Posted by: Joseph Dixon | June 15, 2014

Science: Unintended Consequences; Ancel Keys, Cholesterol, and the Transition to an Obese Society; Part XXII, Living the Mediterranean Way, The Discovery of the Mediterranean Diet

When Dr. Ancel Keys wrote the “Seven Countries” book (published in in 1980), he seemed to follow the strategy of writing ”Just the facts” from his multi-country study and interpreting the data as best he could without exaggerated speculation. However, the exciting and much more interesting human story of how he came upon his theory that diet and blood cholesterol were responsible for the high rates of CHD in some populations is not in “Seven Countries.”   In fact, the interesting story of how he developed his ideas and how he discovered the “Mediterranean diet” were presented in the first few chapters of the cookbook that he and his wife, Margaret, wrote, “How to Eat Well and Stay Well the Mediterranean Way,” first published in 1969 and then again published in 1975.

This book is rather hard to find now a days. I could not find it in either the Rutgers University or New York Public Library Systems. When I tried to buy it on Amazon and other sites, it was listed at over $300 for a used copy. However, if you find this book in a used book store, buy it, because it is surely a gem of a book. I finally found it in a local library in New Jersey that seems to specialize in cook books!

In the Authors’ Preface, Dr. Keys and Margaret give the background for the book and graciously thank all the scientists, physicians and friends who were involved in the work and who helped them in their travels around the globe in search for the causes of CHD. They write that the book was the result of 25 years of research by them with the help of hundreds of co-workers and friends. No where is it stated that their endeavor was a singular enterprise. They give ample credit to many others who contributed to their story.

In 1962 Dr. Keys and his family moved, part-time, to Pioppi, Italy, south of the city of Naples. The house they finally settled in is on the Cilento coast and overlooks the Mediterranean sea, and Dr. Keys named it “Minnelea”, from the first letters of Minnesota and the ancient Greek Elea.   Quite remarkably, the house he lived in can be rented during the summer months.

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In chapter 1, “Introduction-Why and How,” Dr. Keys and Margaret explain, in a relatively short chapter of 24 pages, how the idea about diet being an important component of the onset of CHD was hatched, how it progressed slowly at first, and then, how the concept was formerly presented and studied under the well planned structure of the “Seven Countries” study. Anyone who has heard the invectives that claim that the diet-cholesterol-CHD theory was a conspiracy put forth by Dr. Ancel Keys can’t possibly believe this claim after reading the story of how the ideas coalesced among Dr. Keys and his colleagues.

“How to Eat Well and Stay well the Mediterranean Way,” which is a combination “Who done it mystery” and health/cookbook, was written before there was any controversy concerning the fat and cholesterol hypothesis, and therefore, the detailed descriptions of how their ideas were made more concrete was written without any sense of defending a core idea. In fact, what comes across in this chapter is a sense of wonder how a meandering course led to one of the most important discoveries in modern medicine. And it is hard for us to realize that at the beginning of their journey, no one had any idea concerning what caused CHD, or that simple changes in life style could protect against CHD, or enhance its ghastly effects.

Although Dr. Keys had been a successful and well known scientist since the 1930s, and he had been involved in a variety of studies, including measuring cholesterol in blood in several smaller studies, the current story really begins in February 1952, when the Keys traveled to Naples, Italy, to study the role of diet in CHD. They had been living in England as part of a Fulbright Fellowship, and they had been invited to the University of Naples by Professor Gino Bergami.

Quite amazingly, they wrote about a singular observation that had stimulated their thinking, “A totally obscure Dutch language publication stated that natives of Java lived on a diet very low in fat, had remarkably low cholesterol levels, and almost never suffered heart attacks.”

Concerning their work in Naples, they were going to follow-up on the dual observations made by local physicians that the local Neapolitan diet was low in fat and that there were few cases of CHD among the common people of the city. They did, in fact, find this to be true, and found that the men they studied in Naples had an average cholesterol of 165 compared to the 230 that was the average Dr. Keys usually observed in Minnesota, USA. Later on that year, they visited Spain for the purpose of observing the eating habits of the people in several villages there. They observed a similar situation concerning the foods eaten and the good health of the people living in these villages. The Keys’ trips to these two Mediterranean countries were fairly casual, but the observations they made had a great impact on them, that the diet consumed in these communities, at the time, appeared to be protective against CHD.

In the spring of 1954, the year I was born, the Keys returned to Naples to continue their studies. They brought with them several other investigators, including the prestigious American cardiologists, Joseph T Doyle of New York and Paul Dudley White, who was President Eisenhower’s cardiologist. They extended their studies to several other sites in Italy, including Cagliari, on the island of Sardinia, and the northern city of Bologna, known for having a richer cuisine than the other locations in Italy. Their findings concerning the fat content of the diet and blood cholesterol concentrations held up in these locations.

The year 1954 also saw the beginning of a collaboration with Dr. Noboru Kimura, a young heart doctor from Japan. By 1956 a fair size study was underway in Fukuoka, Japan, a city with surrounding farming villages and also a nearby US military base.

A month long visit to Japan by Dr. Keys and his team confirmed the widely reported but unsubstantiated claims that Japanese men, who were fairly heavy smokers, had very low rates of CHD.

Studies also commenced in Hawaii, where white men who consumed a fairly American diet could be compared to men of Japanese ancestry, who still followed a basically Japanese diet.

The results were startling, the Japanese in Fukuoka, Japan and in Hawaii, had blood cholesterols of about 160, but the white Americans in Hawaii had cholesterol levels similar to the white men Ancel Keys studied in Minnesota. This led to an interesting yet unique conclusion at the time. This conclusion was that high cholesterol and high rates of CHD were not related to climate! Sounds funny now, but this really was considered a possibility at the time.

In 1956 Dr. Keys was afforded the the opportunity to collaborate with Professor MarttiKarvonen of the Institute of Occupational Health in Helsinki, Finland. The first village they sampled was Karelia and they found very high rates of CHD among the men. The average blood cholesterol concentration was a shocking 260, compared to the 230 Dr. Keys had consistently measured in Minnesota. When he saw what they ate, however, it became apparent what was the cause of the high cholesterols. Dr. Keys states that he, “…watched in disbelief to see some of them take slabs of cheese the size of slices of sandwich bread, smear them a quarter of an inch deep with butter and eat them, with a beer, as an after-sauna snack.”

Earlier I wrote how the CHD rates in Finland were cut in half by a combination of decreasing fat intake, decreasing blood pressure, and lowering smoking.

In 1957 Dr. Keys and a team of scientists next surveyed the village of Nicotera, near the toe of the Italian boot, and several villages on the island of Crete. The blood cholesterol levels were very low (160) in Nicotera because of the extremely low fat intake of its inhabitants. Crete was especially interesting because the fat intake was relatively high there. But because most of the fat consumed was olive oil, the cholesterol concentrations in the blood of the men of Crete were below 200. At this time, in the 1950s, the foods on Crete were served usually drenched in olive oil. Butter and milk were not used. Meat was only consumed once or twice per week. Some farmers had the habit of drinking wine glasses of pure olive oil for breakfast! Although roughly 1/3 of the calories consumed on Crete were from fat, the rates of CHD were extremely low. This was an early sign that it was the type of fat that was important in influencing the cholesterol levels of blood, and not fat per se.

All of what had gone on before was sort of a feasibility study for a much larger study. There were critics who thought the small studies carried out by Dr. Keys and his team were too haphazardly designed and performed.   So the plans went forward to start a well designed study that would measure blood cholesterols and rates of CHD in different populations throughout the world, and to measure in precise ways (using dietitians and analyzing samples of diets) the dietary intakes of subjects in the different regions. This was the start of the “Seven Countries” study. It eventually would study about 13,000 men in seven countries, with some countries providing several distinct geographical locations to be studied.

One must remember that the “Seven Countries” study was started before statins had been discovered. Therefore, there was a great deal of emphasis on stopping the progression of any CHD that was already a scourge of Western populations. As discussed in other chapters, in Finland, dietary recommendations changed the diet of many Finns such that there was a large decrease in CHD. But changes occurred in the other direction, too. As Europe recovered from the drastic effects of World War II, the diet of many began to become richer in terms of meat and dairy products. This had the effect of slowly increasing CHD where before there had been almost none. The Mediterranean diet was becoming less “Mediterranean” in several of the cohorts while the follow-ups to the “Seven Countries” study were underway.

What was the Mediterranean Diet as Dr. Keys Observed it?

Chapter 2   The Mediterranean World.

In Chapter 2 Dr. Keys and Margaret wrote about the foods they found in the Mediterranean diet and the Mediterranean life style they observed in their travels.   They make the comment in the beginning of the Chapter that they are specifically talking about the countries of Greece, Italy, the Mediterranean portion of France, and Spain. Each had their own special dishes and customs. The location they knew best was southern Italy, because they decided to move to a house in southern Italy for at least six months of the year while Dr. Keys was still working, and for the full year after they retired in 1972.

What was the Mediterranean diet they observed and experienced?

Vegetables and fruits.

The availability of vegetables and fruits depended upon the season. Early in the spring there were cauliflower, artichokes, and lettuce available. Later there were fava beans and a dozen different wild greens in the markets. Later still came spinach, green beans, and zucchini. Late spring brought cherries, kumquots and mushrooms.

Summer brought figs, tomatoes, eggplants, peppers and onions. At the end of summer, wine was prepared during the grape harvest.   All sorts of melons were available in the early fall.  From their own property they harvested apples, pears and a whole family of citrus fruits.  Late fall saw the production of persimmons, pomegranates, and finally olives. In the end, one senses that there was a cornucopia of fresh vegetables and fruits that were brought in from the local farms and hillsides the year round.


Olives pressed early in the season were the source of virgin olive oil. A small percentage of olives were prepared for whole storage to be used as table olives during the year. The largest per capita consumption of olive oil occurred on Crete, where it provided 30% of the total caloric intake. In other areas of the Mediterranean, olive oil provided from 15% to 20% of total calories. French cooking used more butter and therefore was not as healthy as the cuisine of Greece and Italy.


Freshly baked bread provided a considerable amount of calories for Mediterranean peoples. In Greece, it could provide up to 38% of the total calories consumed. In other countries it was less, but it still was a significant percent of the total calories consumed. On average, at the time of Dr. Keys’ investigations, three times more bread was eaten in the Mediterranean areas compared to what was eaten in the USA.


Fruit was the main dessert served in Mediterranean households. Sweet desserts were reserved for holidays. Peoples of the Mediterranean region ate, on average, 150% more fruit than Americans.

Garlic and onions

These were used in cooking, stews and salads. Garlic soup is a specialty of the Spanish whereas the French are known for their onion soup. The Italians are known for their bruschetto, which is a slice of hot toast brushed with olive oil and raw garlic.

Tomatoes and garden greens.

The Mediterranean peoples harvested tomatoes and prepared tomato sauce every August. Bottled tomato sauce was used throughout the year in stews and with pastas. Also eaten all year round was a vast array of leafy greens that come from the garden or from the roadside. The Mediterranean people ate a much wider variety of greens than do Americans.

Dr. Keys wrote in a later article, “Near our second home in southern Italy. all kinds of leaves are an important part of the everyday diet. There are many kinds of lettuce, spinach, Swiss chard, purslane. and plants I cannot identify with an English name such as lettuga, barbabietole, scarola, and rape. Some are perennials.  The climate permits replanting annuals several times a year so leaves to eat are always at hand.  No main meal in the Mediterranean countries is replete without lots of dure (greens).  Mangiafoglia is the Italian word for “to eat leaves” and that is a key part of the good Mediterranean diet.”

Seafood and Meat

Mediterranean people were strong consumers of anchovies, octopus, mackerel, dried codfish from northern seas, and a vast array of ocean fish.

Americans were eating four times more meat than what was consumed in Greece and Spain. In Mediterranean countries more veal than beef was consumed, except in France. Only about half the eggs Americans ate were consumed by Mediterraneans. The French ate more butter than Americans, but the other Mediterranean countries consumed only about one third to one half the butter Americans did at the time.


The consumption of wine was much greater in Mediterranean countries, but it was usually consumed with main meals. For men, the amount of wine consumed possibly amounted to about 10% of total caloric intake coming from alcohol. There was very little consumption of hard liquor except on special occasions.

The Mediterranean people are known to drink strong and freshly made coffee, often using an “espresso” machine. In fact, coffee with added hot milk was a common breakfast for Mediterranean people. Spain was the one country where people also drank a considerable amount of hot cocoa. Other drinks that were popular were lemonade, cola drinks, and mineral water. Cola drinks were not consumed at the level observed at the time in the United States

The Intangibles

Mediterranean people were more likely to take an evening stroll than Americans.  They were also likely to eat a wider variety of foods, especially fresh seafood and vegetables.  Because of the southern sun, they received more sunlight on a yearly basis, spread across the year round, than in northern regions where there are periods of little sun followed by intense sun exposure during the summer.

At the time Dr. Ancel Keys and Margaret wrote their Mediterranean cookbook, they commented that although the expenditures of the Mediterranean countries on health care were much less than that expended in the US, the Mediterranean peoples’ “overall health and longevity are impressive, both in the vital statistics and in our own many years of scientific observations.”

The main difference in health was that there was much lower rate of CHD in Mediterranean countries compared to the US. Dr. Keys specifically commented that the difference was not explained by climate, genes, nor the way disease was diagnosed nor how statistics were kept. And another plus was that deaths from all causes were lower in the the Mediterranean countries than in the US.

The remainder of the book, “How to Eat Well and Stay well the Mediterranean Way,” is chock full of recipes of all types, and as stated by the Keys in the Authors’ Preface, all were tested first in their kitchens, sometimes in Pioppi, Italy, sometimes in Minnesota, before they were entered into their cook book.

Their book was the first one to promote the Mediterranean diet.   Combined with the early chapters on diet and health, it represents an additional major triumph in the life of this extraordinary scientist and his companion spouse.

Ancel and Margaret Keys had three children, a boy and two girls. He retired from the University of Minnesota in 1972. Due to many factors (genetics, personal traits, diet) that can’t possibly be known for any particular individual, but one would like to think that the Mediterranean diet played an important role, Ancel Keys lived to be a hundred years old. He died in Minneapolis on November 20, 2004, two months short of his 101st birthday. Margaret died in 2006 at the age of 97. It is safe to say that Ancel and Margaret had a long and productive partnership, and that they were giants in the fields of Nutrition and Medicine.

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