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The Seven Countries Study in Crete: Olive oil, Mediterranean diet or fasting?

Authors:
Letter to the Editor
The Seven Countries Study in Crete: olive oil, Mediterranean diet
or fasting?
Sir,
In the December 2004 issue of your journal, in his Out of
the Box column
1
, Geoffrey Cannon referred to Ancel Keys’
Seven Countries Study
2
and the fact that Keys and his
colleagues seemed to have ignored the possibility that
Greek Orthodox Christian fasting practices could have
influenced the dietary habits of male Cretans in the 1960s
3
.
For this reason, we had a personal communication with
Professor Christos Aravanis, who was responsible for
carrying out and following up the Seven Countries Study
in Greece
4
. Professor Aravanis confirmed (Aravanis C,
personal communication) that, in the 1960s, 60% of the
study participants were fasting during the 40 days of Lent,
and strictly followed all fasting periods of the church
according to the Greek Orthodox Church dietary
doctrines. These mainly prescribe the periodic abstention
from meat, fish, dairy products, eggs and cheese, as well as
abstention from olive oil consumption on certain Wednes-
days and Fridays.
However, it is indeed the case that this was not noted in
the study, and no attempt was made to differentiate
between fasters and non-fasters. In our view this was a
remarkable and troublesome omission.
The Greek Orthodox Church prescribes almost 180 days
of fasting per year. It is unknown to what extent the
Cretans who were the original subjects of the Seven
Countries Study and who fasted during Lent also followed
the precepts of their Church throughout the year, and thus
on how many days in total and to what extent the Cretan
participants of the Seven Countries Study fasted.
Therefore, it still remains unknown whether the results
of the Seven Countries Study in Crete, which have been
very widely cited and have crucially influenced dietary
guidelines and industrial practices all over the world, were
about olive oil in particular, the Mediterranean diet in
general or the beneficial effects of fasting in the sense of
regular restriction of certain foods, notably those of animal
origin.
Nevertheless, from our own recent studies
3,5
, we are
sure that the effects on serum lipids and longevity of
fasting according to Greek Orthodox Church practices
would have been significant, if relative data had been
made available in the Seven Countries Study. Geoffrey
Cannon was right to propose this.
Katerina Sarri and Anthony Kafatos
Preventive Medicine and Nutrition Clinic
Department of Social Medicine
Faculty of Medicine, University of Crete
PO Box 2208
Iraklion 71003, Crete, Greece
Email: katsarri@med.uoc.gr
DOI: 10.1079/PHN2005765
References
1 Cannon G. Out of the Christmas Box. Public Health Nutrition
2004; 7(8): 98790.
2 Aravanis C, Corcondilas A, Dontas AS, Lekos D, Keys A.
Coronary heart disease in seven countries. IX. The Greek
islands of Crete and Corfu. Circulation 1970; 41(4 Suppl.):
I88100.
3 Sarri KO, Linardakis MK, Bervanaki FN, Tzanakis NE, Kafatos
AG. Greek Orthodox fasting rituals: a hidden characteristic of
the Mediterranean diet of Crete. British Journal of Nutrition
2004; 92(2): 27784.
4 Verschuren WM, Jacobs DR, Bloemberg BP, Kromhout D,
Menotti A, Aravanis C, et al. Serum total cholesterol and long-
term coronary heart disease mortality in different cultures.
Twenty-five-year follow-up of the seven countries study.
Journal of the American Medical Association 1993; 274(2):
1316.
5 Sarri KO, Tzanakis NE, Linardakis MK, Mamalakis GD, Kafatos
AG. Effects of Greek Orthodox Christian Church fasting on
serum lipids and obesity. BMC Public Health 2003; 3(1): 16.
qThe Authors 2005
Public Health Nutrition: 8(6), 666
... The most commonly recognized dietary patterns that have been linked to longevity and protection against non-communicable diseases (NCDs) are the Mediterranean, Nordic, and Okinawan dietary patterns [5][6][7][8][9]. Evidence of the benefits of the Mediterranean diet were first reported in the Seven Countries Studies (SCS) in the late 1950s, showing that a population of men from Crete who followed a traditional lifestyle way of living, with an (i) increased level of physical activity, (ii) consumption of traditional foods, and who (iii) fasted according to the Christian Orthodox Church (COC) recommendations, had a higher life expectancy [10][11][12]. Indeed, the COC fasting regime is part of the Mediterranean diet in Greece, which is followed for 180-200 days spread throughout the year in four major fasting periods (i.e., Christmas, Easter, Assumption, and Holy Apostoles). ...
... It is shown that the extensively studied Mediterranean diet has been proven to play a key role in both the prevention and treatment of NCDs, including cardiovascular diseases, type 2 diabetes, cancer, and metabolic syndrome (MetS) [10][11][12][13][14][15][16][17][18]. MetS represents a major public health problem, being associated with the development of several cardiometabolic diseases, including type 2 diabetes and its complications, cardiovascular diseases, and non-alcoholic fatty liver disease [14][15][16][17]. ...
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It is well known that the Mediterranean diet contributes to healthy living, prevention of non-communicable diseases, and longevity. A cross-sectional study was conducted with participants from Greece who follow the Mediterranean diet and were further divided into two categories: (i) Christian Orthodox Church (COC) religious fasters and (ii) non-fasters. Four-hundred individuals underwent anthropometric measurements, whereas information regarding dietary intake was collected via three 24 h diet recalls and a monthly food frequency questionnaire. Principal component analysis was performed to derive dietary patterns, whereas associations between dietary patterns and metabolic syndrome (MetS) risk factors were investigated with the general linear model. Non-fasters (n = 200) were found to consume significantly more beef, chicken, turkey, sausage, broth, fried potatoes, ketchup, and mustard, while consuming less seafood, snails, soya, tarama salads, fresh fruits, margarine, olives, and decaf coffee. Two distinct dietary patterns were identified in fasters: (i) the “Mixed Diet” and (ii) the “Plant-based/Fasting Diet” pattern. Moreover, three patterns were identified in non-fasters, and were identified as follows: (i) the “Western Diet”, (ii) the “Mixed Diet”, and (iii) the “Mediterranean-like Diet” pattern. No significant association was observed between dietary patterns and the prevalence of MetS in our population. Further epidemiological studies should evaluate the links between dietary patterns and MetS prevalence within the adult Greek population.
... Specifically, the MD provides an adequate supply of B-complex vitamins, including thiamine, due likely to its emphasis on consuming unrefined foods such as wheat, barley, bran, and certain types of meat, notably pork [32]. The Cretan diet is further characterized by its low caloric intake, possibly influenced by the widespread adherence to fasting practices recommended by the Eastern Orthodox Church [33] and by the predominance of plant-based foods such as olive oil, greens, pulses and fruit complemented with a moderate amount of fish, non-red meats, and dairy products [29]. ...
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Background Cognitive and mood status influence both personal and social daily activities, with great impact on life quality, particularly among the elderly population. Aim This cross-sectional study aimed to investigate the psycho-affective status concerning eating habits within an elderly population of the Chania area in Crete, Greece. Methods Cognitive status was assessed in 101 elderly subjects through the Mini-Mental State Examination (MMSE), and mood was evaluated using the Hospital Anxiety and Depression Scale (HADS). Nutritional status was assessed using a validated food frequency questionnaire. Results Multivariable statistical analysis, after adjustment for age, marital status, education, and comorbidity, highlighted among males a positive association of the MMSE score with vegetable consumption (RR 1.18; 95%CI 1.03‒1.34) and a negative association with potato consumption (RR 0.83; 95%CI 0.72‒0.95). Conversely, among females, no statistically significant association was observed for any food. Further, among males, a protective effect on affective status was identified for chicken meat (RR 0.45; 95%CI 0.27‒0.77), fish (RR 0.41; 95%CI 0.21‒0.82), fruit (RR 0.70; 95%CI 0.52‒0.94), cereals (RR 0.67; 95%CI 0.53‒0.87), and cheese (RR 0.78; 95%CI 0.63‒0.97) consumption. Among females, the adjusted model showed a significant detrimental effect of vegetable consumption (RR 1.33; 95%CI 1.02‒1.73). Conclusion A predominantly vegetable-based diet—with the notable exception of fruits and legumes—was associated with better cognitive status in males, albeit not in females. A higher intake of fruit, as well as fish, chicken meat, and cheese among males was associated with a better affective status, indicating that adequate protein supply may play a role in maintaining emotional balance.
... During the fasting periods, consumption of seafoods and snails is allowed, together with the increased consumption of fruits, vegetables, legumes, and cereals. The COC fasting represents an interchange of plant-based to vegetarian diet and is considered as the underpinning of the Mediterranean diet [22,29]. ...
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... The Mediterranean diet has attracted much attention and interest because of its beneficial effects on health in comparison with other diets in the world (Sarri and Kafatos, 2005). It has been the subject of abundant research on its food components (Benjelloun, 2011;Salas-Salvadó and Papandreou, 2020). ...
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... Saturated fats were therefore very likely undercounted in this population, yet Keys downplayed this issue in his report and concluded that the excellent health of the Cretans could be credited to their low consumption of these fats. The failure to adjust for the Lent data was a 'remarkable and troublesome omission,' wrote researchers in Public Health Nutrition in 2005 [13], yet this analysis took place long after the diet-heart hypothesis had become solidified as public policy. ...
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... In consideration of the fact that approximately 50-60% of the year is dedicated to COC fasting, the traditional Mediterranean diet of Greece strongly mimics those fasting dietary guidelines [2]. The Cretan Diet, as depicted in the Seven Countries Study, was itself Nutrients 2022, 14, 1383 2 of 11 a reflection of those religious guidelines as per the fact that 60% of the Seven Countries Study participants declared strict adherence to the COC fasting recommendations [3][4][5][6]. ...
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... 16 Detailed scrutiny of the methodology of the seven countries study reveals some glaring measurement errors. 26 In the surveys in Greece (where the concept of Mediterranean diet originated), Keys and his co-workers had sampled diets in Crete and Corfu number of times to capture the variation in food consumption. One major oversight made by these workers was that one of the major surveys undertaken was during the 48 days fasting period of Lent -the Greek orthodox fast is very strict where meat, eggs, cheese or any other food of animal origin is forbidden. ...
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