It is my final week in San Giovanni. Four weeks in Italy have flown by. I have been welcomed into office spaces, homes, and restaurants by the most sincere people. Italians share a common, radiant pride in their culture and are consistently generous with their excitement for newcomers to experience the sights, sounds, smells, and tastes of their most notable resources.
I was introduced to so many people in town as one of the American doctors in San Giovanni in Fiore. After the first week, I realized I was probably one of the only Americans or native English speakers in town. I stuck out like a sore thumb many days when I could barely mutter the words "Parlo inglese" or "Parlo poco poco italiano". It was frustrating at first to engage with a group of people who spoke a language so familiar to my Italian ancestors but unfamiliar to me. I learned to politely say "Parli lentamente" meaning "speak slowly" when I was trying to understand a conversation in Italian. I also downloaded the Babble app and practiced with young adults who also wanted to improve their American English. I realized most Italians were excited that I was trying to speak their language. That was very encouraging and motivating.
The Italian love for the country, traditions, history, resources, and traditions was shown to me by many colleagues in San Giovanni in Fiore. My hosts took me to the Sila National Forest, the sea in La Castella, the castle in Santa Severina, and the upstairs balcony in the San Giovanni Abbazia. I indulged in porcini mushrooms, pizza crust unlike any I have tasted in America, homemade red wine, and a variety of almond-flavored pastries. I drank a cappuccino every morning and waited until 8 PM every night to sit down for dinner. I am thankful for this opportunity to experience the Italian way of life.
Calabria was more than what I was expecting for a cultural immersion. I truly got to understand the life of a local and what made this rural part of Calabria so special. I dabbled in the Mediterranean way of life - up in the Sila Mountains surrounded by fresh air and tall trees. Therefore, I find it fitting to culminate this series of blog posts about my time in Calabria by comparing what I have studied about the Mediterranean Lifestyle with what I have experienced this cultural immersion of mine.
The Mediterranean Diet research first began by Ancel Keys in the 1950s in his famous Seven Countries study. This research on Italy, Greece, Yugoslavia, the Netherlands, Finland, Japan, and the United States was intended to study the risk of heart disease with variation in diet across cultures. He noted that Mediterranean and Japanese cultures ate diets full of fish, vegetables, fruits, and oil and had a lower incidence of heart disease. On the other hand, Finland and the United States had higher rates of heart disease with diets high in saturated animal fats. Research on the Mediterranean Diet has grown since the original work of Ancel Keys. Newer research attributes not only a diet rich in unsaturated fats, legumes, whole grains, fruits, vegetables, and nuts to a lower risk of heart disease but also emphasizing the importance of physical activity and social engagement.
Italian culture is admired by many throughout the world for its excellent resources, food, health, and healthcare system. The Mediterranean lifestyle is embodied by Italian people through both what they eat and how they spend their time exercising their bodies and spirits. I thought it might be important to include some statistics on their population health to understand the areas in which they rank above others and where they are striving for improvement.
Italian culture is The State of Health in the European Union’s Country Health Profiles provides an annual overview of health and health systems in the EU/European Economic Area. The reports are the joint work of the Organization for Economic Cooperation and Development OECD and the European Observatory on Health Systems and Policies, in cooperation with the European Commission. The most recent publication was released in 2021 and emphasizes the particular challenges and characteristics of each country to foster an environment for mutual learning and collaboration. (2)
Some of the information I read about in the "Italy: Country Health Profile 2021" was alluded to me by physicians and community members that I met during my medical exchange. Things mentioned were the prevalence of obesity in children, a large number of young adult smokers, and the toll that COVID-19 had taken on the patient population. I highlighted some of the statistics below.
According to the OECD/European Observatory on Health Systems and Policies 2021 publication on Italy, life expectancy in Italy in 2020 was 82.4 years. It fell by 1.2 years since 2019 due to the deaths of COVID-19. Due to the harsh and early hit by the pandemic, Italy heightened its vaccination campaign. By the end of August 2021, 60% of Italians had received two doses of the COVID-19 vaccine, and an additional 10% had received only one dose. (2)
The OCED's 2021 publication also highlighted that tobacco and dietary risks are major contributors to mortality in Italy. Some 15% of all deaths in 2019 could be attributed to tobacco smoking, and dietary risks (including low fruit and vegetable intake, and high sugar and salt consumption) could attribute to 14% of all deaths. (2)
Smoking continues to remain a public health problem, although its rates have decreased throughout the 2000s with the nationwide ban on smoking in most indoor and public places. In 2019, 18% of Italian adults still smoked regularly with men smoking more prevalently than women. That rate was even higher in teenagers. In 2018, nearly 30 % of 15-year-olds reported having smoked in the past month. The EU has an ambitious goal to decrease the rate of smoking in adolescents to 5% by 2040. (2)
With a deeper dive into the weight and nutrition concerns in Italy, the OCED's 2021 publication highlights a national survey of primary school children. In that cohort, 30% of children aged 8-9 were either overweight or obese in 2019. (2)
The OCED report attributed poor nutrition as the main contributing factor to overweight and obesity. Adults reported a lower obesity rate than children at 11% in 2019. It was also reported in 2019 that nearly 40% of Italian adults do not eat vegetables every day, and over 70% of 15 year old do not eat vegetables every day. (2)
I find these statistics to be incredibly interesting when compared to my home state of West Virginia where the incidence of obesity or overweight among West Virginia children aged 10-17 has increased from 34.7% in 2017 to 41.0% in 2021 (1), which is a good bit higher than in Italy. While WV has a higher obesity prevalence in both childhood and adulthood, the two national populations have drastically different trends in adulthood. In WV, obesity remains high into adulthood at 37.7% in 2018 (3) while Italy's decreases as mentioned previously.
I found it super interesting that one of my Italian colleagues was very aware of the American prevalence of food deserts. I emphasized their significance in my home state of WV. On the contrary, Italy is rich in resources of fresh fruits and vegetables that are offered pending the season. The city streets were abundant with fresh fruit markets available daily to access things like broccoli, radishes, lettuce, oranges, and apples.
One of the physicians at the public health department has tried to capitalize on this fresh fruit and vegetable concept by remodeling the school lunch program. He is very passionate about preventative health and wants to make contributions to lowering the rates of childhood obesity.
His menu is modeled after the Mediterranean Diet which I have studied extensively as a medical student in the Culinary and Lifestyle Medicine Track at WVU SOM and written about earlier in this post. The daily school lunch menu includes appropriate portions and quantities of carbohydrates, fats, and protein depending on the child's age. The meals coincide with the principles of the Mediterranean Diet and emphasize the use of unsaturated fats, lean proteins, fresh fruits and vegetables, and legumes while minimizing dairy and sugar consumption.
I spoke extensively with this physician about the program because I was amazed by its nutritional content and how much the primary school students really cleaned their plates. It took him 6 months to implement this program and required a great team of cooks and organizers. Prior to this program, most students were bringing bagged lunches with poor nutritional content. This lunch program has allowed the health department to capitalize on nutrition at school hours to make up for the lack of nutrition that students may get for their evenings at home. I was so impressed.
When thinking about daily physical activity, the infrastructure in Italy makes walking to school, the grocery store, the park, or the doctor fairly accessible - unless mobility restricts the use of stairs and inclines. I saw many young people walk to the clinic or work every morning. In the evenings I would see so many Italian adults in the city center just out for "una passeggiata". They would meet up with friends, soak in some fresh air, and just get some movement and social activity in before the end of their day.
All of these components - nutrition, movement, sense of belonging, and social time are important components Mediterranean lifestyle. It is one focused on taking a breath each day, sharing a laugh, looking out for a friend, or celebrating an occasion. Italians take time to rest daily. They take time for meals with their family. They feast on simple foods made with the freshest ingredients.
Is it by these principles of the Mediterranean lifestyle that Italians live longer and reduce their risks of cardiac disease?
A large amount of literature points to say so. However, the lifestyle and the diet are not feasible for everyone. I can honestly say the quality of the grains, produce, and oils in Italy are far superior to what I have access to in the USA. We have a variety of options in the US, but the processing of those options someetimees strips the food of its nutritional contents.
When thinking about my future patients and neighbors, I have to think of the barriers to fresh fruits and vegetables with the food desserts or cold tundras across the world. I have to think of the busy mom who doesn't have time to cook fresh every night for her family or sit down at the dinner table. I have to think of the family who eats pizza for dinner every night because it's the most affordable and filling option for their income. These are the barriers I will face as a family medicine physician in the USA. These are the barriers we I comprehend and empathize with. These are the barriers that hopefully someday can be understood and overcome to improve health for all ages.
The difficulty with weight management is that it is often hard to pinpoint a single cause of obesity in a community. Weight changes could be multi-factorially attributable to nutrition, lack of physical activity, genetics, metabolism, age, chronic disease, medications, and psychosocial influences. The solution will likely be different for everybody.
As we continue to learn and grow together, we can trial different preventative actions for a reduction in obesity and heart disease. I hope to be a part of this effort through my love for culinary and lifestyle medicine as well as my completed Italian health exchange.
My global health rotation in 2023 hosted by the most wonderful colleagues in San Giovanni in Fiore in Calabria did not disappoint. After four rigorous years of medical school, I was officially immersed in the culture of my ancestors. I was refreshed with a new concept of work-life balance. I was reminded of the importance of family and supporting one another. During four short weeks in SGF, I was welcomed into a family that I am truly grateful to know and celebrate with.
Thank you to all who made this possible.
Next stop, graduation! 🎓
Sources:
(1) America's Health Rankings analysis of National Survey of Children's Health, U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), United Health Foundation, AmericasHealthRankings.org, accessed 2023 https://www.americashealthrankings.org/explore/measures/youth_overweight/WV
(2) OECD/European Observatory on Health Systems and Policies (2021), Italy: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris, https://doi.org/10.1787/5bb1946e-en.
(3) West Virginia Department of Health and Human Resources (2018), Fast Facts: Statistics about the population of West Virginia, Health Promotion and Chronic Disease, Charleston, WV, https://dhhr.wv.gov/hpcd/data_reports/pages/fast-facts.aspx
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