It is refreshing to read the advice of an internationally known health expert who performs original research and calls for an increase in the consumption of fruits and vegetables, avoidance of salt and refined sugars, abstinence from smoking, regular exercise, outdoor recreation, and the management of stress.
That advice is found in the book Eat Well and Stay Well, authored by Ancel and Margaret Keys in 1959.
It is therefore quite ironic that Dr. Aseem Malhotra, a cardiologist from the UK frequently quoted in the press and co-author in 2017 of The Pioppi Diet: 21-Day Lifestyle Plan,advocates for these same lifestyle habits. What is the irony? Malhotra has been one of the most outspoken critics of Dr. Keys, accusing him of “demonizing “ fats in the diet.
Dr. Keys was a scientist and physiologist who during his 100-year lifespan was awarded 2 Ph.D.’s, did ground breaking research at the University of Minnesota on the physiology of high altitude and starvation, developed the K ration food pack for soldiers in WWII, and led an international research team that published the Seven Countries Study (SCS) to assess the accuracy of the Diet-Heart Hypothesis. More can be learned about Ancel Keys and his academic contributions in an exhaustive White Paper. Malhotra blames Keys for single-handedly influencing food policies starting in the early 1960’s towards a low-fat extremism that they contend has led to the current worldwide explosion of obesity, type 2 diabetes, and chronic diseases.
Why write a review of the The Pioppi Diet more than a year after its publication? Some books gain a following that grows with time and The Pioppi Diet is mentioned in the media, both pro and con, with increasing frequency. My patients bring it up on a regular basis asking if they should adopt it. In The Pioppi Diet, Dr. Malhotra and his co-author Donal O’Neill, visit the fishing village of Pioppi on the Mediterranean coast south of Naples. Pioppi has a population of under 300 residents. They visit the town for one week and derive a life’s worth of lessons from their stay. By coincidence, I also visited Pioppi just weeks after Malohtra. It is recommended stop for the views of the sea and the museum dedicated to the research of Dr. Keys on the Mediterranean Diet. The town however is a one street wonder. Pioppi has been has never been studied for any particular longevity or health traits, is not a Blue Zone, and was not part of the Seven Countries Study. The ultimate irony, if not chutzpah, of calling the book The Pioppi Diet after visiting for just one week is the fact that Dr. and Mrs. Keys spent 40 winters in Pioppi and were celebrated guests year after year. From that residence, they led a team of international scholars that were part of the SCS. Malhotra’s efforts to taint the legacy and research of Dr. Keys and his international research team, displayed in detail in the museum in Pioppi dedicated to the Mediterranean Diet, is rogue and biased to the extreme.
The first half of The Pioppi Diet containes the authors’ recommendations on nutrition and fitness. The second half of the book is recipes and an exercise routine. Much of the first half returns to Malhotra and O’Neill’s favorite sport, bashing the research of Ancel Keys and his co-workers, often with distorted statements. The foreword sets the tone, indicating that “current scientific analysis demonstrating that much of Ancel’s work was flawed”. This statement has no references and is denied by a recent in-depth analysisconfirming the accuracy of Key’s research on the Diet-Heart Hypothesis. On page 15 of The Pioppi Diet it is asserted that Key’s never accounted for periods of religious fasting days in his analyses for the SCS and that this omission introduced a fatal miscalculation of what the native populations ate. In fact, fasting was accounted for in the SCS, particularly in theanalysisof data in Crete. On page 40, the authors of The Pioppi Diet question whether the sugar industry funded Keys’ research and influenced his decision to “ignore” sugar and health. In conversations with Sarah Tracy, Ph.D., the Edith Kinney Gaylord Presidential Professor in the Medical Humanities Program at the University of Oklahoma, Keys was funded in 1943 via a grant from the sugar industry on a study of vitamins and rehabilitation as it pertained to soldiers (personal communication). The SCS began 15 years later, and during its 5 decades of acquiring field data and follow-up, the SCS investigators never had funding from the sugar industry. The study actually measured and analyzed sugar intake in the 16 populations studied and found it a factor in health, but not as big a factor as foods high in saturated fats like butter and meats.
Can The Pioppi Diet “drastically reduce your risk of type-2 diabetes and heart disease” as is stated on the book cover? The top-ten foods recommended by the authors begins with 7 items that would make Dr. and Mrs. Keys smile years after publishing Eat Well and Stay Well. These include extra virgin olive oil, nuts, fibrous vegetables like broccoli, fruits, herbs and spices, fatty fish, and dark chocolate. The next 3 “top 10 foods” recommended by Malhotra and O’Neill represent the “great divide” of fact vs. fantasy. The authors recommend coconut oil (including a daily ritual of adding it in morning coffee), eating a minimum of 10 eggs a week, and adding full fat dairy such as butter.
Does anyone actually follow this diet in Pioppi? The coconut (cocos nucifera) is not native to Italy or the Mediterranean. You will not see coconut palms growing in the gardens of Pioppi nor will you see them eaten by the native population. In a movieproduced by the authors of The Pioppi Diet, Dr. Malhotra is seen touring the Museum of the Mediterranean in Pioppi. Malhotra points near the base of the Mediterranean food pyramid in the museum and indicates that the row with whole grains is to be replaced with coconut oil and other foods high in saturated fats. Has Dr. Malhotra done any research on the impact to cardiac health by replacing whole grains with coconut oil and full fat dairy? He has not but he does not hesitate to recommend for all, including heart patients with advanced atherosclerosis.
The book includes a section on the diet that Dr. Malhotra follows and recommends. He starts each day with coffee to which he adds a tablespoon of coconut oil. This dietary habit is promoted by Dr. Malhotra, an interventional cardiologist, fully aware of the consequences of atherosclerosis as the leading cause of death in the Western world. There is no evidence for health benefits of dietary coconut oil for cardiac patients and the recommendation contradicts the recent advice of a panel of academic nutrition experts who advised avoiding coconut oil. An even more recent consensus published in the British Medical Journal also advised caution with coconut oil until more research is available. The recipe section of The Pioppi Diet is notable for the absence of desserts. Human nature suggests that banning desserts is unlikely to succeed and even Dr. and Mrs. Keys included some desserts in their 1959 book, such as fruit compote without added sugar.
Overall, The Pioppi Diet is a disappointment and it lacks foundation in clinical research done by Malhotra or O’Neill. While it might be superior to a typical hyper-processed Western diet rich in low quality oils, butter, meats and cheeses, the assertion that the plan can reduce type-2 diabetes and heart disease is untested by the authors in even a small pilot group. Malhotra has taken important stands against bad examples of hospital meals and conflicts in the funding of research and public foundations promoting health agendas. His diet is not in alignment with these efforts to promote public health.
The Pioppi Diet stands in contrast to dietary recommendations by leaders in nutrition who analyzed dozens of original research studies. The relentless attacks on Dr. Ancel Keys and his SCS co-authors grow tiresome and have been proven to be wrong. The Pioppi Diet neither reflects the diet of Pioppi, where coconut oil is not added to morning espresso, nor does it provide any proven path to health. One would be better off reading the books written by Ancel and Margaret Keys almost 60 years ago where the real Pioppi Diet is described.