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Learning objectives

After completing this continuing education course, nutrition professionals should be able to:

1. Understand the state of "health affairs" in the U.S. compared to the healthiest countries in Europe

2. Identify at least 4 key cultural and lifestyle differences in European countries

3. Define the Mediterranean diet and compare it to modern diets of healthy European nations

4. Know the 5-basic dietary guidelines of the Mediterranean diet and the 5-basic guidelines to eat like a healthy European.

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America is fatter than ever

obesity is THE leading cause of

preventable death & Disease WorldWIDE

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4https://www.statista.com/chart/11497/america-is-fatter-than-ever/

The OECD (Organization for Economic Co-operation and Development) is an intergovernmental economic organization composed of 36 member countries with the goal of stimulating economic progress and world trade.

Top 10 Most Obese OECD Countries

Top 10 Most Obese OECD Countries: 2016

OECD Rank(Global Rank)

Country% of AdultPopulation

That Is Obese

1 (12) United States 36.2%

2 (17) Turkey 32.1%

3 (22) New Zealand 30.8%

4 (26) Canada 29.4%

5 (27) Australia 29.0%

6 (28) Mexico 28.9%

7 (32) Chile 28.0%

8 (33) United Kingdom 27.8%

9 (41) Hungary 26.4%

10 (44) Israel 26.1%

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RankCountry

% of AdultPopulation

That Is Obese

1 Nauru 61.0%

2 Cook Islands 55.9%

3 Palau 55.3%

4 Marshall Islands 52.9%

5 Tuvalu 51.6%

6 Niue 50.0%

7 Tonga 48.2%

8 Samoa 47.3%

9 Kiribati 46.0%

10 Micronesia (Federated States of) 45.8%

11 Kuwait 37.9%

12 United States of America 36.2%

6Source: World Health Organization 2017

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87 France 21.6%

112 Switzerland 19.5%

106 Italy 19.9%

RankCountry

% of AdultPopulation

That Is Obese

12United States of America

36.2%

62 Spain 23.8%

54 Greece 24.9%

7Source: World Health Organization 2017

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Obesity rates are expected to increase further

OECD projections show a steady increase in obesity rates until at least 2030.

Source: Recreated from OECD 2017

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Obesity in children aged 3-7 years

Source: Recreated from OECD 2017

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Over 80% of the world’s deaths from heart disease occur in low- and middle-income countries.

Where in the world is heart disease?

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Highest rates of heart disease deaths

1) Russia 2) Bulgaria 3) Romania 4) Hungary 5) Argentina

Lowest rates of heart disease deaths

1) France 2) Australia 3) Switzerland 4) Japan 5) Israel

The French diet is high in dairy, fats, and red meat—factors that are known to increase heart disease risk. Scientists aren’t sure why France is at the top of the healthy heart list (aka French Paradox), but a 2005 study published in the American Journal of Clinical Nutrition suggested that high dietary fiber intake of the French may help offset harmful effects.

Source: World Heart Federation

• According to a 2016 report by the Center for Health Statistics, on average, Americans can expect to live 78.6 years, a statistically significant drop of 0.1 year.

• Women can now expect to live a full five years longer than men: 81.1 years vs. 76.1 years.

• Life Expectancy across EU countries has increased by over 6 years between 1990 and 2014.

U.S. Life Expectancy is on the decline

even though we spend more on

health care than any other

country

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Rank Country/Economy Score

1 Hong Kong SAR 84.3

2 Japan 83.8

3 Italy 83.5

4 Spain 83.4

5 Switzerland 83.2

6 Iceland 82.9

7 France 82.7

8 Singapore 82.6

9 Sweden 82.6

10 Australia 82.5

11 Luxembourg 82.2

12 Korea Rep. 82.2

13 Canada 82.1

14 Norway 82.1

15 Israel 82.1

16 Malta 81.9

17 Austria 81.8

18 Chile 81.8

19 Netherlands 81.7

20 United Kingdom 81.6

21 Greece 81.6

22 Portugal 81.5

23 Ireland 81.5

24 New Zealand 81.5

25 Finland 81.4

26 Belgium 81.3

27 Denmark 81.1

28 Germany 81.1

29 Slovenia 81.1

30 Cyprus 80.3

31 Taiwan, China 80.1

32 Lebanon 79.6

33 Costa Rica 79.6

34 Czech Republic 79.5

35 Brunei Darussalam 79.0

36 Qatar 78.8

37 United States 78.7

38 Poland 78.2

39 Albania 78.0

40 Panama 77.8

41 United Arab Emirates 77.5

42 Oman 77.3

43 Croatia 77.3

44 Slovak Republic 77.2

45 Uruguay 77.1

46 Estonia 77.1

47 Mexico 76.9

48 Bahrain 76.8

49 Bosnia and Herzegovina 76.6

50 Montenegro 76.3

51 Argentina 76.3

52 Ecuador 76.1

53 China 76.0

54 Hungary 76.0

55 Jamaica 75.8

56 Viet Nam 75.8

57 Iran. Islamic Rep. 75.6

58 Serbia 75.5

59 Turkey 75.4

60 Lithuania 75.1

61 Nicaragua 75.1

62 Algeria 75.0

63 Tunisia 75.0

64 Romania 75.0

65 Sri Lanka 75.0

66 Malaysia 74.9

67 Georgia 74.8

68 Armenia 74.8

69 Peru 74.8

70 Kuwait 74.7

71 Brazil 74.7

72 Thailand 74.6

73 Saudi Arabia 74.5

74 Bulgaria 74.5

75 Venezuela 74.4

76 Mauritius 74.4

77 Morocco 74.3

78 Jordan 74.2

79 Colombia 74.2

80 Latvia 74.1

81 Dominican Republic 73.7

82 Cape Verde 73.4

83 Honduras 73.3

84 Seychelles 73.2

85 Paraguay 73.0

86 El Salvador 73.0

87 Bangladesh 72.0

88 Kazakhstan 72.0

89 Guatemala 72.0

90 Moldova 71.6

91 Egypt 71.3

92 Ukraine 71.2

93 Russian Federation 70.9

94 Azerbajian 70.8

95 Kyrgyz Republic 70.7

96 Trinidad and Tobago 70.6

97 Nepal 70.0

98 Bhutan 69.8

99 Mongolia 69.8

100 Tajikistan 69.8

101 Indonesia 69.1

102 Cambodia 68.7

103 Philippines 68.4

104 India 68.3

105 Senegal 66.8

106 Lao PDR 66.5

107 Pakistan 66.4

108 Tanzania 65.5

109 Madagascar 65.5

110 Namibia 64.9

111 Ethiopia 64.6

112 Rwanda 64.5

113 Botswana 64.5

114 Yemen 64.0

115 Malawi 63.8

116 Mauritania 63.2

117 Haiti 63.1

118 Kenya 62.1

119 Ghana 61.5

120 Liberia 61.2

121 Zambia 60.8

122 Gambia, The 60.5

123 Benin 59.7

124 Guinea 59.2

125 Uganda 59.2

126 Zimbabwe 59.2

127 Congo, Democratic Rep. 59.0

128 Mali 58.5

129 South Africa 57.4

130 Burundi 57.1

131 Cameroon 55.9

132 Mozambique 55.4

133 Nigeria 53.0

134 Chad 51.9

135 Sierra Leone 51.3

136 Lesotho 50.0

137 Swaziland 48.9

Life

Expectancy

Source: Recreated from The World Bank, 2017

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Source: Organization for Economic Co-operation and Development. Not all OECD members shown.

(L.A. Times Graphics)

https://www.latimes.com/nation/la-na-healthcare-comparison-20170715-htmlstory.html

Countries with largest per capita healthcare expenditures, 2015

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Swiss Food Pyramid

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French Stairs

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The Italian Dietary Guidelines

❖ Watch your weight and be active

❖ More cereals, vegetables, tubers and fruit

❖ Fat – choose quality and limit the amount

❖ Sugars, sweets, sweet drinks – just the right amount

❖ Drink plenty of water everyday

❖ Salt? Better if little

❖ Alcoholic drinks – only if in limited amounts

❖ Make varied choices

❖ Special advice for special people

❖ The safety of your food depends also on you

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MAP

OF EUROPE

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Geneva,

Switzerland

home-base

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Map of Switzerland, See Bordering Countries

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• Food law protects public health from unsafe food

• Regulates the competition in the food markets by requirements on quality and the protection against misleading information

• Against the law to use antibiotics and growth hormones in feed

• Strict laws on egg production (High levels of animal welfare protection)

Strict swiss food law

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Local

bio (organic)

dairy

biodynamic

wines

chocolate

grass-fed

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Sérac is made from the whey, which is left over after the making of cheese• Sérac is made in the valley of the

Rhone• Ricotta is another type of whey

cheese (fresh, not aged) • Lower in salt and fat, high in

protein

Swiss german-Zurich:

Swiss French-Geneva:

Swiss Italian-lagano:

Raclette, birchermeusli, Hiltl, fermented foods

Gruyere, fondue

Risotto, polenta

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Lyon, France

gastronomic

capital of france

• Bouchon is the type of restaurant found in Lyon, France, which serves traditional Lyonnaise cuisine, such as sausages, duck pâté or roast pork.

• Compared to other forms of French cooking such as nouvelle cuisine (new cuisine) originating in France during the 1960s and ’70s, the dishes are quite fatty and heavily oriented around meat.

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Chef paul bocuseGrandfather of nouvelle

cuisine

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• A rejection of excessive complication in cooking

• Cooking times for most fish, seafood, game birds, veal, vegetables and pâtés were reduced to preserve natural flavors

• Steaming was an important trend

• The cuisine was made with the freshest possible ingredients

• Large menus were abandoned in favor of shorter menus

• Strong marinades for meat and game ceased

• Seasoning dishes with fresh herbs, high quality butter, lemon juice, vinegar to replace heavy cream sauces such as béchamel

• Regional dishes for inspiration rather than cuisine Classique

• New techniques were embraced and modern equipment was often used; Bocuse even used microwave ovens

• Chefs paid attention to dietary needs of their guests through their dishes

• The chefs were extremely inventive and created new combinations and pairings

Nouvelle cuisine - 1969

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A special treat

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Fromage

blanc

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Les halles de bocuse

THE FRENCH PARADOX: the French consume luxurious, fat-laden items like foie gras (the fatty liver of a force-fed goose or duck) and rich, creamy

sauces like béarnaise (made with butter and egg yolks). Yet, they have the lowest rate of death from heart disease in Europe — a whopping 60% lower

than the rate in the United States. How can this be and is this true?

• French and American researchers have speculated that perhaps the chemical make-up of wine (red wine, in particular) negated the harmful effects of the fats.

• Once the eager-to-believe American audience accepted that it was okay to eat fatty foods (as long as you washed them down with red wine), wine sales skyrocketed!

• Even the airlines were running out of red wine on domestic flights.

The French paradox

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• U.S. wine industry jumped on the bandwagon and lobbied to add health claims to their wine labels.

• Red wine became the newest diet fad of the 1990’s, matching the “oat bran craze” of the 1980’s.

• Here is where the Americans and the French differ widely on their approaches to food, and to diet in general. The French generally do not embark on a fad diet based on speculative studies and media-hyped messages. They’re not easily persuaded, and respond to news of this type with a “grain of salt” and a healthy dose of skepticism.

• Wine is consumed with meals, in small quantities as a culinary experience (pairing with food), not to get drunk!

The French paradox

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france

locavores

luzien

Biarritz-

basque

Lyon - vegetarian

each city, town, village have their own delicacies

(like pasta shapes in Italy)

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bourgogne

beaune

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St remy, provence

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ItalyCountry of low sugar consumption

Where Starbucks was conceived and

Espresso was born

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sicily

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Mt etna

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• Mount Etna's beginnings are seen on the "Cyclops Riviera" where the mythical stories of the Greek Odysseus (known as Ulysses in Roman mythology) battling the fierce one-eyed monster Cyclops and the six-headed sea monster Scylla, bring you back in time to the epic journey in Mediterranean history.

• Mount Etna, Europe's largest active volcano, is visible high above the eastern coast of Catania and continues to enrich the island's soil with black ash from its ongoing eruptions (although short-term impacts can be negative to livestock). This soil offers optimal conditions to grow Sicily's mouth-watering produce responsible for the robust flavors of traditional Sicilian cuisine.

• During the time of the Greeks, olives and grapes were the most important food crops. Later, Sicily became the wheat granary of the Roman Empire. Today, Sicily is the garden of Europe with specialty fruits and vegetables including blood oranges, tangerines, chestnuts, lemons, artichokes, tomatoes, table grapes, wild fennel, stick-long zucchini, eggplant, wild asparagus, fava beans, pistachios and the list goes on.

Sicily, ITALY

46Source: http://www.huffingtonpost.co.uk/layne-lieberman/sicily-insider-kitchen-di_b_5589635.html

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Unlike in other parts of Italy, Sicilians do double up on carbs--breadcrumbs on top of pasta or couscous--is traditional fare. Scarpeta practice!

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▪ Wheat grain has been used for thousands of years to provide food for humans.

▪ Wheat has been found in pits where human settlements flourished over 8,000 years ago.

▪ In the British Museum, you can see actual loaves that were made and baked in Egypt over 5,000 years ago.

▪ Wheat is the product of a cross between three different grass species which is reputed to have happened about 10,000 B.C.

▪ Wheat is not a genetically modified crop!

▪ Common wheat known as “bread wheat,” raised breads, tortillas, doughnuts and cakes, and East Asian noodles.

▪ Durum wheat used in most dried pasta and couscous, for raised and flat breads in parts of Europe and the Middle East.

▪ Ancient wheat varieties Each ancient species occupies a different branch of wheat’s family tree: a) Spelt is an older form of common wheat b) Emmer (farro) is the direct ancestor of durum wheat, c) Einkorn is closely related to a wild grass species that played a part in the ancestry of all wheats

Wheat – since the beginning

of civilization

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Local

organic

fresh

no gmos

no growth

hormones

no dough

softeners in bread

ancient grains

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The Wall Street Journal

Carbs, Good for You? Fat Chance! Dietary dogma’s defenders continue to mislead the public and put Americans’ health at risk. By Nina Teicholz, Sept. 11, 2018

Needlessly scaring people away from diets with established health benefits could endanger the public.

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NBC News

Is a low-carb diet healthy? Science proves why diet fads like keto can’t beat eating in moderation.

By Matt Fitzgerald, Sept. 22, 2018

A new study shows a link between low-carb diets and shorter lifespans. But does this finding really contradict anything we already knew about diet and longevity?

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Portions

traditions vs fads

respect-aging

family ties

social-Town squares

religion-Community

wine-in-MODeration

olive oil sparingly

strolling-old cities

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Us (DIET) compared

to Europe (LIFESTYLE)

*external cues/meal timing

*snacking vs. meals VS. PORTIONS

*TRADITIONS

*Fast Food vs. FAMILY recipes

*food shopping-local markets

*SOCIALIZATION/community

*media/advertising

*DIET fads vs. FOOD culture

*government regulations

*small homes/outdoor active lifestyle

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The term, “Mediterranean diet”, was derived from the foods and lifestyle enjoyed by the people living in proximity to the Mediterranean Sea during

the late 1940s, 50s and 60s. The diet was locally sourced, and comprised of fruits, vegetables, grains, legumes, seafood, olive oil, some poultry and some dairy, occasional red meat and wine in moderation. Daily walking was a way

of life. These people had surprisingly low rates of heart disease and long lifespans compared to most other populations.

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Seven countries study

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The Seven Countries Study was conceived by Ancel Keys, a Minnesota physiologist, who brought together researchers from all over the world as a result of surveys showing high heart attack rates in US, Finland and European communities in South Africa, but low in Mediterranean countries, Japan and native populations in South Africa. It became a collective effort to study questions about heart and vascular diseases among countries having varied traditional eating patterns and lifestyles. This cross-cultural prospective study began in 1958 and lasted for 50 years.

USA

Netherlands

Finland

Italy Greece Japan

Yugoslavia

Ancel Keys and his colleagues were central to the modern recognition, definition, and promotion of the eating pattern they found in Italy and Greece in the 1950s and ’60s, now popularly called “The Mediterranean Diet.”

➢ Dietary patterns in the Mediterranean and in Japan in the 1960s were associated with low rates of coronary heart disease and all-cause mortality.

➢ The studies in the elderly showed that a healthy diet and lifestyle (sufficient physical activity, non-smoking and moderate alcohol consumption) also is associated with a low risk of cardiovascular disease and all-cause mortality. A healthy diet and sufficient physical activity may also postpone cognitive decline and decrease the risk of depression.

➢ The Seven Countries Study provided evidence: ✓ for the concept of sick and healthy populations✓ that the major cardiovascular risk factors (smoking, high BP, diabetes, obesity,

stress, inactivity) are universal ✓ for the diet-heart hypothesis ✓ that cardiovascular disease is preventable ✓ that a healthy lifestyle may promote different aspects of health

Seven countries study

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1. Eat plenty of fresh and seasonal fruits and vegetables; dry-roasted nuts and seeds; legumes like chickpeas and lentils; potatoes; whole grains including bread and pasta; and local seafood-- and use fresh herbs, spices and cold-pressed fresh olive oil. (This still holds true for Beyond The Mediterranean Diet- today’s modern European diet)

2. Enjoy local eggs, poultry, fresh cheeses and yogurt in moderation.

3. Drink wine in moderation and with meals.

4. Choose red meat occasionally.

5. Eliminate added sugar and sugar sweetened beverages, refined grains, processed meat, refined oils and other highly processed foods.

5-basic Mediterranean diet guidelines

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1. Cut back on sugar, and opt for whole fruits to satisfy your sweet tooth. Bake an apple or poach a pear instead of digging into a store-bought cake.

2. Break the habit of emotional eating. Enjoy non-caloric activities that make you feel better, like sipping herbal tea or connecting with a friend over a cup of coffee (dodging the super-sized muffin).

3. Avoid oversized portions; use a salad plate instead of a dinner plate.

4. Fill half of your plate with lightly dressed vegetables and salads. This will make the plate look fuller while reducing portions of starchy foods and protein.

5. Be mindful about quality and quantity. When you choose one square of good-quality dark chocolate, rather than one king-sized candy bar, your waistline will reflect your change in size, and your taste buds will be satisfied too!

5-ways to go

beyond the Mediterranean diet

• Emphasis on local olive oil, whole grains, vegetables, fresh cheese and fish

• Prime example of a healthy and modern Mediterranean diet.

• Spend an unforgettable week learning the secrets of a deeply passionate food culture in an authentic region of Italy.

• Openness and rustic charm reflected not only in the warmth of the people, but also in the sharing of food and dietary secrets.

• Local dishes are simple yet flavorful

• Passed on from generation to generation.

• This unique “hands-on” trip is a celebration of healthy cooking and the Mediterranean lifestyle, and offers an insiders view of a culture that has maintained biodiversity in its growing regions for centuries.

TRAVEL WITH ME TO ITALY & EARN

Continuing Education Credits

culinary & cultural immersion beyond the

Mediterranean diet

Southern Tuscany, 2019Puglia, 2020Sicily, 202030 Continuing Education Units for Registered Dietitian-Nutritionists

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Let’s stay

connected!

It’s an

important

part of

staying

healthy

www.WorldRD.com

Facebook: WorldRD.com

Instagram: LayneWorldRD

Twitter: @LayneWorldRD

YouTube: Layne WorldRD

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Disclosures: This webinar is sponsored by Quaker.

Layne Lieberman is a culinary RD-nutritionist and entrepreneur; and the award-winning author of Beyond The Mediterranean Diet: European Secrets of The Super-Healthy. She consults in the food industry and leads tours in Italy.

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1. About the study. The 7 Countries Study website. https://www.sevencountriesstudy.com/about-the-study/2. McCarthy N. Statista website. https://www.statista.com/chart/11497/america-is-fatter-than-ever/. Published

October 17, 2017.3. Perez FX. Taking consumers seriously: the Swiss regulatory approach to genetically modified food. The

National Agricultural Law Center website. http://nationalaglawcenter.org/wp-content/uploads/2013/06/v8n3a6.pdf. Published 2000.

4. Lairon D, Amault N, Bertrais S, et al. Dietary fiber intake and risk factors for cardiovascular disease in French adults. Am J Clin Nutr. 2005;82(6):1185-1194.

5. Kim S. 11 food ingredients banned outside the U.S. that we eat. ABC News website. https://abcnews.go.com/Lifestyle/Food/11-foods-banned-us/story?id=19457237. Published June 26, 2013.

6. Fox M. We’re no. 26! US below average on most health measures. NBC News website. https://www.nbcnews.com/healthmain/were-no-26-us-below-average-most-health-measures-2D11635080. Published November 21, 2013.

7. Tinker B. US life expectancy drops for second year in a row. CNN website. https://www.cnn.com/2017/12/21/health/us-life-expectancy-study/index.html. Updated December 21, 2017.

8. Beer M; Swiss Federal Food Safety and Veterinary Office, Federal Department of Home Affairs. Compulsory labelling on food and nutritional labelling in Switzerland: current state and international cooperation. https://www.wto.org/english/tratop_e/tbt_e/9_Switzerland_e.pdf

9. Organisation for Economic Co-operation and Development. Obesity update 2017. https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf

10. Obesity. World Health Organization website. http://www.who.int/gho/ncd/risk_factors/obesity_text/en/Prevalence of obesity among adults, BMI ≥30, age-standardized: estimates by country. World Health Organization website. http://apps.who.int/gho/data/node.main.A900A?lang=en. Updated September 22, 2017. Accessed October 19, 2017.

11. Global obesity levels. ProCon.org website. https://obesity.procon.org/view.resource.php?resourceID=006032

REFERENCES

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Credit claiming

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You must complete a brief evaluation of the program in order to obtain your certificate. The evaluation will be available for one year; you do not need to complete it on December 12, 2018.

Credit Claiming Instructions:

1. Go to CE.TodaysDietitian.com/MedDietWebinar OR log on to CE.TodaysDietitian.com and go to “My Courses” and click on the webinar title.

2. Click “Take Course” on the webinar description page.

3. Select “Start/Resume Course” to complete and submit the evaluation.

4. Download and print your certificate.