What is the Mediterranean Diet? - with Dr. Steven Masley | The Empowering Neurologist EP. 87

Well, hi everyone, Dr. Perlmutter here, and welcome to The Empowering Neurologist. Today we're going to talk to my friend, Dr. Steven Masley, who's written this new book called The Mediterranean Method. Dr. Masley has written quite a bit about nutrition. And does a lot of work in that area, a lot of research. And this time around, to learn more about the Mediterranean diet, what did he do? He spent seven months on a boat with his wife in the Mediterranean, going from village to village, learning about the local cuisine, and then reviewed several thousand peer-reviewed references to construct this book, The Mediterranean Method. Again, here's the COVID and what he does basically. does his very best to tell us why the Mediterranean diet is so good, and then how to actually make it better. He says it's the Mediterranean diet 2.0, and it really is. So lots of great information about a diet that has really proven itself through many years of research. So we're going to jump right on the boat and talk to Dr. Masley. How are you doing today?

I'm doing great. Really a pleasure to get to speak with you.

Sure. And, you know, as I said in the introduction, I mean, it wasn't just you decided to write a book that's talking about how wonderful the Mediterranean diet is and how to make it better. But you actually spent 7 months in the Mediterranean, going from port to port, exploring native cuisine, and in a sailboat. Tell us about that.

It was amazing. So we sailed from Spain to Turkey, Along the coastline, small ports, intentionally going to markets, local family-run restaurants, looking for regional dishes, how did they make them, and then tried to look at the health issues that you could see along the way, addressing things like, why are people in Spain now the longest living population on the planet? Why are the French so slim? How can the Italians eat pasta and not gain weight? Darn. It was— and why are Greek children now having really high rates of obesity? I mean, trick answer is that they're not following the— the children in Greece are not following the Mediterranean diet anymore.

Yeah, we've heard that to be the case, that really, even though it's called the Mediterranean diet, the diet that's, uh, is pretty much Americanized, or at least westernized, all around the Mediterranean basin. So there's so much research that we've looked at over the years that really praises the Mediterranean diet in terms of the associations with decreased risk for various chronic degenerative conditions like Alzheimer's, coronary heart disease, breast cancer, and you have taken it upon yourself to create the Mediterranean diet 2.0, if you will. What parts of this diet did you amplify, and what parts of the diet did you tamp down?

Well, I think one of the key messages I got from the research, you know, reading over 2,000 published articles on the Mediterranean diet. Maybe the EPIC study out of Greece was one of the most important, where they looked at the components, and which components translated to the greatest benefit. The least benefit really came from grains. You know, they talk about grains in the Mediterranean diet. Well, that had the least benefit, and as you know, eating more grain has the risk for higher glycemic load and blood sugar issues. So, and if they didn't show benefit, Why include them? So, the big benefits were produce, especially colorful vegetables, colorful fruit like berries, nuts, seeds, healthy fat, fiber sources, seafood, some poultry, some dairy, but in smaller portions than maybe we would eat here, a little bit of red wine, and lots of spices and herbs. Those were the ingredients that really were shown to have the greatest benefit in the Mediterranean diet.

So, it sounds like it's a higher fiber diet overall.

Yes, it is, but the fiber— but I would encourage the fiber is not going to be coming from grains, especially flour, because any source of flour has as much glycemic load as just eating table sugar. So, whether it's white flour or whole grain flour, once you grind a grain into flour source, you've really raised the glycemic load significantly. And grains are already high. So, yes, very high fiber source without the grain, without the flour.

The PREDIMED study looked at the Mediterranean diet with added fat, added olive oil, or added nuts, and showed even enhanced benefit. How did that influence what you ended up putting in your book?

Well, just to expand upon that, they showed lower rates of heart attack and stroke better blood sugar, cholesterol control, blood pressure control in those cohorts. But for the brain, they also showed that when people followed that, that they had improved cognitive function and less progression to dementia in a randomized clinical trial. So, for me, it's really powerful that adding more fat, especially a healthy source of fat like nuts and olive oil, was clearly able to improve clinical outcomes, not just in association, but a randomized clinical diet with firm outcome measures. To me, that was so powerful that I felt I had to get the word out.

Who knew that lifestyle choices could influence the brain's destiny? I mean, who would ever think of such a thing? That said, let's talk for a minute about the role of the Mediterranean diet, and now the improvements in the Mediterranean diet that you are offering up, with respect to the gut bacteria, and why that really matters.

Well, your gut bacteria, I mean, you've written about this extensively, but from my perspective, we've had this symbiotic relationship with our gut bacteria for millennia, hundreds of thousands of years. It's been an essential part. They transport, they help with hormone metabolism, they improve our blood sugar control, they give us a better cholesterol profile. And they lower— especially the right microbiome lowers inflammation. The number one source for inflammation in the body is the gut, and the big thing that regulates that is the type of gut bacteria we have. So, from blood sugar, weight control, blood pressure, all those things are microbiome-related, but I think the biggest aging issue, and maybe brain issue, is inflammation, and by far the biggest component there is gut microbiome. Yeah. So, the Mediterranean diet, fortunately, is very gut-friendly, if followed properly, and it really does help support the microbiome and lower inflammation levels.

So then, what are some of the biggest threats that not being on a Mediterranean diet, that you would find in a non-Mediterranean approach to eating that would be so pro-inflammatory?

Well, sugar and flour, you know, eating more sugar and flour really increases inflammation levels. Causes your gut to leak, an assault from chemicals, pesticides, additives, sweeteners, artificial sweeteners, all those things impact our gut lining, our gut permeability, and when our gut starts leaking, that creates an incredible inflammatory cascade that just perpetuates itself in a vicious cycle. The nutrients that are in it help heal the gut. So there's many aspects of things that they avoid and things that they add that nourish the gut, help heal gut leaky— leaky gut and increased permeability, and nourish the bacteria that we have there.

And, you know, as it relates then to controlling blood sugar that you talk quite a bit about in not just the context of diabetes, but how that relates to risk for other things like heart disease, cancer, and Alzheimer's. What do you like to look at with respect to clinically that gives you a sense as to an individual's— where they fall on the scale of blood sugar control?

If I had to pick my favorite top 3 labs, they'd probably be fasting blood sugar, fasting insulin, and high-sensitivity CRP, C-reactive protein. Those give you a marker of blood sugar control, insulin sensitivity, and inflammation. All 3 of those tests combined are less than $50 in a lab like I would have been at my clinic. I mean, inexpensive ways of monitoring how we control our blood sugar, our inflammatory levels in a way that have tremendous benefit for our

health. Well, yeah, I've been sort of, over the years, really— I hate to say fixated, but really emphasized the importance of A1c as an average as a marker of average blood sugar. And I think there's plenty of good reason these days to call that ideology into question, because we know that people glycate differently, and that certain nutrients and foods affect the rate of glycation that, to some degree, is independent of the blood sugar over time. And I think now that continuous glucose monitoring is so widely available, it gives a much better picture in terms of What are the dynamics of an individual's blood sugar based on his or her food choices and beyond? Yes. How might your lack of sleep one night, your lack of exercise, etc., contribute to some pretty good or bad glucose dynamics that in the long run, you know, that then has some play in terms of how you modify those lifestyle issues? And, you know, having broached this topic of lifestyle, There's a lot more to the Mediterranean diet that goes on, at least as you must have experienced in the Mediterranean, than simply the food that's on the table. What are those other factors that really matter in terms of making this a very healthy lifestyle?

So, a Mediterranean lifestyle is more than just the ingredients in the food they eat. It's especially how they eat. Meals are leisurely, they're with friends, they're with family, you're discussing, it's It's a fun social occasion. I don't mean social as in social media and how many clicks are we getting, or, you know, their intent— it's definitely not. There's no screen time. They're not watching TV. They're not, and they don't snack. They sit at a table with other people to enjoy a meal. I mean, there was just a few experiences I had that were really enlightening, like the mechanic on our boat. I would ask him to try something for a snack. He's not able to snack and eat while he works. He just— a mechanic wouldn't do it in there because he'd say, well, I'd have to sit down and enjoy the food with you. He wouldn't just take a bite and try it and keep working because that's not how they eat food. So, and I think here in the US, way too commonly, we'll eat in front of the computer, on our smartphone, in front of the television, all those screens, and we're not communicating with their food and people. So, their communication is over food at mealtime, where they sit in a relaxed and joyous fashion. I mean, think of how much stress reduction that provides.

Yeah, I can't imagine I would want a mechanic in the Mediterranean to be offering him or her up some food while they're doing their job, because it would end. They'd bust out the red wine, or depending on where you are, the ouzo, and the next thing you know, there'd be a A tablecloth set out for the next 2 hours. You never get the job done. What I hear you saying is that this Mediterranean diet is great, and it looks as if what you're trying to do is extract, then, what are those most valuable components that you amplify in the book? That's what this is all about. It's basically, as you say, it's the Mediterranean diet 2.0. Yeah. So, where do we amplify? What are the most important things we want to bump up if we're already eating pretty much a Mediterranean diet?

Well, other things that they do really well is they work out regularly. Everywhere I went in Europe, I would see people out jogging, swimming, bike riding. They're physically more active than we are. It's just part of their lifestyle. They believe in it, and oftentimes, it's social. It's people going out and chatting while they're running down the street or bicycling. And so, there's, again, just like the way they eat their meals, not in isolation, they work out together socially as well.

The value of the relationship then.

Yes. And then, so, in addition to physically active, they have— they do value their relationships with people and they're more interconnected. But they're also with nature more. It's not just more with people. Their activity is much more— they didn't absorb as well the gym promotions as we've had in the US. They're much more likely to go for a walk, to be in a forest, to be with nature, to be on a bike ride. And even when they eat, oftentimes they eat outside in a garden.

Wow. Getting their nature exposure and their relationships covered.

Personal relationships, activity, How they eat, and the amount of time they spend with nature. I think those are all components of a Mediterranean lifestyle that give them better outcomes that we have, that are independent, in addition to just eating the right ingredients for food.

And fish seems to be obviously an important part. And how does that play into, you know, what's available these days? I mean, it's all well and good to tell people, you know, you should only eat wild fish because it has higher levels of this and that, and doesn't contain this and that. But, you know, what's a person to do then these days as it relates to fish? Not everyone is going to have access to wild fish.

So, well, they eat a lot more shellfish than we do, you know, so they're actually eating lower on the food chain. I think the Mediterranean is well fished out. You know, you can order bigger fish, but it's in a restaurant, and they're pretty hard to catch. So, they're more, you know, that kind of seafood is more expensive, but when you look at those smaller, like, Sea trout, or dorade, the little tiny fish, and the baitfish, they eat lots of sardines.

As do I.

We eat them in a can here, hopefully with olive oil instead of cottonseed oil or something, but they're eating them fresh, and grilling them, and in many different ways. So, the seafood they eat is lower on the food chain, and they eat 3, 4, up to 5 times a week, they're eating seafood, something that we don't really do. So, they get the benefit of more. Maybe different forms of seafood. And yes, and they tend to avoid more farm-raised fish, and they're looking at more— with the exception probably of the shellfish, that is usually farm-raised, but they're not feeding it, you know, fish meal that's soy and corn from its GMO-fed herbicides.

And as it relates to then the protein, fish and poultry and some red meat as well, What's your recommendation in terms of how much and how often?

I think we do need protein, and if someone wants to be vegetarian and get it from vegetarian sources, I'm supportive of that, as long as they can get their B12 and long-chain omega-3s from seaweed, or supplements, or something else. I'm an advocate of eating a vegetarian source of protein probably at least once a day. To help meet our needs. But if someone chooses to eat animal protein, my number one concern is it's clean, that it's not— the animals have not been fed on grains that are herbicide and pesticide enriched, they're not given hormones, and preferably not given any antibiotics. So, they've lived a clean life, so if we consume them, we're getting clean protein with it instead of dirty protein. How

about the amount that people, you know, there's certainly a push in seniors to get more protein, and I wonder what's your opinion on that?

Well, after age 65, 70, there is a physiologic change in protein absorption. So, whereas you and I might, you know, be getting away with 2 servings of protein a day, as we age over time, We're going to need to spread that out a little bit and get at least 20 grams 3 times a day, so to ensure we meet our protein needs and it gets absorbed, because you can't do it all in one big meal of protein. So, it will become more important as people age and get older. So, I do appreciate what you're saying there, but I think most Americans can get by with having 2 to 3 servings of protein a day. And here, let's put it in perspective. You know, how much is that, 20 grams? That's like 2 to 3 eggs, a 3.5 to 4 ounce serving of chicken, meat, or fish, you know, 1 cup of organic plain yogurt, or 1 cup, you know, something like beans. Those are all great protein sources that we can get on a regular basis that are going to meet our needs.

Well, Truth be known, I am in the 65 to 70-year group, or at least I will be very soon, and I tend to have protein once a day, and I tend to have that earlier than later, and it's really a lot less than I used to have, though I weight train every other day, so I have a little bit more than I could probably get away with, but it's still not as much as I used to think that I needed. And I was fearful not having enough protein that I would feel weak, and my muscles would atrophy. It hasn't happened, and I know what I'm able to lift. And that said, I think we're learning a lot more now about various signaling pathways, like IGF-1 and mTOR, and the importance of allowing those pathways to be active, and therefore enhancing autophagy, the importance of autophagy. Which I think is something we really need to consider moving forward in terms of health in general, and certainly degenerative disease, and cancer, et cetera. So there's, I think, a lot more to be learned. Always this conundrum between, do we want to suppress IGF-1 peripherally, whereas it's important centrally in the brain for its action as a trophic hormone, much like brain-derived neurotrophic factor? That said, Awesome book. And again, how rare that you get a book by somebody who said, yeah, it's one thing to write a book about the Mediterranean, but it's certainly a lot more experiential from your side of the story to jump in a sailboat and go there and spend 7 months and from port to port and see what the heck is really going on, you know, in this area that's been credited— that's, you know, the The eponymous Mediterranean diet, you go there, and that's super cool. So, I want to thank you for spending time with us today.

Well, thank you very much for the opportunity. I've followed your work for decades. I've really appreciated all the publications you've generated and teaching you've provided, so this is really quite an honor for me.

Well, great. Well, thank you, Dr. Massey. I hope we get to talk soon.

Thank you, Dr. Perlmutter.

Okay. Bye for now. Well, great information from Dr. Steven Masley. Again, here's his book, The Mediterranean Method, and this is a great book talking about why the Mediterranean diet is good, and even more importantly, I think, since we all kind of get that message, how to make it even better. You know, what are those parts of it that really need amplification? And, you know, as he mentioned, you heard him say, That there are other parts of the Mediterranean approach to eating that aren't necessarily food-related, that have to do with being in community, have to do with relationships and taking time out to really participate in the meal. So very, very important. So thanks for joining us today. I'm Dr. Perlmutter, and bye for now.