School.
the study 61 overweight men and women consumed
one of two diets: a standard low-fat diet or a
Mediterranean-style diet with regular moderate
consumption of healthy monounsaturated fat from
olive oil, olives, nuts and nut products (such
as nut oils and peanut butter). Both groups were
instructed to consume the same number of calories.
six months both groups had experienced roughly
the same amount of weight loss, but the big difference
came at the end of the study, 12 months later.
It was found that a large number of the Mediterranean
diet group had stuck with the diet and maintained
their weight loss. However, many of those on the
low-fat diet couldn't stick with it and had not
only regained their lost weight, but weighed more
than they did before the study began. "In
our study, three times as many people trying to
lose weight were able to stick to a Mediterranean-style
diet versus the low-fat diet," reported lead
author of the study Kathy McManus, R.D., director
of nutrition at Brigham and Women's Hospital.
She noted that "Patients loved this diet
because they could include favorite foods if they
carefully watched portion sizes."
researchers concluded that "Motivation and
adherence are very hard to sustain in any weight
loss programs, but the results from this study
suggest that the tastier the food, the greater
overall success of the diet planeven if
it does include moderate amounts of fat."
K, Antinoro L, and Sacks F. A randomized controlled
trial of a moderate-fat, low-energy diet compared
with a low fat, low-energy diet for weight loss
in overweight adults. International Journal
of Obesity (2001) 25:1503-1511.
The Ni-Hon-San Study
Ni-Hon-San Study was initiated in the 1960s
to evaluate dietary and lifestyle differences
between middle-aged Japanese men living in Japan,
Hawaii and San Francisco, and how this influenced
their risk of cardiovascular disease and mortality.
five years, the study found that the Japanese
men living in Japan (who generally followed traditional
Japanese dietary and lifestyle practices) had
low blood cholesterol levels and very low rates
of heart disease. However, it was found that the
partly-Westernized Japanese men living in Hawaii
had higher blood cholesterol levels and almost
twice the rate of heart disease, while the fully-Westernized
Japanese men living in San Francisco had the highest
blood cholesterol levels and almost triple the
rate of heart disease compared to the Japanese
men living in Japan.
Because there were no genetic differences between
the study participants, the researchers concluded
that migration and the adoption of Western dietary
and lifestyle practices were the main reasons
behind the differences in blood cholesterol and
heart disease rates.
H, Tillotson J, Nichaman MZ, Rhoads GG, Hamilton
HB. Epidemiologic studies of coronary heart disease
and stroke in Japanese men living in Japan, Hawaii
and California: serum lipids and diet. American
Journal of Epidemiology (1973) 97:372-85.
TL, Kato H, Rhoads GG, et al. Epidemiologic studies
of coronary heart disease and stroke in Japanese
men living in Japan, Hawaii and California. Incidence
of myocardial infarction and death from coronary
heart disease. American Journal of Cardiology
Mediterranean Diet and Survival of the Elderly
six-year study conducted by an international team
of researchers found that people who live in Greece
and consume a traditional Mediterranean-style
diet have much lower mortality rates than Greeks
who have adopted Western dietary practices.
study involved 182 elderly Greek men and women,
who were first surveyed about their eating habits,
using an extensive validated questionnaire, between
1988 and 1990. During the follow-up in 1993-94
it was found that 53 of the people originally
surveyed had died. The researchers then compared
the eating habits of the subjects who had died
to those still living.
aid in their analysis they broke down the traditional
Greek diet into eight separate components including
low consumption of red meat, high consumption
of grains, moderate consumption of wine and high
consumption of vegetables. Each component was
assigned a "diet score."
researchers found that the more closely a person
followed a tradtional Greek diet, the less likely
they were to die. For each traditional dietary
component included in a person's diet, the risk
of death dropped by 17 percent. Most of the people
who died during the 6-year study tended to have
lower diet scoresthey ate more red meat,
less olive oil and fewer vegetables, grains and
fruits than those who lived the study showed.
knew fruits and vegetables helped stave off cancer
and heart disease, and that modest amounts of
wine are cardio-protective," reported study
author Dr. Dimitrios Trichopoulos from Harvard
School of Public Health,"now we know that
the overall dietary patternrather than individual
componentsis important for health and longevity."
He also pointed out that "It's a diet you
can easily introduce or use even in the American
diet because it does not require sacrifice. You
do not have to cut down on fat."
D, et al. Diet and overall survival of the elderly.
British Medical Journal (1995) 311:1457-1460
Mediterranean Diet Advantages in Other Populations
researchers involved in the Greek dietary practices
study (above) conducted
a similar study in Melbourne, Australia. This
time they looked at the dietary practices of two
groups of men and women, 189 Greek-Australians
and 141 Anglo-Celtic Australians.
results mirrored those of their original Greek
study. For each traditional Mediterranean dietary
component included in a person's diet, the risk
of death dropped by 17 percent. This was the case
for both the Greek-Australian group and the Anglo-Celtic
Australian group. The authors of the study concluded
that a diet that adheres to the principles of
the traditional Mediterranean diet is associated
with longer survival among people of either Greek
or Anglo-Celtic origin.
A, Wahlqvist ML, Trichopoulos D, Lukito W, Trichopoulou
A. Are the advantages of the Mediterranean diet
transferable to other populations? A cohort study
in Melbourne, Australia. British Journal of
Nutrition (1999) 82:57-61.
The Okinawa Centenarian Study
who live on the Japanese island of Okinawa enjoy
life-expectancy in the world. Their rates of obesity,
heart disease, osteoporosis, dementia and breast,
colon and prostate cancer are also far lower than
the rates of these illnesses in industrialized
Western countries like the United States, Australia
and Britain. The 25-year Okinawa Centenarian
Study investigated why Okinawans enjoy such
examining over six hundred Okinawan centenarians
(people who live to 100 or more) and numerous
other elderly Okinawans, it became clear to researchers
that their robust good health was mainly due to
their traditional dietary and lifestyle practices.
was found that the traditional Okinawan diet contained
high amounts of rice and other grains, high amounts
of vegetables, fruits and legumes (particularly
soybeans), moderate alcohol intake, very little
red meat but at least 3 servings a week of fish
(particularly salmon, tuna and mackerel which
are all rich in healthy omega-3 fat).
also noted that elderly Okinawans included regular
moderate physical activity in their daily livessuch
as practicing Tai Chi, cycling or walking to see
friends. And interviews revealed that elderly
Okinawans had strong social bonds and an optimistic
and easy-going approach to life.
researchers discovered that many younger Okinawans
had adopted a more Westernized diet and lifestyle,
and not only weighed more but had higher rates
of heart disease and cancer than elderly traditional-living
Okinawans. They noted that this correlated with
a study of Okinawans whose life-expectancy had
dropped by 17 years when they had migrated to
Brazil and abandoned their traditional ways.
researchers concluded that traditional Okinawan
dietary and lifestyle practices have the potential
to make a profound difference to the health and
wellbeing of anyone who decides to adopt them.
BJ. Et al. (2001). Evidence-based Extreme Longevity:
The case of Okinawa, Japan. Presidential Poster
Session of the American Geriatrics Society Annual
S, Moriguchi EH, Nakada Y, Biosca MDG, Nara Y,
Murakami K, Horie R, Moriguchi Y, Mimura G, Yamori
Y. The relationship of dietary factors to cardiovascular
diseases among Japanese in Okinawa and Japanese
immigrants, originally from Okinawa, in Brazil.
Hypertension Res (1992) 15:45-55.
Mediterranean Diet and Arthritis
A study published in Annals of the Rheumatic
Diseases found that a group of arthritis sufferers
from Sweden who followed a Mediterranean-style
diet for three months improved their arthritic
symptoms and lost weight.
study involved 51 rheumatoid arthritis sufferers
who were divided into two groups. One group followed
a Mediterranean-style diet (which included lots
of vegetables, grains, fruits, legumes, regular
servings of fish but little red meat, wine in
moderation and olive oil as the main source of
fat) while the other group, who were used as controls,
did not change their eating habits.
three months, those on the Mediterranean-style
diet had experienced a number of improvements
not seen in the control group, including a decrease
in pain, inflammation, disease activity and the
number of swollen joints. The Mediterranean diet
group had also lost an average of nearly seven
pounds and had lower cholesterol levels.
"The treated group felt significantly improved
compared to the controls after three months with
this diet," reported the lead author of the
study Dr. Lars Skoldstam. He also noted that "the
Mediterranean diet is palatable and should be
easy for most patients to accept, even lifelong."
of the Rheumatic Diseases (2003) 62:208-214.
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