The Pioppi Diet

The Pioppi Diet is a book by the London cardiologist Aseem Malhotra and Donal O’Neill, an Irish film-maker.

Pioppi is a small village on the Tyrrhenian Sea which is located on the west coast of Italy. It is approximately 150 km (90 miles) south of Naples. Ancel and Margaret Keys resided here for over 25 years. Martii Karvonen of Finland and Jerimiah Stamler of the USA are other well-known medical researchers who resided in the village.


The foreword for the book is written by Professor David Haslam of the UK National Obesity Forum. This is what he has to say about the book.

Aseem Malhotra and Donal O’Neill trace the modern Mediterranean Diet back to its authors, Margaret and Ancel Keys, in a rather fond, nostalgic way, despite current scientific analysis demonstrating that much of Ancel’s work was flawed.

One of the last great and sensible medical textbooks was written in 1951 by Raymond Greene (the novelist Graham’s brother). After this, falsehoods and misperceptions were peddled ubiquitously. Greene wrote, with regard to obesity:

Foods to be avoided:

  1. Bread and everything else made with flour

  2. Cereals, including breakfast cereal and milk puddings

  3. Potatoes and all other white root vegetables

  4. Foods containing much sugar

  5. All sweets

You can eat as much as you like of the following foods:

  1. Meat, fish, birds

  2. All green vegetables

  3. Eggs, dried or fresh

This is the perfect advice for a healthy diet and to counteract obesity.

Haslam does not say (and is unable to say) why Keys’s work is flawed.


Malhotra states in the book that:

When he [Keys] visited the region after the Second World War (he had, famously, invented the K-ration, a portable, non-perishable ration containing enough calories to sustain a soldier for up to two weeks), Keys was so taken with Pioppi that he would return years later, to conduct the research that has ultimately framed our modern, albeit skewed, interpretation of the traditional Mediterranean lifestyle.

Keys and his wife, Margaret, would live and work among the people of Pioppi for four decades before his death in 2004. His name is still spoken with reverence and no short measure of affection there.

The K-ration was originally designed to last for 15 meals – not two weeks as stated.[1]

Malhotra claims that Keys’s interpretation of the Mediterranean diet is skewed, without saying why.

Keys did not do research at Pioppi. This is where Ancel and Margaret lived after he retired from the University of Minnesota and where he wrote.

The Mediterranean diet at described by Ancel and Margaret Keys is based on the diets of Greece, southern Italy and the Mediterranean coasts of Spain and France of the 1960s. Below is how Keys described the diet.

The heart of what we now consider the Mediterranean diet is mainly vegetarian [or lactovegetarian]: pasta in many forms, leaves sprinkled with olive oil, all kinds of vegetables in season, and often cheese, all finished off with fruit, and frequently washed down with wine.
I say “leaves.” 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. [2]

Whole grain bread is an important part of the diet in these regions, consisting of 30-40% of energy intake. Bread consumption was less in Italy because “they eat so much pasta”.[3]


Malhotra’s version of Pioppi’s Mediterranean diet includes the following advice.

  • Don’t fear fat
  • Sugar and refined carbs are the enemy
  • Extra virgin olive oil is medicine, 2-4 tablespoons a day (30-60ml)
  • A small handful of nuts every day
  • Eat 10 eggs a week – they’re satiating and full of protein
  • Oily fish at least 3 times a week
  • Two portions of vegetables in at least two meals a day
  • Fast once a week for 24 hours after dinner
  • Eat the local eat pasta – but only in small quantities
  • full-fat dairy
  • coconut oil
  • dark chocolate

Coconut oil, dark chocolate, no bread, only four portions of vegetables a day? This advice is far removed from the actual diet of Pioppi and from the Mediterranean diet as described by Keys.

Pasta and bread as well as fruit and vegetables were the major components of Keys’s Mediterranean Diet – not eggs, dairy, chocolate, dairy, fish and definitely not coconut oil. It is Malhotra that is misrepresenting the Mediterranean Diet – not Keys. Recall that Keys based his version of the Mediterranean Diet on the diets of Greece, southern Italy and the Mediterranean coasts of Spain and France of the 1960s.


Malhotra published an article in The BMJ, Saturated Fat is not the Major Issue.[4] He starts his article by saying:

Scientists universally accept that trans fats—found in many fast foods, bakery products, and margarines—increase the risk of cardiovascular disease through inflammatory processes.

He give a citation for that statement to the paper, Trans-fatty acids and nonlipid risk factors, which has a completely different conclusion.

Consumption of industrially produced trans-fatty acids (TFA) is associated with substantial risk of coronary heart disease (CHD). The magnitude of this relationship […] cannot be fully explained by the well-established adverse effects of TFA on serum lipids. We review the evidence for effects of TFA intake on nonlipid risk factors. […] These include effects on systemic inflammation, endothelial dysfunction, visceral adiposity, insulin resistance, and arrhythmic risk. […] The multiple adverse effects and implicated pathways are consistent with the observed strong associations of TFA consumption with CHD risk.[5]

Popular commentators state that inflammation is the cause of heart disease whilst neglecting to explain what causes the inflammation in the first place.

LDL particles, which contain cholesterol, enter the space inside the lining of the arteries. The cholesterol becomes oxidised. White blood cells recognise this as a foreign particle and engulfs the intruder and plaques develop inside the artery wall. Plaques consist of dead white blood cells (macrophages), fats, cholesterol, and smooth muscle tissue. The plaques intrude into the arteries. Thrombosis (blood clot inside a blood vessel) at the site of a ruptured plaque precipitates most heart attacks.

Without high levels of blood cholesterol, there is no inflammation.
Malhotra also states:

Now two thirds of people admitted to hospital with a diagnosis of acute myocardial infarction really have metabolic syndrome—but 75% of these patients have completely normal total cholesterol concentrations. Maybe this is because total cholesterol isn’t really the problem?

Malhotra quotes a newspaper report[6] for this information. The article quotes Dr. Gregg Fonarow from the UCLA, who states, “that the current guidelines may not be low enough to cut heart attack risk in most who could benefit”. Having “normal” cholesterol levels when it is normal to die from a heart attack is not a healthy choice.

Malhotra completely misrepresents the newspaper article’s message, which is the cholesterol guidelines are too high.

William Roberts is a leading cardiovascular pathologist. He is the current editor (at 2016) of the American Journal of Cardiology—a position he has held since 1982. Dr Roberts has also suggested cholesterol goals should be less than 150 mg/dL (3.9 mmol/L) for total cholesterol and less than 60 mg/dL (1.5 mmol/L) for LDL cholesterol. He also contends that the HDL-cholesterol is largely irrelevant and that there is only one risk factor for heart disease—that is, “It’s the cholesterol, stupid”.[7]


Trichopoulou and colleagues[8] [9] conclude that the major components of the traditional Mediterranean diet are:

  • high monounsaturated to saturated fat ratio—the main fat consumed is olive oil
  • moderate alcohol consumption, consumed with meals
  • high consumption of legumes
  • high consumption of cereals (including bread)
  • high consumption of fruits
  • high consumption of vegetables
  • low consumption of meat and meat products
  • minimal consumption of milk and dairy products

Malhotra aversion to wheat results in him ignoring the role of bread and pasta in the Mediterranean Diet of Pioppi.

The popular view that wheat and bread is a major health issue is misplaced. Celiac, wheat allergies and non-celiac gluten sensitivity are important issues but their prevalence is overstated. A review, published in The Journal of Nutrition, of 45 prospective cohort studies and 21 randomized-controlled trials between 1966 and February 2012 found that an increase in the intake of whole grain foods is associated with lower risk of type 2 diabetes, cardiovascular disease, and weight gain.[10]

Eggs are also problematic. David Jenkins, the Toronto-based researcher of glycaemic index fame, was a co-author of a paper, Egg yolk consumption and carotid plaque[11] that concluded, “Our findings suggest that regular consumption of egg yolk should be avoided by persons at risk of cardiovascular disease.” Given that approximately 30% of Australians and Americans die of heart disease, that would place the majority of people at risk.

Jenkins is now advocating a whole-food, plant-based diet for optimal health.

A key finding of the Physicians’ Health Study[12] is that physicians consuming 7 or more eggs per week had a 31% increase in all-cause mortality compared with those consuming less than 1 egg per week. For diabetic physicians, the association was much higher with the increase in mortality slightly more than doubled.
A British study reported a 2.7 times greater risk of death with an egg consumption greater than 6 eggs per week.[13]


Malhotra is a keen high-fat, low-carbohydrate diet advocate and is desperately trying (unsuccessfully) to combine a high-fat, low-carbohydrate diet into a distorted view of the Mediterranean diet.

Related articles

Ancel Keys and the High-Fat Diet “Experts”
Ancel Keys did not manipulate his data
Robert Lustig and the Men Who Made Us Fat
The Big Fat Surprise
TIME Magazine Article – Eat Butter
TIME Magazine Article – Eat Butter – Part 2
Heart of the Matter – ABC Catalyst

Footnotes

  1. Army Quartermaster Foundation (n.d.) History of Rations [online]. Available from: https://www.qmfound.com/article/the-history-of-rations/ (Accessed 2 October 2017).
  2. Keys, A. (1995) Mediterranean diet and public health : personal reflections. American Journal of Clinical Nutrition. 61 (6), 1321S–1323S.
  3. Keys, A. & Keys, M. (1975) How to eat well and stay well the Mediterranean way. Doubleday, Garden City, NY. p38
  4. Malhotra, A. (2013) Saturated fat is not the major issue. BMJ. [Online] 347 (oct22 1), f6340–f6340.
  5. Wallace, S. K. & Mozaffarian, D. (2009) Trans-fatty acids and nonlipid risk factors. Current Atherosclerosis Reports. 11 (6), 423.
  6. Champeau, R. (2009) Most heart attack patients’ cholesterol levels did not indicate cardiac risk | UCLA [online]. Available from: http://newsroom.ucla.edu/releases/majority-of-hospitalized-heart-75668 (Accessed 3 October 2017).
  7. Roberts, W. C. (2010) It’s the cholesterol, stupid! American Journal of Cardiology. 106 (9), 57–73.
  8. Trichopoulou, A. & Vasilopoulou, E. (2000) Mediterranean diet and longevity. British Journal of Nutrition. 84 (6), 205–209.
  9. Trichopoulou, A. et al. (2009) Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study. British Medical Journal. 338 (1), b2337.
  10. Qing Ye, E. et al. (2012) Greater Whole-Grain Intake is Associated with Lower Risk of Type 2 Diabetes, Cardiovascular Disease, and Weight Gain. The Journal of Nutrition. 142 (7), 1304– 1313.
  11. Spence, J. D. et al. (2012) Egg yolk consumption and carotid plaque. Atherosclerosis. 224 (2), 469–473.
  12. Djoussé, L. & Gaziano, J. M. (2008) Egg consumption in relation to cardiovascular disease and mortality: the Physicians’ Health Study. American Journal of Clinical Nutrition. 87 (4), 964–969.
  13. Mann, J. I. et al. (1997) Dietary determinants of ischaemic heart disease in health conscious individuals. Heart. 78 (5), 450–455.

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