Mei Wan - BSc (Hons), MBDA, Registered Dietitian and Health Writer
Fruity, Italian cold-pressed extra virgin olive oil, a melt-in-the-mouth fillet of salmon, fruits, and vegetables brightly coloured from being kissed by the sun…they all sound pretty yummy don’t they? Did you know that these foods partly make up the Mediterranean diet? Luckily, you don’t need to book the next flight to Naples as these nutritious goodies can be found in your local supermarket, online, and at farmer's markets. In this article, I will share why you should consider incorporating a Mediterranean diet (also known as MedDiet) when living with osteoarthritis.
A Timeless Tradition + Modern Marvels
The MedDiet is based on a holistic healthy lifestyle rather than a prescriptive diet (hooray for food flexibility!). It’s based on natural food resources and the eating principles of people living in the Mediterranean basin, including Italy, Spain, and Greece [1]. A globally renowned and extensively researched dietary approach, the MedDiet has been recognised to improve cardiovascular health [2], type 2 diabetes prevention and progression [3], lowering the risk of certain cancers [4], and reducing the risk of dementia [5]. Where does the science stand for a MedDiet with improving symptoms and managing osteoarthritis? Let’s talk about that a little later but first…
The Mediterranean Trio: Nuts, Seeds + Olive Oil
The MedDiet is primarily based on plant-based foods:
All types of vegetables and fruit
A relatively high intake of nuts - specifically walnuts, almonds, hazelnuts, pistachios, and pine nuts [6]
A relatively high intake of seeds
A high intake of olive oil [7]
A variety of beans and pulses [8]
A range of wholegrains [9]
Lean proteins such as eggs and chicken
Moderate amounts of dairy and fish
Processed meats and all types of red meat are enjoyed in much smaller amounts
And light to moderate intake (up to 1 glass for women and two glasses for men a day) of wine [10]
The Power of the Mediterranean Diet for Osteoarthritis Relief
People living with obesity or people classified as overweight on the body mass index (BMI) are at a higher risk of osteoarthritis, and the prevalence is increasing due to the aging population [11]. Living with obesity significantly worsens osteoarthritis by increasing joint stress and inflammation. Excess weight directly puts more pressure on joints, accelerating cartilage wear and tear. In addition, adipose (fat) tissue releases inflammatory markers that may further aggravate joint inflammation, leading to faster disease progression and more severe pain [12]. Persistent, low-grade inflammation is a key driver in the development of osteoarthritis [13] and higher intakes of trans and saturated fats increase pain and risk factors associated with the condition [14]. A small number of studies have suggested that high adherence to a MedDiet can lower the prevalence of osteoarthritis by contributing to weight loss [15].
For example, a randomised feeding trial including males and females (91.2%) aged between 40 to 75 years with knee osteoarthritis demonstrated that weight, waist circumference, pain, pain severity (using the Visual Analogue Scale (VAS) pain intensity scale), and morning stiffness (using the Western Ontario and McMaster Universities (WOMAC) Arthritis pain index) all significantly reduced and improved following a MedDiet for 12 weeks [16]. They propose that as the MedDiet is higher in fiber, beta-carotene, magnesium, calcium, potassium, and omega-3 fatty acids, it has anti-inflammatory effects on the body. Therefore, regardless of weight loss, the pain severity of osteoarthritis in patients was reduced suggesting that dietary components of the MedDiet are efficacious [16].
Furthermore, a systematic review similarly suggested a positive association between the quality of life of people living with osteoarthritis and high adherence to a MedDiet [17]. The prevalence of osteoarthritis was also lower following a MedDiet as well as decreased biomarkers of inflammation and degradation of cartilage [17]. However, there are methodological differences and limited evidence on osteoarthritis and MedDiet so more high-quality studies are still needed.
In the same vein, a literature review found diets rich in fibre, featuring whole grains, fruits, vegetables, nuts, seeds, and legumes, like the MedDiet, helped manage osteoarthritis [18]. However, the effectiveness of nutritional interventions in preventing or managing osteoarthritis remains unclear due to mixed research findings [18].
A systematic review and meta-analysis (a total of 468 male and female participants aged between 30-90 years) found very low-quality evidence that a low-inflammatory diet like the MedDiet, is associated with improved health outcomes [19]. It suggested the need for dietitian-led trials to evaluate the low inflammatory diet on clinical and patient-reported outcomes specifically in osteoarthritis [19].
Final thoughts…
While the MedDiet could be helpful for most people, those living with medically diagnosed IBS, coeliac disease, who have specific food allergies and intolerances and/or are taking medications that may have drug-nutrient interaction(s), are encouraged to seek the support of a registered dietitian and/or a medical professional for a more personalised approach. Ultimately, what works for some people, might not work for everyone. What’s more, it is not only what you eat, but also how much of each food type you eat, when, and how you combine the foods to form a balanced diet that matches the requirements of your daily life. Healthnix strongly believes in the power of personalisation when it comes to diet, particularly if you suffer from multiple chronic conditions. Getting advice from a registered dietitian can help simplify your complex nutritional needs into a personalised and attainable plan which works around your lifestyle instead of forcing you to adopt dietary habits or lifestyle changes that simply do not fit your preferences.
Finally, as with most nutritional studies, we need more studies that have been well-designed and look at specific biomarkers relating to different chronic conditions. Outcomes can be nuanced when interpreting data from clinician-reported and patient-reported studies, particularly with the MedDiet and osteoarthritis research. Healthnix will be working with academic partners to generate reliable and robust evidence.
References
[1] Lacatusu CM, Grigorescu ED, Floria M, Onofriescu A, Mihai BM. The Mediterranean Diet: From an Environment-Driven Food Culture to an Emerging Medical Prescription. Int J Environ Res Public Health. 2019 Mar 15;16(6):942. doi: 10.3390/ijerph16060942. PMID: 30875998; PMCID: PMC6466433.
[2] Martínez-González MA, Gea A, Ruiz-Canela M. The Mediterranean Diet and Cardiovascular Health. Circ Res. 2019 Mar;124(5):779-798. doi: 10.1161/CIRCRESAHA.118.313348. PMID: 30817261.
[3] Martín-Peláez S, Fito M, Castaner O. Mediterranean Diet Effects on Type 2 Diabetes Prevention, Disease Progression, and Related Mechanisms. A Review. Nutrients. 2020 Jul 27;12(8):2236. doi: 10.3390/nu12082236. PMID: 32726990; PMCID: PMC7468821.
[4] Morze J, Danielewicz A, Przybyłowicz K, Zeng H, Hoffmann G, Schwingshackl L. An updated systematic review and meta-analysis on adherence to mediterranean diet and risk of cancer. Eur J Nutr. 2021 Apr;60(3):1561-1586. doi: 10.1007/s00394-020-02346-6. Epub 2020 Aug 8. PMID: 32770356; PMCID: PMC7987633.
[5] Nucci D, Sommariva A, Degoni LM, Gallo G, Mancarella M, Natarelli F, Savoia A, Catalini A, Ferranti R, Pregliasco FE, Castaldi S, Gianfredi V. Association between Mediterranean diet and dementia and Alzheimer disease: a systematic review with meta-analysis. Aging Clin Exp Res. 2024 Mar 22;36(1):77. doi: 10.1007/s40520-024-02718-6. PMID: 38519775; PMCID: PMC10959819.
[6] Ros, E. (2015). Contribution of Nuts to the Mediterranean Diet. The Mediterranean Diet, 175-184. https://doi.org/10.1016/B978-0-12-407849-9.00017-8
[7] Fernandes J, Fialho M, Santos R, Peixoto-Plácido C, Madeira T, Sousa-Santos N, Virgolino A, Santos O, Vaz Carneiro A. Is olive oil good for you? A systematic review and meta-analysis on anti-inflammatory benefits from regular dietary intake. Nutrition. 2020 Jan;69:110559. doi: 10.1016/j.nut.2019.110559. Epub 2019 Jul 25. PMID: 31539817.
[8] Viguiliouk E, Glenn AJ, Nishi SK, Chiavaroli L, Seider M, Khan T, Bonaccio M, Iacoviello L, Mejia SB, Jenkins DJA, Kendall CWC, Kahleová H, Rahelić D, Salas-Salvadó J, Sievenpiper JL. Associations between Dietary Pulses Alone or with Other Legumes and Cardiometabolic Disease Outcomes: An Umbrella Review and Updated Systematic Review and Meta-analysis of Prospective Cohort Studies. Adv Nutr. 2019 Nov 1;10(Suppl_4):S308-S319. doi: 10.1093/advances/nmz113. PMID: 31728500; PMCID: PMC6855952.
[9] Aune D, Keum N, Giovannucci E, Fadnes LT, Boffetta P, Greenwood DC, Tonstad S, Vatten LJ, Riboli E, Norat T. Whole grain consumption and risk of cardiovascular disease, cancer, and all cause and cause specific mortality: systematic review and dose-response meta-analysis of prospective studies. BMJ. 2016 Jun 14;353:i2716. doi: 10.1136/bmj.i2716. PMID: 27301975; PMCID: PMC4908315.
[10] Minzer S, Estruch R, Casas R. Wine Intake in the Framework of a Mediterranean Diet and Chronic Non-Communicable Diseases: A Short Literature Review of the Last 5 Years. Molecules. 2020 Oct 30;25(21):5045. doi: 10.3390/molecules25215045. PMID: 33143082; PMCID: PMC7663679.
[11] Sowers MR, Karvonen-Gutierrez CA. The evolving role of obesity in knee osteoarthritis. Curr Opin Rheumatol. 2010 Sep;22(5):533-7. doi: 10.1097/BOR.0b013e32833b4682. PMID: 20485173; PMCID: PMC3291123.
[12] Mobasheri A, Henrotin Y. Biomarkers of (osteo)arthritis. Biomarkers. 2015;20(8):513-8. doi: 10.3109/1354750X.2016.1140930. PMID: 26954784; PMCID: PMC4840279.
[13] Robinson WH, Lepus CM, Wang Q, Raghu H, Mao R, Lindstrom TM, Sokolove J. Low-grade inflammation as a key mediator of the pathogenesis of osteoarthritis. Nat Rev Rheumatol. 2016 Oct;12(10):580-92. doi: 10.1038/nrrheum.2016.136. Epub 2016 Aug 19. PMID: 27539668; PMCID: PMC5500215.
[14] Jungmann PM, Kraus MS, Alizai H, Nardo L, Baum T, Nevitt MC, McCulloch CE, Joseph GB, Lynch JA, Link TM. Association of metabolic risk factors with cartilage degradation assessed by T2 relaxation time at the knee: data from the osteoarthritis initiative. Arthritis Care Res (Hoboken). 2013 Dec;65(12):1942-50. doi: 10.1002/acr.22093. PMID: 23926027; PMCID: PMC4144858.
[15] Pitaraki EE. The role of Mediterranean diet and its components on the progress of osteoarthritis. J Frailty Sarcopenia Falls. 2017 Sep 1;2(3):45-52. PMID: 32313850; PMCID: PMC7161934.
[16] Sadeghi A, Zarrinjooiee G, Mousavi SN, Abdollahi Sabet S, Jalili N. Effects of a Mediterranean Diet Compared with the Low-Fat Diet on Patients with Knee Osteoarthritis: A Randomized Feeding Trial. Int J Clin Pract. 2022 Jan 31;2022:7275192. doi: 10.1155/2022/7275192. PMID: 35685492; PMCID: PMC9159202.
[17] Morales-Ivorra I, Romera-Baures M, Roman-Viñas B, Serra-Majem L. Osteoarthritis and the Mediterranean Diet: A Systematic Review. Nutrients. 2018 Aug 7;10(8):1030. doi: 10.3390/nu10081030. PMID: 30087302; PMCID: PMC6115848.
[18] Wei N, Dai Z. The Role of Nutrition in Osteoarthritis: A Literature Review. Clin Geriatr Med. 2022 May;38(2):303-322. doi: 10.1016/j.cger.2021.11.006. PMID: 35410682.
[19] Genel F, Kale M, Pavlovic N, Flood VM, Naylor JM, Adie S. Health effects of a low-inflammatory diet in adults with arthritis: a systematic review and meta-analysis. J Nutr Sci. 2020 Aug 27;9:e37. doi: 10.1017/jns.2020.31. PMID: 32983422; PMCID: PMC7503186.
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