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When facing diabetes, do it like the 'Healthy Greek Migrant'

Professor Catherine Itsiopoulos describes the benefits of following a Greek Mediterranean diet

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21 February 2017

Professor Catherine Itsiopoulos has been a champion of the Greek Mediterranean diet for more than 25 years, doing research and publishing books on the subject, such as The Mediterranean Diet − and the wonderful associated cookbook. Her work at LaTrobe University, where she is head of the School of Allied Health, has allowed her to be in touch with many PhD students undertaking research in diet, offering new, valuable insight on how nutrition can be beneficial in the management and prevention of diseases.

This experience will lead her to the Melbourne Diabetes Expo on Saturday, where she will take part in a panel of speakers discussing what the healthiest diet is for managing diabetes.

"I've been involved in the Diabetes Expo before," she says. "This year I will describe the role of Mediterranean diet in prevention and management of diabetes."

Mediterranean diet has been at the core of her work as a dietitian. "My work started by looking at health differences between Greek migrants to Australia and Australian-born people, with or without diabetes, and from this work we found that Greek migrants who arrived in Australia in the 1950s and '60s are now in their 70s, 80s or even 90s," she says, describing what has been code-named 'the Healthy Greek Migrant'.

"We're still investigating the Greek migrant story because what we're finding is that first generation of migrants still has longevity, so something is protecting them from early mortality, primarily from cardiovascular disease and stroke and cancer," she explains.

"The majority of Greek migrants in the '50s and '60s came from rural areas of Greece where the availability of meat was low. And they came to a country where there was readily-available meat, they could buy a whole lamb for a few shillings. So in the early days the Greek migrants were consuming a lot more meat and also more dairy; they may have changed their diet somewhat, which led to obesity and increased risk of diabetes, but they also retained all the positive elements of the Greek Mediterranean diet; they are using extra virgin olive oil as the main fat in their diet, they consume legumes on a regular basis, as well as lots of leafy vegetables, tomatoes, onions and garlic. Our theory was that they were somewhat protected from the diabetes complications of the traditional Greek Mediterranean diet."

Catherine Itsiopoulos, Professor of Dietetics and Human Nutrition at LaTrobe, will present the benefits of the Greek Mediterranean diet at the Melbourne Diabetes Expo.

LEGUMES, NOT SOUVLAKI

Before explaining the benefits of the Greek Mediterranean diet on diabetes management, Professor Itsiopoulos feels the need to clarify what that means.
"In any conversation that I have or presentation that I make I dispel the myth of the 'typical Mediterranean' diet and I preface that by saying 'Greek Mediterranean diet'." This, of course, does not mean souvlaki. "When people think about Greek restaurants they think of festive food, high on meat − lambs on a spit, with a lot of bread and dips.

"Traditionally, the Greek Mediterranean diet of the '50s and '60s was primarily a plant-based diet; extra virgin olive oil was the main fat used in all cooking and salads and in desserts as well; legumes are the key protein source, eaten three to four times a week; fruits are the main dessert; other snacks would be dried fruit and nuts; dairy is used in moderate amounts, mostly in the form of yoghurt, fermented, not just glasses of milk and certainly not big mugs of coffee with a litre of milk in it," she adds, laughing.

"Feta and other types of cheese would also be consumed in moderation, not in excess. Today we see a 'Greek' salad with 250g of cheese sitting on top. It is not typical to have that amount of cheese daily. Meat is also consumed in moderation, and the same goes with fish. Many people think that the Mediterranean diet is full of fish. It is, in coastal regions, but that also means consumption a couple of times per week. Another common thing is having a glass of wine with meals, but not drinking in between meals and getting drunk. So that's what we define as a typical Mediterranean meal."

But what is it that makes the Greek Mediterranean diet so beneficial for the management of diabetes?

"The first trial that I did, more than 20 years ago, was in Australian-born people of Anglo-Celtic background with type-2 diabetes," she says.

"We put those people on a very traditional Mediterranean diet and followed them for three months. After that, they went back on their usual diet and not only had their glucose control improved but they also reported many other positive changes in their health. The largest evidence we have comes from a Spanish study, PREDIMED (Prevención con Dieta Mediterránea - Prevention with Mediterranean Diet), which recruited 7,500 people at risk of developing diabetes because they were overweight or had hypertension, etc. Within five years, those on a Mediterranean diet had 50 per cent less risk of developing diabetes compared to those on standard care, i.e. a low-fat diet.
"The Mediterranean diet is high in healthy fat; extra virgin olive oil is rich in antioxidants. In diabetes there's oxidation damage to the cells. A diet rich in antioxidants helps reduce this risk. Greek migrants with diabetes compared to Australian-born ones had much lower risk of diabetic retinopathy and this was linked to the much higher intake of antioxidants in their food.
"The other important factor is the balance between carbohydrate, fat and proteins that is a trait of the Mediterranean diet. It is a more satiating diet, making it less likely for someone to resort to snacks high in carbs.
"Also, when you have diabetes, the ability to manage high loads of carbohydrates becomes affected. A great intake of carbohydrate means that you rely on more insulin. People with type 2 diabetes are insulin resistant and those with type 1 need to provide insulin externally. So you follow a diet with moderate carbohydrates, of low glycaemic index, like those from legumes or from sourdough bread."

The emphasis on sourdough is not accidental. "I know many Greek people love to eat white, fluffy bread," she laughs. "We have to revert even Greek people to a more traditional type of carbohydrate food like sourdough bread."

TEACHING GREEK DIET TO AUSTRALIANS

It is more crucial to spread the word to the broader population, says Professor Itsiopoulos.

"One of the key issues I'm working on is how to 'translate' this diet to a non-Greek, non-Mediterranean population to show whether this traditional Mediterranean diet can be applied to Australia, that it isn't just a concept that works in Europe," she says.

"That's what I'll be talking about at the Expo. What we do with our studies here at LaTrobe is translate the Mediterranean diet principles to fit different cultures in Australia; we recruit people from all cultures and introduce elements to their diet, suggesting modifications, such as using olive oil in curries and stir-fries. So far, the response has been very positive."

But there is still much work to be done for Australians to change their ways.

"According to data from a 2010-2011 National Nutrition Survey, one third of the calories in most Australians' diet comes from discretionary foods, that are high in sugar, high in fat, ready-made food and alcohol," she explains. "Also, a very small percentage of Australians, only seven per cent, are eating enough vegetables per day. If you look at the plate, in the Greek Mediterranean diet, four-fifths consists of plant food and one- fifth is animal food. Whereas in the Australian diet, the ratio is 2 to 1 or in some cases 1 to 1 − half a plate of meat, half a plate of salad, which is not the right balance.
"One of my PhD students from the University of Canberra did a detailed study on meat consumption and found that meat portions are much higher than recommended. A typical meat portion would be around 200-250g, whereas our guidelines recommend 80g of meat up to four or five times a week, which means around 300g per week, in small serves, not in one serving".

But the greatest challenge is moving from the content of the plate to a general lifestyle associated with Greek Mediterranean eating.

"It is definitely not just the diet, it is a cuisine; a reliance on fresh-cooked, home-grown foods as much as possible and avoidance of processed foods and ready-made foods," says Professor Itsiopoulos.

"Elderly Greek migrants don't eat out, they don't eat take-away food, they eat home-cooked food. From my experience as a clinical dietitian, the problem with Australians is their reliance on ready-made food, the lack of focus in preparing your own food. We're working long hours, not having time to prepare our food. There's also less knowledge of how to prepare food, a significant lack of cooking skills."

People should learn more from their grandmothers and grandfathers and how they are about the kitchen, or the garden.

She answers that growing home gardens is a big factor in maintaining good health, as when one grows vegetables, they are more likely to eat more of these foods, but also the activity associated with keeping a home garden is important, as well as the practice of shopping for fresh food every day.

Another important and not much discussed factor is the social aspect of eating.

"When we look at the new Mediterranean diet pyramid that was developed across Europe and even in south Asia, at the bottom it includes the concept of people eating with company," she says. "Eating with people and sharing recipes, eating around the table with your family, away from television, which is also an opportunity to connect, to talk − this is all important. In Europe, and particularly in places like Greece or France, you don't see people in the street munching on food or drinking milkshakes, whereas in our society we take away a large coffee and a doughnut instead of sitting down and enjoying the day. As our lives become busier and busier, we're disconnected from that. We eat very quickly, which causes problems in digestion. It is all part of a stressful culture, which poses risks of chronic disease. We need to talk about our work-life balance".

This is something the professor learned from her Greek background, which allowed her to do research in Ikaria and conduct in depth interviews with the people of 'the Island of the long-living'.

"If I couldn't speak Greek I wouldn't be able to do this," she says. Her Greek background has also been helpful in establishing academic relationships with the National Kapodistrian University of Athens, and also with the Harokopio University, which is acclaimed for its research in Nutritional Sciences and Dietetics. Not to mention that it was where it all started for her.

"When I did my first clinical trial in the '90s I used all my mother's recipes which I grew up with and published in my first book," she says, reminiscing how her work started in managing diabetes, and then moved on to the management of cardiovascular disease to now working with a cohort of PhD students, now researching the benefits of a Greek Mediterranean diet on reversing depression, reducing the rate of progression of Alzheimer's and managing brain and mental conditions.

"It's been fantastic to grow up in this environment and be able to combine my academic work with my cultural background," she says.

* The 2017 Diabetes Expo will take place on Saturday 25 February (9.00 am-5.00 pm) at the Melbourne Convention and Exhibition Centre (South Wharf). For more information, call 1300 136 588 or visit www.diabetesvic.or.au.

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