Foreword to the Mediterranean Diabetes Cookbook

Like most of her fans, I relish the opportunity to embrace Chef Amy Riolo’s words of wisdom-be it from her classes, lectures, videos, blogs, culinary tours, TV appearances, or her numerous books. Rare is the cookbook that has valuable lessons about culture, geography, seasons, people, and of course food. Amy’s philosophy is at its root a wholistic and integrated ethos that looks at an ingredient, food, meal, or recipe in the context of its origins and cultural significance in addition to its health value.  I’ve had the good fortune to see Amy’s work up close and personal as we’ve collaborated on her esteemed culinary course, presentations, and small group sessions. I have witnessed firsthand the positive effect her energy and passion have had on her audience regardless of the medium she has used.  In particular, my patients have been able to utilize Amy’s knowledge to springboard into a new and positive health chapter.                                     

The Mediterranean Diet has been gaining recent acclaim for its impressive benefits as demonstrated in many studies which have included the prevention of chronic disease and the association with longevity. For the first time ever, the USNEWS and World Report magazine have ranked it as the Best Diet Overall. However, the term diet is a misnomer as evidenced by the deeper meaning of its origin from the Greek word diata. A more appropriate definition of the original Greek would best describe this as a way of life; encompassing such areas of importance as the quality of food, eating with others, nothing in excess, the rhythm of the day, and important religious and spiritual tenets such as fasting.

Technically the Mediterranean Diet is the diet of the olive-growing regions of the Mediterranean Sea which was first described in the late 1950s/early 1960s by American scientists to explain the diet of post-World War II Greece, specifically the island of Crete, and Southern Italy, with extension to other countries in the region. The traditional Mediterranean Diet is the heritage resulting from millennia of exchanges within the Mediterranean basin region that has defined and characterized the eating habits of the countries in those regions until the mid-twentieth century. It is thus not surprising that we have come to find research that such a dietary approach is able to assist those with impaired metabolism and diabetes.

But first, some background on how to think about diabetes and its precursor and close relative metabolic syndrome.  Diabetes is not technically a sugar problem but a metabolic dysfunction that is characterized at its root by insulin resistance,  an impaired ability of the body to properly handle the important anabolic and energy storage hormone insulin. Insulin resistance results in an impaired responsiveness of muscle, liver, and fat tissue to the effects of insulin; in particular liver and fat cells keep taking in insulin which leads to a fatty and dysfunctional liver and persistence of weight gain. When you are insulin resistant, your body is flooded with an abundance of glucose or sugar and insulin and ceases in its ability to import glucose and fat into the cells. How do you know if you have this phenomenon also known as metabolic syndrome? In addition to belly fat, other key findings include increased blood pressure, and an increase in the critical cholesterol profile triglyceride often coupled with a lower HDL. This can all occur with normal blood glucose on your lab report; however metabolic chaos is lurking under the surface and attention is needed. 

For a while, your pancreas, the organ that makes insulin, can compensate by making more of the insulin hormone to remove the excess glucose but it eventually begins to strain and the key beta cells (which make insulin) become weakened and dysfunctional. It is at this point that diabetes becomes prevalent.  Thus, it is critical to understand that diabetes is the final stage of a long pathogenic process that begins with insulin resistance and increased strain on the pancreas, progresses to an impaired ability to control blood sugar known as prediabetes, and only then develops into full-blown diabetes. Insulin resistance alone, aside from predisposing to diabetes and obesity, is associated with (like diabetes) increased risk of heart disease, memory loss, certain cancers, kidney dysfunction, nerve problems, and all cause mortality. 

Diabetes has reached epidemic proportions, affecting over 25 million people in the United States alone and approximately  8% of adult Americans have the diagnosis, with another 3.5% who are undiagnosed, and close to 40% who have prediabetes. Furthermore, this grim situation appears to be getting worse with annual rates of new cases tripling over the prior 20 years and the estimation that as many as 1 in 3 individuals will develop diabetes by 2050. Fortunately for us, the tenets in this book provide a powerful tool to help to shift the curve.

There has been compelling evidence that the Mediterranean Diet and its components are associated with reductions in metabolic syndrome features and that such a diet prevents both the occurrence of diabetes and its complications. Perhaps even more importantly there has been no negative study reported thus far. Although there is research supporting other dietary approaches to help with diabetes such as a low carbohydrate or vegetarian-based diet, it is my opinion that a Mediterranean type diet is an ideal place to begin.  It shares with all successful nutritional plans the absence of processed and artificial ingredients;  is easily reproducible as it is associated with benefits to populations throughout a vast geographic and cultural landscape including not only the Mediterranean basin and the Middle East but encompassing Northern Europe, the United States, and parts of Asia; has a very high compliance rate because it is enjoyable, an area deemphasized in most diets; encompasses a balance of the whole spectrum of macronutrients and includes at its core healthy fats, which have been unnecessarily minimized and vilified for far too long; is abundant in bioprotective micronutrients such as vitamins, minerals, and antioxidants which are critical to optimal health; is easily customizable so that macronutrients such as carbohydrates, proteins, and fats can be altered based on personal needs and goals ( for example there is exciting research that a lower carbohydrate Mediterranean Diet is effective for weight loss and improving markers of dysfunctional metabolism); and when expressed in its most traditional origins is enjoyed with others in a relaxing setting.

Here is what I recommend to those patients with dysfunctional metabolism, insulin resistance, diabetes or just trying to lose weight.

Take measure of your mental and physical state of the union. Reflect and organize your thoughts. What has led you to a place of metabolic dysfunction? What choices are you making that contribute to your current state of affairs? What actions can you make to reclaim your health inheritance and how will you feel when you achieve them? What is your weight, waist size, and percent body fat? What is your blood pressure and pulse rate; the latter is an underappreciated marker for health and longevity (aim for less than 70 beats per minute).

Initially begin with a controlled carbohydrate diet and lower your overall caloric intake, since most people will lose weight and lower their blood glucose with such an approach. Seek out to measure your current carbohydrate intake and look to decrease it along with your calories; many people find success with an initial daily carbohydrate intake of 50-100 grams. Increasing your protein intake in the short term may also be of help with the reduction of weight and belly fat. Amy’s book makes measuring and tweaking these macronutrients very easy as she lays out detailed nutritional information for each recipe.

Aim to eat less often. Most of the inhabitants of the Mediterranean basin would eat 2 larger meals and 1 smaller meal. They would also not routinely snack, so you shouldn’t either. Exceptions exist, for example, if you have been very active and engaged in strenuous exercise.

Engage in regular and sustained activity and partake in a dedicated exercise program when possible. Since movement is medicine, walking is a great place to start and is excellent for stress reduction. Couple this with regular resistance exercises that safely stresses one’s muscles (a great way to improve insulin resistance) and layer in safe cardio that should include periods of intervals and bursts. Exercise does not move the needle on weight loss as much as an effective diet but is critical to helping repair a dysfunctional metabolism and getting your brain and thoughts in order.

Get outdoors as often as possible and partake in the bountifulness of nature.

Push the pause button routinely and engage in a contemplative state away from the noise and complexity of modernity. I highly recommend intermittent periods of silence, simplicity, and solitude. 

Engage and connect with others, it’s good for lowering your stress hormones and for improving one’s outlook. Also, assess how your social surroundings are affecting your health philosophy. Recent studies point to the fact that you are more apt to gain weight if your friend or colleague is overweight than if your parents had a weight problem.

Utilize targeted supplements and nutraceuticals. There is significant data demonstrating how using safe and selective natural agents can augment and attenuate the success of an improved diet and lifestyle on the markers of diabetes and insulin resistance. Minerals such as chromium and magnesium, antioxidants such as alpha-lipoic acid, and plant extracts such as cinnamon, berberine, and bergamot are all safe and effective.

Check your labs regularly. Your blood is the river of life and you should routinely know your levels of not only glucose but also of such critical factors as inflammation, minerals and vitamins, hormones, and advanced lipid profiles. Don’t depend on depersonalized guidelines but look to regularly assess your individual situation so that you may utilize the data to make informed decisions. 

I enthusiastically encourage you to take part in the journey of Chef Amy’s wonderful book. Amy’s nutritional knowledge and culinary skills are matched only by her zeal and infectious spirit to engage in first principles of health, food, and culture. I can personally assure you of the quality and fantastic taste of the recipes. Moreover, you will come away enriched and enlivened with knowledge and guideposts that are not to be found anywhere else. Amy’s explanations of the characteristics of the Mediterranean cuisine are the best I have seen in any such cookbook with her emphasis on not only the mighty olive oil but also of fresh, seasonal, and local produce; the importance of seafood which is often deemphasized in other similar books; the sacredness of the mealtime ritual;  and the emphasis of homemade food and the limits of dessert for special occasions just to name a few. The seasonal menu categories are also rightly emphasized and highly important and an area not given enough attention in other publications. Traditional cultures such as those of the Mediterranean basin intuitively emphasized seasonal and local and we would do well as a society to return to such wisdom. I especially enjoyed the small plates and sides section and believe it’s a great place to start as many must learn to optimize foods with high nutritional density while simultaneously minimizing caloric density. Lastly, taking a dive into Chef Amy’s award-winning book will expand joy in your life which is a powerful tonic in and of itself. As the renowned nutritionist Robert Crayhon once said, “Pleasure is a nutrient.”

Yours in health-
Sam Pappas, M.D.