April 4, 2018

Mediterranean Diet: Efficacy, Compliance, and More: An Interview with Nutritionist Jolie Root

Sponsored by Carlson Laboratories
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In this interview, nutrition expert Jolie Root explores the key components of the Mediterranean Diet, and discusses its health-promoting benefits. Listeners will learn which conditions this diet may help prevent, and how to effectively utilize the diet in their clinical practice and enhance compliance with their patients.

Approximate listening time: 32 minutes

Continuing Education Credits Available

This podcast interview qualifies for 0.5 general continuing education (CE) units. The Oregon Board of Naturopathic Medicine has approved this educational content for 0.5 “general” CE units for naturopathic physicians. Naturopathic physicians licensed in any U.S. state except California may obtain general CE by listening to this podcast and completing a 10-question test on the material contained within the clinical topic. Click the button below to take the test for FREE, thanks to an educational grant from Carlson Laboratories. Upon successful completion, you will receive an email confirming you passed. This CE approval may also qualify for the CE requirements of other practitioner types.

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About the Expert

Jolie Root, LPN, LNC, is a nutritionist, health educator, nurse, medical journalist and well-known radio personality. She travels North America attending medical conferences and educating the public about the roles of nutrition in integrative medicine. She also spreads the word through informational articles published in magazines and newsletters across the country, including Alternative Medicine, Whole Foods, Taste for Life, and Senior Living. In addition, she hosts a weekly talk show called “Food for Thought,” which can be heard Fridays at 10:00 a.m. Eastern Time on AM 1160 WVNJ.

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Since 1965, Carlson has produced pure, quality, award-winning vitamins, minerals, omega-3s, and other nutritional supplements. Carlson began with a single vitamin E product, helped launch the omega-3 market in North America in the early 1980s, and now offers a product line with more than 200 nutritional supplements. Carlson is most renowned for the high quality of their award-winning omega-3s, and now they’re available in a premium olive oil. Olive Your Heart® blends cold-pressed Greek Terra Creta extra virgin olive oil with premium Norwegian marine oil sourced from deep, cold-water fish and is available in basil, lemon, garlic, and natural flavor. Each serving provides 1,480 mg of omega-3s, including EPA and DHA. Olive Your Heart® is mild and smooth, and makes it easy and delicious to add heart healthy nutrients into your diet.


Karolyn Gazella: Hello. I'm Karolyn Gazella, the publisher of the Natural Medicine Journal. Today, we are going to explore the efficacy of key components of the Mediterranean Diet. We'll also be talking about enhancing patient compliance to this diet. Before we begin, I'd like to thank the sponsor of this topic, who is Carlson Laboratories. My guest is nutritionist Jolie Root. Jolie, thank you for joining me.

Jolie Root, LPN, LNC: Oh. It's a pleasure to be with you, Karolyn. Thanks for the opportunity.

Gazella: Well, this is a great topic. We've actually written about this topic a lot in our journal, and I am a big fan of the Mediterranean Diet. I think most practitioners know what makes up the Mediterranean Diet, but can you remind us what the key components of the diet are that contribute most to its health promoting aspects?

Root: Yes. It is a diet that is high in plant foods, so that means fruits, and vegetables, and whole grains, and whole grain breads, legumes, and nuts, and seeds. They also use hefty amounts of extra virgin olive oil, and it may or may not include moderate amounts of red wine, and also fish, and poultry, dairy, and eggs are featured, and red meat is minimized. It's only very occasionally that there will be red meat in this diet. It's a plant-based diet with a variety of fruits and vegetables, fresh foods, and whole grains, legumes, nuts, and seeds, and olive oil.

Gazella: Now, let's talk about the olive oil, because it seems like the healthy fats are a big component of this diet. What are some examples of the healthy fats in the diet, and why are these fats better for patients?

Root: Well, I think that you could say that part of the overarching benefit of walking away from unhealthier fats and towards healthy fats in the diet has to do with inflammation. We know in Western culture that we have an imbalance of fats that promote inflammation relative to an inadequate intake of fats that help to balance inflammation, so specifically I'm saying that one of the really I think imminent qualities of the Mediterranean Diet is that it relies on olive oil and then omega-3s from nuts and from fish, and it's low in omega-6s. That's the problem when you contrast that to the Western pattern diet, which is much higher than it should be in omega-6 relative to omega-3, and in the US, in North America, people rarely use olive oil as their main cooking oil.

Here in the West we eat a diet that promotes inflammation, and it's not just inflammation. It also promotes an unhealthy level of clotting in the blood and constricted blood vessels, so the result of that is high blood pressure and arterial stiffness. The Mediterranean approach, using olive oil and omega-3s from nuts and from fish oil, relaxes the blood vessels, helps to govern excess inflammation, and promotes health in areas from heart disease all the way to cognitive function.

Gazella: Now, I'd like to continue to deconstruct the diet a bit more, but let's stick with the conditions that you just mentioned, and I'd like to talk about first prevention and then treatment. Let's talk first about prevention. Purely from a preventative standpoint, which conditions benefit most from the Mediterranean Diet? You mentioned heart conditions, but can you expand on that a little bit more?

Root: Well, cardiovascular disease, so disease of the heart and the blood vessels, so that would mean not just heart disease with its inherent health risks, but cardiovascular death as an endpoint is something that has seen reduction in the double-blind, randomized, controlled studies and even in single-blind, controlled studies with the Mediterranean Diet, so the Lyon Heart Diet Study and the PREDIMED Study are studies that practitioners can look up and read. They saw a reduction in heart disease and a reduction in heart disease deaths as an endpoint, but along with that we also see blood vessel issues, so hypertension and endothelial function as components of heart disease, are improved on the Mediterranean Diet, because some of the elements in the Mediterranean Diet relax the blood vessels, and that allows for supporting blood pressure in a normal range.

The other thing is when you look at the heart, before we have heart disease, we may have diabetes or metabolic syndrome, conditions leading up to sometimes an increased likelihood of an endpoint of heart disease. The Mediterranean Diet helps with blood sugar stability and some of the issues that contribute to the metabolic syndrome, such as derangement of lipids, so cholesterol numbers that are not where we want them, triglycerides that are elevated, and that blood sugar control, and higher than what would be optimal inflammatory markers, and then that's metabolic syndrome, which also sometimes we might call pre-diabetes, but also diabetes itself is something that we have seen benefit in reducing risk of with Mediterranean Diets.

That's kind of in the cardiovascular realm, but if you want to go to the cognitive realm, we have seen improvement in cognition in elderly people who followed a Mediterranean Diet with either additional nuts or additional olive oil, and we have even seen some changes in some of the suspected markers of Alzheimer's risk, things like amyloid deposits and amyloid protein. So, earlier in life we're concerned about heart disease. We're concerned about metabolic syndrome, diabetes. Later in life we start thinking about dementia and ultimately with the worst endpoint there, which would be Alzheimer's.

Gazella: Yeah. I mean, that's a pretty broad range of conditions. I'm curious. When we switch over to treatment intervention, can the diet be used as a treatment intervention for many of these same conditions?

Root: Well, I wouldn't go so far as to say that it would be a treatment for Alzheimer's. We don't generally find that treating Alzheimer's works particularly well once that disease itself has set in, although I would urge practitioners to look up Dale Bredesen and the work that he's doing. However, the cardiovascular disease? Yes. I would recommend the Mediterranean Diet as a treatment if someone were to come to me and ask for a recommendation, because of the ability to change the inflammatory markers, the lipid balances back to a more favorable profile.

There is, for example, one of the elements ... I know we're going to talk about this in more depth as we go forward, but think about resveratrol, which is known to enhance nitric oxide production, and that means relaxing blood vessels and promoting endothelial health. In those cases, people that are in pre-diabetes, metabolic syndrome, or actually know that they have cardiovascular disease are looking to improve these factors, and Mediterranean Diet has shown to do exactly that.

Gazella: Before I leave this subject, are there any studies on obesity? It seems like obesity can increase the risk of so many things, not only heart disease, but also some cancers, and of course diabetes, and metabolic syndrome, and some of the other things that you've mentioned. Are there any studies showing that the Mediterranean Diet will help people lose weight?

Root: Yes. They weren't looking at that as an endpoint, so I'm not aware of studies, Karolyn, where they were specifically looking for weight loss as an endpoint in the study, but they have seen, as an aside, the additional benefit in some of the big studies of Mediterranean Diet of weight loss, although that wasn't really what they were after or what their intent was. People do seem to lose weight when they follow, when they adhere to a Mediterranean Diet. There's the key.

Gazella: Right.

Root: You know, that's the key in everything that we do, either successfully or not, when we talk about integrative health. But the weight loss factor seems to be more pronounced than in people who follow something like a low fat diet. I think that it's a happy additional benefit of following a Mediterranean Diet.

Gazella: Well, that's good. Now, is there anybody who should not be on the Mediterranean Diet? Are there any contraindications or safety issues?

Root: I can't think of any. I thought about that. I expected you to ask me that question, and I thought about that. I can't think of any, because the factors in Mediterranean cooking and following that approach are varied enough that if you had ... Let's say, okay, one caution is always what if you have a really strong food sensitivity or food intolerance, so a gluten issue, or what if you have a real sensitivity to nightshades? You could avoid those foods and still follow a Mediterranean approach, so there's enough variety I think in the foods in a Mediterranean lifestyle, a Mediterranean Diet, that I can't think of anyone that really would be a problem.

If you choose to be a vegetarian, omit the fish and include more olive oil and nuts for healthy fats. If you are avoiding gluten, then don't eat the gluten containing foods that are part of the diet. There's no hard and fast rule that says that you absolutely must include every element of the diet. If you have an issue with alcohol, you do not have to have the red wine. But as far as just a strict avoidance, I can't think of anyone.

Gazella: You know, I would agree. I have not seen anything ... I mean the diet is so fluid and so varied, so I think that that's definitely one of the benefits. I'd like to continue to kind of deconstruct this diet a bit more. You know, you mentioned healthy fats. You mentioned resveratrol. This diet includes a lot of key nutrients. It comes from the spices and the other foods that are featured in the diet. Can you give us some more examples of the specific polyphenols and other compounds that we can find when we break down this diet?

Root: Definitely. Let's say tomatoes, which are certainly something that people in Italy, and people in Spain, and France, and most of the Mediterranean countries enjoy, so with tomatoes we have lycopene, and lycopene is one of the dominant antioxidants in the bloodstream when people do eat a Mediterranean Diet. Lycopene itself has been associated with protecting the prostate health in men, reducing certain aspects of risk factors for health disease. So, lycopene from tomatoes is an example.

If you look at the leafy greens that are in the diet, then we can talk about lutein and zeaxanthin, and we'd also have to talk about the magnesium that is a very strong element benefit of leafy greens, and the carotenoids, the betacarotene, but lutein has been shown to be very beneficial for the retina. You know, dating back to the 90s, more lutein, even a single serving of spinach a day, reduced macular degeneration by more than 40% in men who were eating a healthy diet including spinach on a daily basis. Lutein is there in the leafy greens.

Think about garlic. You've got allicin, and you've got a lot of phenolic compounds in the garlic. Garlic is a benefit for being, first of all, an antioxidant, but also an antifungal. It's just a very healthy food. It also helps to normalize lipids. It helps with blood vessel expansion, so garlic is another element. I mentioned the resveratrol in the red wine. You wouldn't need to do red wine. You could get resveratrol from the purple grapes and from other red foods that are in the diet. If you eat blueberries, you could get pterostilbene, which is another very potent blood vessel health supporting antioxidant.

Let's not even get started on the dark chocolate, which is one of the elements, and we love that part, in moderation, meaning about an ounce a day of a good dark chocolate, full of flavonoids, beneficial for the blood vessels. Turmeric, so in the spice cabinet we have the turmeric, which provides us with the curcumin, which is an antioxidant, protects the lining of the blood vessels, associated with benefits in the brain, associated with a reduction in the amyloid deposits. You know, those are just some that come to mind.

Then the olive oil, which is certainly a big part of this. There's the oleuropein. There's the oleocanthal. These are antiinflammatory. When you get a good olive oil, you get a little sting in your throat if it's a really good one. Antioxidant, antiinflammatory. We're always a little reluctant to talk about cancer, but anti-proliferation. There are some studies that have shown the biological activity of oleuropein too, and that's an olive oil compound, antimicrobial, antiviral. So, you could apply that to heart disease, absolutely, diabetes, but also neurological diseases. There are just so many mechanisms from the specific compounds that would benefit almost the entire lifespan. I can't think of ... Even children would benefit from having these very nutritionally potent foods as the centerpiece of their diet, rather than pop tarts.

Gazella: Yeah. Exactly. It is a long list. I have to say that I've only heard one complaint about the Mediterranean Diet from a clinical perspective, and that is that sometimes practitioners feel like it's not specific enough. You know, the DASH Diet and some of the other diets, they have very specific directions on how to follow the diet, X number of this and X number of this. Now, how do you describe the Mediterranean Diet in very specific terms to ensure proper adherence to the diet?

Root: Well, I try to describe the things to include and the things to avoid in order to hopefully be following it quite well. So, we don't include added sugar, for example. I say get rid of that. I talk about limiting and hearty limits on red meats, and instead fish, and also feel free to have days where you don't have an animal protein or the animal protein might be cheese or eggs, but that we keep eggs even limited somewhat. What we're doing is changing out saturated fats for unsaturated fat. I'm not one of these that thinks that saturated fats are all bad, but this is a diet that emphasizes olive oil, rather than butter.

When we start to make these changes and we begin to develop a taste for these more natural and less processed foods, your taste buds change, and you begin to find it easier to embrace this more ... It's a simpler approach to cooking, so very few things from boxes, for example, in the Mediterranean Diet. People always say, "But what about pasta?" I say, "Well, what about whole grains? What about exploring using bulgur wheat? If you're going to do a pasta, do something like a couscous. You know?" Fewer things from boxes, fewer things from cans, although tomatoes from cans I think are okay. More fresh herbs, less salt, and more fresh herbs and seasoning as spices.

As far as adherence goes, I recommend cookbooks, Karolyn. I think that it's easier to take a kitchen table approach to this. I find a lot of times when diets are specified very strictly, people get very frustrated and overwhelmed with the weights and measures of it all. How do we actually keep ourselves to 200 milligrams of cholesterol in a day, for example? How many milligrams of cholesterol are in an egg? I take a different approach as far as specificity and try to encourage a variety of colors of fruits and vegetables, less canned and boxed and more fresh.

Shop more often, not less often, so that you're going and you're getting some fresh produce, and you're going home and having it in the next couple of days. Several meals a week that don't feature meat. At least two or three meals a week that do feature fish, so that you're getting those omega-3s. If you're going to do the eggs, get the omega-3 eggs, because those are full of a very absorbable form of DHA, and also lutein, and other nutrients, the choline that your brain needs.

I take more of a Food Network approach to it than I do an American Medical Association approach to it, and I recommend cookbooks. I have a favorite cookbook. It's the Complete Mediterranean Cookbook, and it's done by the people that do Cooks Illustrated Magazine, so it's America's Test Kitchen. I got it from Amazon. It's got 500 recipes in it. I haven't found one that I haven't liked.

Gazella: I love that kitchen table approach. You bring up so many good things. When you're describing it to patients, you're talking about ... Just by telling them what to avoid, it's going to automatically be including healthier options in their diets, you know, like swapping out butter for olive oil and shopping more often. That's a great piece of advice as it relates to a Mediterranean Diet. I think those are some great tips. Now, in addition to describing the diet in those specific terms, is there anything else that healthcare professionals can do to improve compliance?

Root: I think there is. I think it brings up a piece of the Mediterranean Diet that we don't talk about enough, and that is imagine yourself in the South of France. Imagine yourself on the Island of Crete. Think about the way that they approach their day, their meals, their habits. These are people that are moving at a slower pace than we do here, so it's not as much about convenience as it is about community. The meals are a point of shared experience for the family, the extended family, your neighbors, people that you ... Even when you're doing business with people, you bring them to your table, and you break bread, and you have a glass of wine. It's a much more relaxed, chill approach to things than in our zooming from point A to point B, and running into the deli, and grabbing something, and running back out kind of approach to life.

You saunter through the market with a basket over your arm and pick up some fresh veggies, and some fresh fruit, and maybe a nice piece of fish, and maybe they've just baked some crusty bread, and you're going to take that home and break the bread, and dip it in some of that olive oil, which you've ground some seasoning and some spices in, maybe a little balsamic vinegar. You take a very slow approach to that meal. Maybe you're all cooking it together and having it a little bit at a time, but there's this sort of attitude, and this piece of mind, and this slow approach that they take. I think that that is as important to adopt that mindset as it is to be aware of the nuts, and the bolts, and the mechanics, and the ingredients of the diet.

Gazella: I am so glad that you brought that up, because you're right. A big part of the Mediterranean eating is social and communal. Honestly, I don't hear a lot of doctors talking about that benefit. I would agree with you. I think that does add to the health promoting aspects of the diet. Yeah. I think that's a great thing to emphasize to patients. Now, for those people who are having difficulty consistently following the Mediterranean Diet, do you recommend dietary supplements. If you do, take us through some of ... I know this might be kind of an unfair question, because it's not a one size fits all, but are there maybe your top three recommendations that would probably be good for 90% of the people?

Root: Well, of course, you know, I have my favorites, but fish oils, so a good, high quality omega-3 supplement. Obviously you want a trusted company, because you want it purified. These days, with the omega-3s we are taking the approach of reaching an optimal intake, and that's measurable now. There's actually a little finger stick blood test that we can do now to see where you stand as your omega-3 score is concerned. For most adults we actually need a little more than what had been the recommendation. High quality fish oil that provides somewhere around 1,500 milligrams of the active components, the EPA and the DHA, is one thing, fish oil and with olive oil as your main cooking oil.

There's even a functional food supplement now that is even a combination of the two that you don't actually heat up to cook with, but you could use it for salad dressing, or you could use it to do that dip the bread in thing that I described, which is the first course of so many Mediterranean meals. So, that's a place to start is a good, high quality omega-3 or a combination omega-3/olive oil supplement.

Then I think something that not enough people are taking that more people probably would benefit from is a good curcumin supplement. It's made from turmeric. The curcumin itself is not really well absorbed, so you want to take it at mealtime. Get one that is CurcuWIN or one of the trademarked turmeric supplements, because the manufacturers have helped with the absorption. Always in a meal with fat is the best way to take either a fish oil supplement or the curcumin supplement. Those are the first two things that come to mind.

Then if I were going to pick a third thing for Mediterranean Diet, it would probably be a resveratrol or a pterostilbene. Those are things that maybe people aren't getting enough of in their diet, and especially teetotalers. If you're not drinking red wine, then you may not be getting much resveratrol, and there really does seem to be some longevity associated with that.

Gazella: Yeah. I was going to ask you about resveratrol, because even if you are drinking maybe a glass or two, I think that enhancing the resveratrol amount in the diet is probably a good idea. It's such a powerful nutrient.

Root: Me too. There are a lot of people that a glass or two is absolutely as much as they ought to do, women. Really you've got to keep alcohol at a small to moderate level, because extra is so bad. So, we've just seen a look at early onset dementia with chronic, heavy drinking, and it was much worse in men, but that's because men are more likely to be the chronic, heavy drinker, but it was scary when I was reading about it, because these men that it's four to five drinks a day ... So, this is a see something, say something for family members. If you know somebody that's drinking that much, it's intervention time. It takes 20 years off of their life. With the resveratrol a little bit of red wine, great, but I wouldn't do more red wine in order to meet my resveratrol goal. I would take a resveratrol supplement.

Gazella: Yeah. That's such a great point. Well, before we wrap up, Jolie, I'm wondering if there's anything else that you'd like to share to our listeners about the Mediterranean Diet and how they could or should be using it in their clinical practice.

Root: I would encourage physicians to use any kind of teaching tool that they can. There is now the ... I'm drawing a blank on this. The Department of Agriculture makes dietary recommendations, and they actually have one now that talks about Mediterranean Diet, and they help people follow it, a Mediterranean style diet, but there is a wealth of information on the internet from trusted sources that can help with sort of the guidelines for the Mediterranean Diet.

I think Oldways has a Mediterranean Diet pyramid. Maybe even keep some good cookbooks in the office, and hold them up, and say, "Here is a great way to get started," and they can order them, or you can give them a gift or something. People need practical advice, and remind them of the community benefit, the gathering the family around the table, because that's not just about the Mediterranean Diet. That's something that really is missing in our busy culture, and everyone I think would be healthier if they were able to do more sharing over meals.

Gazella: Yeah. I would agree. I think the Mediterranean Diet is such a powerful clinical tool that practitioners can use. Well, once again, I'd like to thank today's sponsor of this topic, Carlson Laboratories, and I'd like to thank you, Jolie, for joining me today and sharing this information with us.

Root: It was a treat, Karolyn. It was so nice to talk to you.

Gazella: Yeah. Well, great. You have a great day.

Root: You too.

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