Back Forty: Embrace the ‘nonna state’

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By Paul Greenberg

Midway through an almost absurdly indulgent Mediterranean Diet tour of Italy’s Campania region, I had an inconvenient thought. What if, just for a day, I and the half dozen Americans with whom I’d been feasting on prosciutto and buffalo mozzarella, were to experience the Mediterranean Diet the way it was observed by clinicians back when they first “discovered” it in the 1950s? 

In this scenario we’d shuffle down the main thoroughfare of Pioppi, past the trattoria where we’d been promised local cheeses, and find ourselves faced with a field of tomatoes, artichokes, and peppers that needed staking and weeding. After several hours of stooped work under a blazing sun we’d be allowed a few dried figs and maybe a brief nap in the shade of an umbrella pine. Next, some of us might head to a hill of chickpeas while others fanned out over a prickly hill of bitter field greens. Plucking and shucking complete, we’d cook our harvest in blackened caldrons along with a liberal pour of olive oil and the remains of last week’s goat. We’d soak up the leavings with coarsely milled bread and wash it all back with homemade wine. Maybe we’d even take a twirl on the dance floor if it were a Saint’s Day, but my guess is that we’d be too bushed. Because, frankly, it would be exhausting to follow the original Mediterranean Diet.

The inconvenient fact is that hard manual labor and food scarcity were common in Mediterranean societies when the physiologist Ancel Keys laid the foundation for what came to be called the Mediterranean Diet (“We are hungry most of the time,” one subject reported to a Keys predecessor during a survey of post-World War II Crete). In Italy, sharecropping was still prevalent and working farmers in the 1950s had 1/16th the number of tractors they would have just 20 years later. Being underweight, over-exercised, and unexposed to the sugar/salt/fat temptations of the contemporary supermarket were notable elements of the lifestyle non-choices that allowed people of the region to regularly age out past 90 with arteries clean as whistles.

That enforced deprivation was a key part of the diet becomes ever more apparent as its evil successor, indulgence, rears its head in contemporary Mediterranean societies. Today in the very places where Keys drew his conclusions, diet-related health problems have risen dramatically. On Crete, where obesity was unheard of pre-1950, the average farmer is now more than 44 pounds heavier than during the time of Keys’ Seven Countries Study. In Campania, where Keys bought a vacation house that he kept until he himself reached his nineties, 54 percent of the population is now overweight or obese — a higher percentage than in any other Italian region.

These changes may actually be a direct response to the very deprivation that was central to the diet’s healthfulness in the first place. “During the economic boom in Italy in the 1960s, the grandparents had come out of World War II when deprivation and famine was the standard of life,” Alessio Fasano, chief of pediatric gastroenterology and nutrition at Mass General for Children, told me during the Percorsi nel Gusto trip that had brought me to Campania. “That led to the attitude that health related to puffy cheeks and being overfed. When the children of that era became parents, their kids were raised with the same attitude, favoring sweets and snacks different than the traditional Mediterranean Diet snacks” — tomatoes, olive oil, and basil.

How then are we to proceed after Michael Pollan’s dictum to “Eat food. Not too much. Mostly plants” has come and gone, largely unheeded? How are we to counter the fact that, just as in the Mediterranean region, the American obesity rate rises and rises — in our case from 35 percent to 41 percent in the 16 years since Pollan gave his Keysian advice?

To begin with, let’s publicly clarify for the average eater what the Mediterranean Diet truly means in terms of food intake and food qualities. One of the things that makes the diet so appealing to so many Americans (it is named the “Best Diet Overall” by U.S. News & World Report year after year) is that, for the distracted consumer, its guardrails have a fungible quality. Want another helping of glycemic-load-boosting white-flour pasta? Sure! It’s Mediterranean. Want a plastic cylinder of sweetened Greek yogurt that has more sugar than a Twinkie? All good. The keepers of the Mediterranean flame might take a page from artisan European food producers who, in the early 1990s, took action against the fraudulent artisanal products that had undermined everything from San Marzano tomatoes to Parmigiano-Reggiano cheese. When the D.O.P. (Denominazione di Origine Protetta) system went into effect, in 1992, it defined what it meant to be a small-scale producer. Clearly it would be near impossible to police the word “Mediterranean” on a global basis. But I don’t think it unreasonable for food producers and restaurants that use that descriptor to try to conform to certain standards. Without such standards, “Mediterranean” is as empty a signifier as the oft-derided label “natural.”

It might also make sense to use the latest tools at our disposal to test the diet in a way that carries more scientific weight. Measuring the impact of what we eat turns out to be notoriously difficult. Pharmaceuticals can be trialed over long periods in controlled fashion. Dietary trials, meanwhile, rely on what are known as “association studies” — subjective, population-level analytics in which self-reported habits and outcomes are weighed side by side, followed by a best guess about causation. The weakness of cause-and-effect in dietary studies has provoked many journalists to question the value of the plant-centered Mediterranean Diet, with some even suggesting that a distinctly un-Mediterranean eating pattern, one that includes high amounts of animal products, might prove more salutary. This question could now actually be settled. As Ronald Kleinman, the physician-in-chief emeritus at Mass General for Children, said to me in Campania, with AI and microchip monitoring it is becoming plausible to measure what a test subject actually eats and how that subject exercises over a statistically significant period of time. Researchers at Harvard, the University of Chicago, and several other institutions are tinkering with the design of these kinds of studies as I write. Before long we might actually be able to effectively trial how a Mediterranean eating pattern stacks up against what is aptly named the S.A.D., or Standard American Diet.

Lastly, and profoundly harder, we need to confront the fact that the societies that followed a proto Mediterranean way of eating and working were much more communal than capitalistic. Wisdom about food and farming was collective wisdom in the sense that ideas and implementations benefitted the village as a whole. You would no sooner plant a field with something that would undermine its fertility than you would give children something to eat that would make them sick.

The combination of AI diet monitoring and strict regulation around things like food advertising to children would elicit howls about the dreaded nanny state. But the for-profit surveillance capitalism monitoring our shopping and eating patterns already does essentially the same thing.

In keeping with my focus on the origins of the Mediterranean Diet, I might propose that instead of worrying about a nanny state, what we might want to foster is a “nonna state” — a grandma state. In the nonna state the good of the village would be sacrosanct. We would protect the most sensitive people (children) from the ravages of food advertising and attempt to reinforce the presence of traditional foods in towns and villages whose diets globalization has torn asunder. Some steps are being made in this direction. In a trial being designed by the University of Salerno, caretakers in the village of Cetara will be instructed and observed in the reintroduction of more traditional foods back into the diets of children.

Scores of Mediterranean Diet tours, like the one I just completed, will cross Italy in the summers to come. And surely we should rejoice in the silky ricotta, the fragrant olive oils, the salty prosciutto, and the bold red wines this bountiful landscape can produce. But if we occasionally indulge in a fantasy of the Mediterranean lifestyle, we also should keep our eye on the steps it would take to make the diet’s historically healthful elements part of an everyday reality. No, we don’t have to grow our own artichokes or starve ourselves half to death to gain many of the benefits that traditional Mediterranean societies enjoyed. As Marion Nestle, the American public health advocate and author, put it, “The classic dishes of Mediterranean poverty taste really good—anyone would want to eat them—in moderation, of course.” Of course. But beyond seeking good tastes, in order to evade the chronic diseases that are engulfing our societies we need to do the hard work of research, regulation, and building a more considered and caring approach to food and community.