By Tim Batchelder for Townsend Letter for Doctors and Patients

Monday, June 07, 2004

Recently I returned from an extended trip to Tuscany, Italy to where I had the opportunity to study the traditional culture and lifestyles of these people and any impact on health status, including heart disease risk. My location was near the village of Cortona, and we arrived there by flying into Rome then renting a car and driving north for 2 hours. We rented a house in the countryside and explored by car but many of the villages we visited can also be accessed by bus or train. Electricity and petroleum products are very expensive in Italy so one immediately notices that most people either own very small, efficient cars, or use public transportation, including bicycles.

A Haven for Urbanites

Tuscany has long been a destination for urban dwellers, frequently artists, seeking a healthy retreat from pollution and stress. Many English writers of the 18th century came to Tuscany for creative inspiration or health reasons. Most were leisured aristocrats or eccentric dilettantes so they hardly provided an objective view of the country. For example Tobia Smollet wrote that he abhorred Tuscan male prostitutes or "cisibei", wild food entrepreneurialism and "sour wine" and eventually died of excess cold baths, goats milk, and opiates. Shelley like to read by fountains in the villages and then jump in for a swim but eventually drowned in one. Dostoyevsky complained about all the walking around at night and excessive singing people did in Florence. Robert Browning brought his wife to Tuscany to wean her off her laudanum habit using Chianti wine. Virginia Woolf described Tuscans as "dried up, gentle, sad, wise and humorous". DH Lawrence noted they wore clothes loosely and felt a man could for a moment be himself here. Welsh poet Dylan Thomas led a hedonistic life here vegetating in the sun and devouring asparagus, strawberries, and wine since it was only 20 lire a glass which induced a constant alcoholic stupor. More recently, E.M. Forester's Room with a View made Tuscany famous along with Francis Mayes who restored a farmhouse, and sought healing, and described the experience in Under the Tuscan Sun. Deservedly so many Tuscans have become quiet fed up with culturally illiterate English speaking people invading their turf for vacations, refusing to speak Italian, and complaining about the lack of modern amenities.

Many 18th century escapees to Tuscany did so out of a desire to survive dreaded diseases of the time. For example TB was epidemic in many urban locations in Italy. In 18th century Italy physicians were required to report all cases of consumption and all belongings of victims were to be destroyed. John Keats (1795-1821) trained as a physician at Guy's Hospital, but abandoned medicine for poetry. Progressive tuberculosis, a family disease, led him to Italy in the hope of a cure and to join Shelley and Byron at Pisa. He died in Rome in an apartment overlooking the Spanish Steps.

Wild Boar and other Staples

Tuscany is home to a variety of wild creatures, many of which make it onto the dinner plates of locals and visitors alike. Scorpions, vipers, and centipedes are all common and I frequently came across the squished body of a scorpion around the house, which actually has a sting no worse than a bee. During my stay I dined on Cow tongue, wild boar, and pigeons. Pecorino cheese, made of local sheep's milk in Pienza, is a favorite. Alba, our caretaker, happily kills her own chickens for each meal she makes and indeed most Tuscans prefer their meats freshly slaughtered or to do it themselves. The freshness and wildness of the meats and participation in their preparation among Tuscans is cardio-protective. An increasing number of studies show that wild animal foods contain superior fats compared to domesticated animals.

I also ate a number of plant harvested from the wilds including Porcini mushrooms, chestnuts, and raw fava beans. The Tuscan refrigerator like that elsewhere in Italy is quiet small by U.S. standards which reflects the habit among these people of cooking with fresh produce only which is purchased every day.

An important cultural habit among Tuscans is the consumption of bitter "digestive" liquors after meals. I was able to try both Amarro and Absinthe (liquor made from Worwood (Artemisia). Absinthe was popular among English writers visiting in the 18th century and aids digestion but has mild psychoactive effects and was banned by the FDA in the US making it impossible to obtain. Gentiana lutea L. (Gentianaceae), which is indigenous to central-southern Europe, produces roots that are employed by the liquor industry for the production of bitters. The roots are in fact rich in amarogentin and gentiopicrin, substances provided with one of the strongest embittering capacities found in nature (Bezzi, 1983).

Fruit trees grew all around the house including figs, apricots, peaches, cherries, apples, plums which could all be found in great profusion in the local village markets. The importance of consuming fresh produce in Tuscan's resistance to heart disease is often overlooked with the rush to buy foods that appear "Mediterranean" which to many US consumers means just dried pasta and canned mushrooms, both distinctly un-Italian foods. Daily food markets in each village are really celebrations and meeting places for the local people to gather in the square. Prices are largely negotiable, and a bit of Italian is required.

Water quality is excellent in Tuscany however much can be very hard (high in minerals) which is tough on the delicate palate of many tourists. As a result, bottled water is consumed regularly. Again, this is an important observation as water quality and mineral intake can play and important role in heart disease. Tuscan bread is unsalted and from what I observed salt, sugar and other condiments are not used in Tuscan traditional cooking as much as in the urban West. In fact, Tuscans ridicule the American habit of pouring tablespoons of sugar into coffee.

Cardiovascular Aspects of Time and Space Conceptions

But perhaps one of the most cardio-protective aspects of Tuscan life isn't a food at all. It is a sense of time. As in many traditional cultures which I have described (and anthropologists such as Edward Hall have documented) Tuscans view 24-hour clock time with a sense of disdain. More in line with basic human physical needs, Tuscan stores and business operate when the owners and workers are ready and willing to operate, not so much according to a rigid schedule. This can be maddening to people from the US attempting to impose their sense of time on these people. For example, stores close from 1-4 in the afternoon, many are closed on Mondays, some on Wednesday afternoons. Each town has its own flavor of hours. Lunch is the largest meal of the day and Tuscans eat very slowly. A menu commonly contains many courses (up to 5-7) and each course is marked by a new glass of wine. We often spent 2 hours eating a single meal and I spend much of the time slightly cocked on wine. Fortunately, then a Tuscan returns to the fields or his or her shop for more physical labor, often with a long hike up a steep hill since this is very hilly country, rather than to a cubicle.

Christine Riley manages a team of six ethnographers employed in Intel's Architecture Lab who have been studying households in Europe to understand how they differ from those in the United States in order to more effectively develop usable technologies. She notes that if you go into a household in Italy, you have to follow their agenda, not yours. Food preparation and cooking a meal are essential there, so you help out. You stand in the kitchen and talk. You sort of steer the conversation to the topics you want. You're watching as well as talking. It's almost frightening how people open up. Riley's team also discovered a need for multimedia authoring tools for seniors hoping to pass on their knowledge based on ethnographic research among this population (Forbes 1999).

Geography, Economics and Industrialization

The health giving lifestyle of Tuscany that we see today and continues to garner so much attention among health professional and the public alike doesn't just continue by chance, another fact that few people realize. It takes a lot of hard work and bit of lucky geography. Tuscany has somehow, like parts of Wales and a few other hotspots I've visited in recent years managed to skip over the whole mess of industrialization and advance right to a stage I'll call small scale high value micro-industry. Tuscan industry today is dominated by eco tourism, gourmet foods (e.g. wild-crafted, organic), crafts, high quality textiles, and fashion. Part of this as with other eco-tourism hotspots is a blessing of geography: the rugged hills of Tuscany made it difficult to colonize with large scale agricultural and mining equipment. And the future looks bright: like the rest of Italy, Tuscany's birthrate is the lowest in Europe with 35% of Tuscan families being childless (in 1998 that is). Literacy is high. It is suggested that in addition to geographic benefits Tuscans also continue to maintain a health giving lifestyle by choice: many realize the costs of racing headlong into industrialism and have chose to proceed at a slower pace.

Architecture, Community, and Spirituality

Tuscan buildings are made from local materials including stone and clay. The house we stayed in was crafted of stone, harvested from the local hills and indeed many of the houses in Tuscany are built of stone, perhaps due a lack of wood, perhaps due the history of warring villages and the fire resistance offered by stone, perhaps due to Catholicism. Whatever the cause, I found the effect compelling: living in a stone house is incredible calming and reassuring. I am not sure of the reasons however I can hypothesize that the protection from temperature fluctuations, human made sounds, synthetic materials emissions, electromagnetic fields, and other benefits of stone construction reduce stress levels. The great number of churches with amazing Gothic architecture are revered by tourists and locals alike for their beauty and permanence. Indeed one feels a closer connection to spiritual forces in such buildings simply because of their architecture. The design of villages also increases social interaction by centralizing activity in an open square where townspeople gather for everything from shopping to conversations, exercise, speeches and important ritual events, people watching and business dealings. I spent hours in the central plaza of Cortona observing local culture as it buzzed with activity all day. A sense of community inclusion is a documented stress reducer and an important aspect of protection from heart disease in Tuscan traditional culture.

Ethnopharmacology

The use of medicinal plants in Italy is as old as human occupation of this region. For example, anthropologists found a 5300 year-old mummified ice man in Northern Italy who used a herbal laxative, Piptoporus betulinus, which is a type of fungus. Tuscans have always maintained a strong connection to their traditional medicine. I frequently walked into pharmacies and found a wide array of natural products lining the shelves next to pharmaceutical drugs. In addition, the products labeling made medical claims that are not possible in the US healthcare system, and pharmacies acted more as community health education centers than as pill dispensers. Natural medicines are covered by insurance and herbalists are well respected in Tuscany to a much greater extent than in the US. One of the most important companies in Italy for natural medicines is Aboca http://www.aboca.us and I made a special trip out to their office in Sansepolcro in the beautiful valley of Valtiberina to tour their store and a museum covering the history of natural products and pharmaceuticals. A new Bastyr University course led by Dr. Robin Dipasquale, ND takes students to Aboca to learn about herbal medicine production including viewing fields of hawthorn in bloom, high volatile plants of helichrysum, rosemary, lavender and sage, anti-inflammatory meadowsweet, freeze dried extraction and instantization technology, and current regulations including German Commission E and ESCOP standards.

While content manager at Mothernature.com I researched natural products used in Ayurvedic medicine for an expedition being featured on the site and found a product originally sourced in the Mediterranean called Fenufibers (Sabinsa Inc.) the fiber-rich fraction obtained from defatted fenugreek seeds (Trigonella foenum-graecum, Family: Leguminosae) which are native to North Africa and countries bordering the eastern Mediterranean. The seeds of Fenugreek are a condiment commonly used in Indian homes and are a rich source of fiber, particularly gel fiber. Gel fiber from Fenugreek resembles guar gum in chemical structure. The product reduces serum total cholesterol, LDL and VLDL cholesterol, as well as triglyceride levels while HDL levels remain unchanged. Fenusterols TM is an extract obtained from defatted fenugreek seeds and is standardized to contain a minimum of 50% steroidal saponins. These saponins are also known as furostanol saponins. The principal furostanol saponin in Fenugreek is diosgenin. Diosgenin has been proven to have various effects on cholesterol metabolism, specifically in maintaining healthful LDL cholesterol levels. Other furostanols in fenugreek include gitogenin, tigogenin, smilagenin, sarsasaponin, etc. This product is also used for weight loss and diabetes.

While content manager at Nutros.com I also researched ethnobotanicals for performance from Mediterranean regions including Tuscany that impacted heart health. In particular I looked at plant sources of high quality fats consumed as part of the traditional diet. Tuscany is known for its olive products including the oil which is pressed from the fruit of the olive tree and contains a favorable fat structure for preventing cardio vascular problems. But more important is the way it is consumed: it is usually consumed cold and added to food after cooking. In the US consumers have taken to cooking with olive oil for cardiovascular goals which changes the fat structure and ignores anthropological evidence upon which heart health claims are found. Also Tuscan olive oil is traditionally produced on a small scale, local level from non-chemically treated, heirloom variety trees and extracted using cold, mechanical means, not chemical solvents. The result is an oil low in pesticide residues and high in various natural products which may work to promote heart health. You can taste the difference: the house we stayed in produced its own olive oil from trees grown on the property. It had a strong, medicinal flavor and dark chlorophyll rich color completely different from the bland, tasteless olive oil US consumers find on supermarket shelves which has been treated and highly filtered for storage and transport.

I also wrote another TLDP column on marine bioproducts which included some analysis of the chemical logic behind traditional use of olive oil and its effects on heart health. In particular I found research that indicated that squalene, an unsaturated hydrogen/carbon compound (a terpene) that occurs in high concentrations in the oil derived from the livers of certain deep-sea sharks and in olive oil, may be related to the latter's beneficial effects. Researchers believe that squalene may be the constituent of olive oil that is responsible for the reduced cancer, heart disease and mortality rates among traditional Mediterranean societies that consume large amounts of olive oil. (Newmark 1997) Animal studies suggest that squalene can lower blood levels of fats and cholesterol, and a recent human study found that squalene promoted the effectiveness of a statin-type cholesterol-lowering drug. (Chan: 1996)

The Tuscan Archipelago, particularly due to its geographical position and its history, presents a large variety of plant species used in traditional medicine in numerous pathologies, including several viral infections. The geographical isolation of this area has permitted the survival of a rich folk phytotherapy involving medicinal herbs and also vegetable resources used by locals as food medicine. Among the more than 400 plants used in popular medicine in Tuscany, over 30 are used in the therapy of hypertension. For example some research has looked at plants belonging to Gentianaceae and in particular Gentiana kokiana. Other examples are the use of Ballota nigra leaves as a trophic protective; the use of Lilium candidum bulbs as an antiviral to treat shingles (Herpes tester); Parmelia sp. as a cholagogue; Crocus napolitanus flowers as antiseptic; Prunus laurocerasus drapes as a hypotensive; and the consumption of chestnut flour polenta cooked with new wine as bechic. Many wild gathered greens are eaten raw in salads, or in boiled mixtures, as 'blood cleansing' and 'intestine cleansing' agents. Of particular interest is the persistence of the archaic use of Bryonia dioica root against sciatica, and the use of ritual plant therapeuticals as good omens, or against the 'evil eye.'

Finally, while product development coordinator at a major Bee Products company we sourced products from Italy and I was able to research bee products from Tuscany many of which serve important uses in protecting the cardiovascular system. My research assistant uncovered many abstracts on novel uses of royal jelly for example for promoting endurance among patients with heart problems, bee venom, and bee pollen. In particular we found a text produced by the FAO in Rome which describes many standards for royal jelly and bee products and their use in medicine.

Summary

Tuscany represents a good example of the role of traditional culture in acting to protect indigenous people from modern health problems. Many of the cardio-protective aspects of Mediterranean cultures including Tuscany have been overly generalized by epidemiological studies into slight shifts in diet among US consumers that do not accurately resemble true cultural conditions that provides protection from heart disease in this population. This article provides a more detailed overview of this subject based on the author's own visit to this region.

About the Author

Tim Batchelder is a bio-communications specialist with a background in medical anthropology and ethno-pharmacology. To reach him, email tim@anthrocode.com or visit his website http://www.anthrocode.com/ where you can find updates to articles including references, further research, feedback and links.