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The present paper reviews the main aspects of the health properties of Mediterranean food pattern and its components with particular regard to rheumatoid arthritis. The Mediterranean diet is based on a pattern of eating closely tied to the Mediterranean region and is characterized by an abundance of foods from plant sources, limited meat consumption, moderate amounts of fish, moderate consumption of wine and extravirgin olive oil as the main source of fat. The Mediterranean food pattern has shown a number of beneficial and healthy effects not only in preventing cardiovascular diseases and cancer, but also diabetes, metabolic syndrome, visceral obesity and arthritis. Most of these effects are related to the consumption of extravirgin olive oil which, with its high content of MUFA and non-fat microcomponents such as phenolic compounds, squalene and oleocanthal, has demonstrated important anti-inflammatory effects both in vitro and in vivo. Biologic response modifiers, such as TNF-alfa blockers, have set new therapeutic standards for the treatment of RA. On the other hand diet may represent a valuable support to the pharmacological treatment in rheumatoid arthritis.
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Current Rheumatology Reviews, 2009, 5, 233-240 233
1573-3971/09 $55.00+.00 © 2009 Bentham Science Publishers Ltd.
Mediterranean Food Pattern in Rheumatoid Arthritis
Francesca Oliviero*,1, Leonardo Punzi1 and Paolo Spinella2
1Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy
2Clinical Nutrition Unit, Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy
Abstract: The present paper reviews the main aspects of the health properties of Mediterranean food pattern and its
components with particular regard to rheumatoid arthritis.
The Mediterranean diet is based on a pattern of eating closely tied to the Mediterranean region and is characterized by an
abundance of foods from plant sources, limited meat consumption, moderate amounts of fish, moderate consumption of
wine and extravirgin olive oil as the main source of fat.
The Mediterranean food pattern has shown a number of beneficial and healthy effects not only in preventing
cardiovascular diseases and cancer, but also diabetes, metabolic syndrome, visceral obesity and arthritis.
Most of these effects are related to the consumption of extravirgin olive oil which, with its high content of MUFA and
non-fat microcomponents such as phenolic compounds, squalene and oleocanthal, has demonstrated important anti-
inflammatory effects both in vitro and in vivo.
Biologic response modifiers, such as TNF-alfa blockers, have set new therapeutic standards for the treatment of RA. On
the other hand diet may represent a valuable support to the pharmacological treatment in rheumatoid arthritis.
Keywords: Mediterranean food pattern, rheumatoid arthritis, diet, monounsaturated fatty acids, phenolic compounds,
inflammation.
INTRODUCTION
During the last few decades, very active research h as
demonstrated the vast array of biological effects induced by
different nutrients and foods. In this regard, the Medite-
rranean food pattern (MFP) has shown to be a very healthy
dietary model [1].
The Mediterranean diet attracted international interest
after the pioneer study conduced by Ancel Keys at the end of
the Second World War. Starting from the observation that
the population of southern Italy was characterized by greater
longevity, minor incidence of heart problems and cancer, in
the 1950s he decided to undertake the “Seven Countries
Study” in order to verify the health similarities of several
Mediterranean populations. The study showed that, despite a
high fat intake, the traditional dietary patterns typical of
Crete and southern Italy in the early 1960s were largely
responsible for the good health observed in these regions [2].
For the last few decades, several population studies
aimed to solidify the initial observation from the Seven
Country Study and demonstrate the relevance of virgin olive
oil, the hallmark of the traditional MFP, as a key cardio-
protective component of this alimentary regimen [3].
*Address correspondence to this author at th e Rheumatology Unit,
Department of Clinical and Experimental Medicine, University of Padova,
Via Giustiniani, 2, 35128 Padova, Italy; Tel: 0039 049 8212190; Fax: 0039
049 8212191; E-mail: francesca.o liviero@unipd.it
Thanks to these findings, we have learned that the cardio-
vascular protection from the MFP is not brought up only by
its effects of plasma lipid risk factors but by effects on
several other pathways, including insulin sensitivity, blood
pressure, inflammatory markers and arterial wall function
[4].
The outcome of these studies consistently supports that
the classical MFP and lifestyle factors are indeed protective
and compatible with healthier ageing and increased longevity
and promote the adherence to the MFP in the primary
prevention of chronic disease [1].
The aim of this report is to review the beneficial effects
of fat and non-fat components of the MFP, and to evaluate
the role of this dietary pattern based in virgin oil as a healthy
dietary model in a chronic condition such as rheumatoid
arthritis (RA).
Over the last decade, several new biologic agents have
become av ailable for the treatment of patients with RA. In
contrast to conventional disease modifying anti-rheumatic
drugs, these biological agents have rapid onset of action and
pronounced disease reducing activity. The impressive results
from numerous large-scale, controlled clinical trials with
biologic response modifiers indicate that monotherapy
treatment regimens and combination therapies with TNF
inhibitors have set new therapeutic standards for the
treatment of RA. Although diet is not part of this therapy,
patients could potentially gain from additional protective
effects of the MFP in particular in light of their increased
cardiovascular risk and drug side effects.
234 Current Rheumatology Reviews, 2009, Vol. 5, No. 4 Oliviero et a l.
THE PRINCIPLES OF THE MEDITERRANEAN
FOOD PATTERN
The traditional MFP is characterised by an abundance of
plant foods, such as vegetables, legumes, fruits, grain cereals
and nuts, and fish. Olive oil is the main source of fat, and the
intake of poultry, dairy products and eggs is moderate. In
addition, variable amounts of wine are usually consumed
with meals. The consumption of herbs and spices in the MFP
contribute to increase its health-promoting ch aracteristics
and the palatability of foods (Fig. 1) [5].
Many of the characteristic components of the MFP are
functional components with positive effects on health, capa-
Fig. (1). The Mediterranean diet pyramid: simple graphic format of the most up-to-date international scientific evidence supporting the
health benefits and culinary pleasures of the healthy, traditional Mediterranean eating and drinking pattern.
All plant foods (fruits, vegetables, grains, nuts, legumes, seeds, olives and olive oil) are placed in a single group at the base of the pyramid,
indicating that they should be the basis of most meals. The frequency of consuming fish and shellfish is at least two times per week, poultry
should be consumed in low-to-moderate amounts; relatively low consumption of red meat and moderate consumption of wine, normally with
meals is suitable. (With perm ission from Oldways Preservation Trust).
Mediterrane an Food Pa ttern in Rheumatoid Arthritis Current Rhe umatolog y Reviews , 2009, Vol. 5, No. 4 235
city and well-being, and may be responsible for the
advantages associated with this diet. Red wine, for example,
is rich in polyphenolic agents which are known for their
protectiv e effect in acute and chronic models of inflam-
mation. In particular resveratrol, a polyphenolic, natural
phytoalexin found with particularly high levels in grape skin
and red wine is potent and specific inhibitor of TNF-alfa and
IL-1beta induced NF-kappaB activation. Furthermore it has
been demonstrated that resveratrol is able to trigger apop-
tosis in fibroblast-like synoviocytes derived from patients
with RA [6].
Unlike other fat-rich diets such as the Western diet, most
of the fat content of the MFP comes from a single food
component, olive oil, which provides about 85% of the fat
content of this diet. This explains why the MFP is low in
saturated fats and cholesterol, lacking trans fatty acids, while
it has a high content of monounsaturated fatty acids
(MUFA), particularly oleic acid. Furthermore, given the fact
that olive oil possesses certain special gastronomic charac-
teristics, thanks to its richness in several microcomponents
that give it odour, colour and taste, the addition of olive oil
to certain dishes makes it easier to consume certain products
such as fruit and vegetables, legumes, and cereals, all of
which contain high proportions of low glycemic index carbo-
hydrates with high health-promoting potential [7]. The
benefits of the MFP are thus not due exclusively to olive oil
itself, but to th e combination with its other health-promoting
components, whose presence is favoured by the use of olive
oil as a gastronomic ingredient [8].
Olive Oil
Higher levels of consumption of olive oil are considered
the hallmark of the traditional MFP.
Olive oil is obtained from the fruits of Olea Europea, a
tradition al tree crop of the Mediterranean Basin. According
the International Olive Oil Council Report 2007-2008 [9] the
European Community supply more than 77% of the world
olive oil production, 82% of which comes from the
Mediterranean countries, mostly Spain (59%), Italy (23%)
and Greece (15%).
Depending on its chemical properties and its degree of
acidity, olive oil is classified into different grades. The most
valuable kind of olive oil is the extravirgin one, obtained
from intact olives that are quickly processed and cold-
pressed. Therefore, in contrast to other edible oils with a
similar fatty composition virgin olive oil is a natural juice
and must not be refined before consumption. It is a source of
healthy unsaturated fatty acids and hundreds of micronu-
trients, especially antioxidants, as phenol compounds, vita-
min E and carotenes (Table 1) [10].
Cumulative evidence suggests that olive oil may have a
role in the prevention of coronary disease and several types
of cancer because of its high levels of MUFA and poly-
phenolic compounds [11].
Olive Oil Fat Components
Peculiar to olive oil is the abundance of oleic acid, a
MUFA (18 : 1n-9) which ranges from 56 to 84% of total
fatty acids, while the polyunsaturated linoleic acid (18 : 2n-
6), the most abundant fatty acid present in the majority of
seed oils, is present in concentrations between 3 and 21%
(usually 7-10%) [12]. Compared to polyunsaturated fatty
acids, oleic acid has one double bond, making it much less
susceptible to oxidation and contributing to the antioxidant
action, high stability, and long shelf life of olive oil [10].
Several in vitro and in vivo studies have examined the
effect of MUFA on cardiovascular diseases, cancer and
aging.
A high- MUFA diet is ab le to lower total and LDL (low
density lipoproteins)- cholesterol levels by 10% and 14%,
respectively, and to enhance HDL (high density lipopro-
teins)-cholesterol levels and triacylglycerol concentrations as
compared with an average american diet decreasing CVD
risk by an estimated 25% [13]. Furthermore, olive oil imp-
roves the postprandial lipoprotein metabolism inducing
Table 1. Major and M inor Components of Olive Oil with the Main Beneficia l Effects
Components Main Effects
FAT
(~98%)
Oleic acid (n-9)
Linolenic acid (n-3)
Anti-inflammatory
Anti-c ar cino genic
Lipid-lowering
Anti-atherogenic
Anti-hypertensive
non-FAT
(~2%)
Phenolic compounds
-simple phenols: tyrosol, hydroxytyrosol, ligstroside
-secoiridoids: oleuropein and oleocanthal
-lignans: acetoxypinoresinol, pinoresinol
Triterpenes
-squalene
-tocopherol and carotenoids
Sterols
Flavonoids
-luteolin an d quercetin
Anti-oxidant
Anti-car cinogenic
Anti-thromb otic
Anti-inflammatory
Anti-angiogenic
Lipid-lowering
Anti-atherogenic
236 Current Rheumatology Reviews, 2009, Vol. 5, No. 4 Oliviero et a l.
lower triacylglycerol postprandial concentrations and higher
HDL-cholesterol concentrations than did acute saturated fat
intake [14]. Dietary monounsaturated fats may also provide
additional benefits by acting on other classical cardiovascu-
lar risk factors, including the reduction of blood pressure,
both in normal and hypertensive subjects, and the improve-
ment of carbohydrate metabolism both in healthy subjects
and in type 2 diabetic patients [15].
Substantial evidence suggests that MUFA can modulate
biological pathways implicated in the development of
atherosclerosis. LDL particles from individuals consuming a
MFP are protected from oxidative modification as compared
with individuals consuming high polyunsaturated fatty acids-
enriched diets [16]. The data obtained from an in vitro model
of early atherogenesis based on cultured endothelial cells
provide evidence that the incorporation of oleic acid [17]
into the cultures, reduces messenger RNA levels for vascular
cell adhesion molecule 1 (VCAM-1), interfering with the
activation of the most important transcription factor contro-
lling endothelial activation, nuclear factor kappa B (NF-kB).
The MFP elicits a less prothrombotic environment by
improving endothelial-dependent vasodilatation and modify-
ing different haemostatic components, such as platelet aggre-
gation, fibrinogen, Von Willebrand factor, total plasma
factor VII, tissue factor and PAI-1 (plasminogen activator
inhibitor type I) plasma levels [16].
The high monounsaturated fat energy intake appeared to
be associated with a reduced risk of age-related cognitive
decline. This effect could be related to the role of monounsa-
turated fatty acids in maintain ing th e structural integrity of
neuronal membranes [18]. Moreover, very recent findings
have shown that high intake of monounsaturated fat may be
protectiv e against Alzheimer’s disease, [19] and cellular
oxidative stress [20].
Epidemiologic and experimental studies have found a
role of dietary lipids in cancer, particularly breast, colorectal,
and prostate cancers [21]. Although human studies about the
effects of dietary lipids are little conclusive experimental
data have clearly demonstrated that the influence of dietary
fats on cancer depends on the quantity and the type of lipids.
Whereas a high intake of n-6 PUFA and saturated fat has
tumor-enhancing effects, n-3 PUFA, conjugated linoleic acid
and gamma-linolenic acid have inhibitory effects. Data
regarding MUFA have not always been conclusive, but high
olive oil diets seem to have protective effects [22].
It has been demonstrated that olive oil has a role on
colorectal neoplasia protection inducing apoptosis and cell
differentiation and down-regulating the expression of cyclo-
oxygenase-2 (COX-2) and Bcl-2, key molecules in colorectal
cancer development [23]. Other researchers reported oleic
acid down-regulates the expression of an oncogene over-
expressed in approximately 20-percent of breast carcinomas
[24]. Menendez et al. found oleic acid acts synergistically
with anticancer biologic drug to enhance its action [24].
A very recent study reveals the anti-diabetic and anti-
inflammatory properties of oleic acid. Oleic acid was found
to be effective in reversing the inhibitory effect in insu lin
production of the inflammatory cytokine TNF demonstra-
ting a beneficial effect in type II diabetes and in reversing the
negative effects of inflammatory cytokines observed in
obesity and non insulin dependent diabetes mellitus [25].
Olive Oil Non-Fat Components
While most vegetable oils are ex tracted from seeds by
solvents, olive oil is obtained from the whole fruit by means
of physical pressure. As a result, the oil retains the lipophylic
components of the olive and all its organoleptic properties.
Among the several minor constituents of virgin olive oil
there are vitamins such as - and -tocopherols and -caro-
tene, phytosterols, pigments, terpenic acids, flavonoids such
as luteolin and quercetin, squalene, and phenolic compounds
[26].
There exist data which indicate that virgin olive oil has
further beneficial effects, which also depend on these minor
components, in particular on phenols. Experimental studies
have shown that they demonstrate antioxidant properties,
chemopreventive activity and the ability to improve endo-
thelial function. Moreover, they may also modify haemo-
stasis, inhibiting platelet aggregation and displaying antithr-
ombotic properties [27].
Phenolic compounds can be divided into three categories:
simple phenols, secoiridoids and lignans. Their concentration
depends on a number of factors, including environmental
growth conditions, method of oil production, and storage
conditions. Major phenols include hydroxytyrosol, tyrosol,
oleuropein, and ligstroside. Hydroxytyrosol and tyrosol are
simple phenols and oleuropein is a secoiridoid [12].
As catechols, both hydroxytyrosol and oleuropein exhibit
antioxidant activity scavenging free radicals and inhibiting
LDL oxidation [27]. One mechan ism associated with th e
anticancer effects of hydroxytyrosol and oleuropein is
prevention of DNA damage, which can prevent mutagenesis
and carcinogenesis [26].
Recen tly a secoiridoid derivative, oleocanthal has been
identified in newly pressed extra-virgin olive oil. This
compound, inducing a pungent sensation in the throat, has
demonstrated anti-inflammatory activity and inhibition of
cyclooxygenase enzymes in the prostaglandin-biosynthesis
pathway similar to that of ibuprofen [28].
An important contribution to the phenolic fraction of
olive oil is constituted by lignans (acetoxypinoresinol,
pinoresinol) which play a major role in the health promoting
effects of the MFP. Lignans are metabolized in the gut to
produce the phytoestrogens enterolactone and enterodiol.
Phytoestrogens have an anticarcinogenic potential through
the anti-estrogenic, anti-angiogenic, proapoptotic and anti-
oxidant mechanisms [29]. Lignans have been shown to
inhibit skin, breast, colon, and lung cancer cell growth [30],
to be potent antioxidants in vitro and to inhibit lipid
peroxidation in vivo [10].
Among those of the unsaponifiable fraction its major
component squalene has been proposed as a causal factor for
the low incidence of cancer in Mediterranean countries.
Squalene is a triterpene hydrocarbon and an intermediate of
the cholesterol biosynthesis pathway. Olive oil contains
higher amount of squalene (0.4%) compared to seed oils
[10]. Experimental studies have shown that squalene can
effectively inhibit chemically-induced colon, lung and skin
Mediterrane an Food Pa ttern in Rheumatoid Arthritis Current Rhe umatolog y Reviews , 2009, Vol. 5, No. 4 237
tumourigenesis in rodents [31] although the evidence for the
inhibition depends on the effective dose used and the time of
exposure and the long-term effects from consuming
increased levels of squalene are not known.
EVIDENCES OF TH E BENEFICIAL EFFECTS OF
THE MEDITERRANEAN FOOD PATTERN: LARGE
CLINICAL STUDIES
There have been a number of epidemiological studies
showing the value and healthfulness of the MFP which
continues to receive strong corroboration through nutrition
research.
The first clinical-trial evidence in support of the health
benefits of the MFP came from the Lyon Diet Heart Study
[32] in which 605 patients who had had a myocardial
infarction were randomly assigned to a Mediterranean-style
diet or a control diet resembling the American usual post-
infarct prudent diet. After a mean follow-up of 27 months,
the rate of coronary events was reduced by 73%, and total
mortality was reduced by 70% in the intervention group.
Greater adher ence to the MFP has been associated with a
lower incidence of degenerative disease, in particular cardio-
vascular disease, cancer [33-35] and a lower total mortality
from these conditions [3].
Some clinical studies have suggested that the MFP can
modulate biological pathways implicated in the development
of atherosclerosis. This dietary pattern has been associated
with a significant long-term reduction in systolic and dia-
stolic blood pressure, and also with many other anti-inflam-
matory and metabolic effects reducing concentrations of C-
reactive protein, IL-6, IL-7, IL-18, and insulin resistance [4,
36]. The Spanish cohort of the SUN project support the
benefits of a MFP and olive oil against coronary heart
disease and hypertension after 28.5 months of follow-up
[37].
Although the global model of the MFP contains other
nutrients that are capable of reducing blood pressure, the
important contribution of olive oil gives it a particularly
prominent role. Most recently, Psaltopoulou, in a Greek
cohort of the EPIC study, which comprised more than 20,000
persons, observed that adherence to the MFP was associated
with lower blood pressures, with olive oil being an
individual predictor of this effect [38]. There also exist
studies that suggest that this action need not be an effect of
oleic acid alone, but also of the microcomponents of virgin
olive oil [39].
Very recently Trichopoulou has investigated the relative
importance of the individual components of the MFP in the
overall mortality in the cohort of the EPIC study, finding that
the dominant components of the MFP that contribute to
lower mortality are moderate consumption of ethanol, low
consumption of meat and meat products, and high consump-
tion of vegetables, fruits and nuts, olive oil, and legumes
[40].
Finally, adherence to a modified MFP, high in foods of
vegetable origin and unsaturated fatty acids, has been asso-
ciated with lower abdominal adiposity measured by waist
circumference as suggested in a study conducted in 497,308
elderly individuals from 10 European countries [41]. These
observations are supported by the MEDIS study carried out
in elderly individuals from eight Mediterranean Islands in
Greece and Cyprus [42].
WHY TO PAY ATTENTION TO DIET IN
RHEUMATOID ARTHRITIS
Rheumatoid arthritis (RA) is a chronic inflammatory
disease that leads to progressive disability and a reduction in
life expectancy. The destruction of cartilage and bone are
hallmarks of chronic RA. A variety of mechanisms charac-
terize joint and tissue damage, many of which involve solu-
ble immune mediators with tumor necrosis factor a (TNF)
and interleukin (IL)-1 providing primary inflammatory
roles in disease development [43]. Reactive oxygen species
also participate in the development of RA joint d amag e
causing destruction of hyaluronic acid and disruption to
collagen, proteoglycans, protease inhibitors, and membrane
function, the latter via oxidation of membrane fatty acids
[44].
A number of pharmacological agents have proven useful
in controlling RA, such as soluble cytokine receptor proteins
and humanized monoclonal antibodies [45]. However,
interventions that support the pharmacological treatment in
RA would be valuable.
Given the strong inflammatory nature of RA, patients are
at increased risk for comorbid ities such as coronary heart
disease and osteoporosis [46]. It is therefore reasonable to
hypothesize that dietary factors may influence the etiology of
inflammatory joint disease and also alleviate the symptoms
of RA.
Moreover, as macro- and micronutrients in the diet are
essential for maintaining the function of immune cells [47]
one could speculate that a dietary pattern rich in nutrients
with favourable anti-inflammatory properties and poor in
pro-inflammatory nutrients may protect from autoimmune or
other chronic diseases that are related to chronic
inflammation (e.g., visceral obesity, type 2 diabetes mellitus,
or atherosclerosis).
Indeed, higher intakes of meat and total protein, as well
as lower intakes of fruit, vegetables, and vitamin C, are asso-
ciated with an increased risk of inflammatory polyarthritis or
rheumatoid arthritis, while several studies suggest that the
Mediterranean-type diet or its main components may have
protective effects on the development or severity of rheu-
matoid arthritis [48].
The anti-inflammatory effect of MFP needs to be
considered in the context of inflammation.
Epidemiological studies have revealed a protective effect
of the MFP against mild chronic inflammation and its meta-
bolic complications.
Chrysohoou et al. [49] in a study of 3042 men and
women without known cardiovascular disease from the
Attica area of Greece examined the association between
adherence to the MFP (assessed by a diet score that
incorporated the inherent characteristics of this diet), and
inflammatory markers. Participants who were closer to th e
MFP had lower CRP, IL-6 and homocysteine levels, lower
238 Current Rheumatology Reviews, 2009, Vol. 5, No. 4 Oliviero et a l.
white blood cell counts, and lower fibrinogen levels, as com-
pared with those who were “away” from this dietary pattern.
Therefore, the MFP could serve as an anti-inflammatory
dietary pattern, which could protect from or even treat
diseases that are related to chronic inflammation.
In addition, dietary n-9 MUFAs, such as oleic acid, have
been found to replace n-6 PUFAs in several aspects of cell
metabolism. Reducing the competition between n-6 and n-3
PUFAs can lead to an increased use and incorporation of n-3
PUFAs.
Moreover, oleic acid (C18:1n-9) is converted to eicosa-
trienoic acid (ETA; C20:3n-9) which, in turn, is converted to
LTA3, a potent inhibitor of leukotriene B4 synthesis [50].
All these aspects, with th e finding that oleic acid is
capable of interfering with the effect of the inflammatory
cytokine TNF- [25] provides further evidence to the imp-
ortance of regulating inflammation using naturally occurring
molecules found in certain foods and support the use of diet
manipulation to treat diseases that have an inflammatory
aetiology.
Mediterranean Diet in Rheumatoid Arthritis
The first controlled randomised trial on the efficacy of
dietary treatment in RA was conducted more than two
decades ago by Sköldstam who tested the effect of fasting
and lactovegetarian diet in patients with RA [51].
Since then a modest number of studies on dietary
interventions have been carried out in p atients with RA. The
effects of these manipulations are, however, still uncertain
due to the fact that studies are small single trials with mode-
rate to high risk of bias and not always directly comparable
[52]. There has been so me evidence the MFP have a role in
protecting against RA onset or in preventing disease
progression although is limited [53-55].
In order to study the relationship between dietary factors
and the risk of RA, Linos et al. studied 145 RA patients and
188 control subjects investigating the relationship between
the consumption of olive oil, fish, vegetables and a series of
food groups and the development of RA. In their study, the
risk of developing RA was inversely and significantly
associated with cooked vegetables and olive oil [55].
In a prospective, double-blind, randomized study of
dietary supplementation with fish oil and olive oil Kremer et
al. found that dietary supplementation with olive oil is asso-
ciated with certain changes in immune function decreasing
neutrophil leukotriene B4 production [56].
Skoldstam et al. investigated the efficacy of a MFP
compared with an ordinary Western diet for suppression of
disease activity in patients with RA. Fifty-six patients with
active RA receiving stable pharmacological treatment w ere
randomly allocated to the MFP or the control diet. After
three months, the patients in the MFP group showed a
decrease in the DAS28 score, a decrease in the HAQ score
and an increase in physical function and improved vitality,
whereas no significant improvements were seen in the
control group [57].
Examining the dietary intake of fatty acids, as well as the
fatty acid profile in serum phospholipids, the same authors
observed a lower ratio of n-6 to n-3 fatty acids in the MFP
group, with patients with a better clinical improvement
having a higher reported intake of n-3 fatty acids [58]. The
importance of the ratio of n-6/n-3 essential fatty acids has
been widely reported. In the traditional MFP it is 1-2 while
in many Western countries is around 15-17 [59]. Although
the results of these study support the importance of the fatty
acid intake in patients with RA, authors emphasise that it
remains to be shown if long term consumption of MFP is
beneficial for patients with RA.
The study of Berbert et al. underlines the role of the
combined consumption of olive oil and fish oil. He found
that patients with RA showed a more precocious and accen-
tuated improvement in clinical and laboratory parameters of
disease activity when fish oil supplements were used in
combination with olive oil [50].
One other study compared an ordinary diet with fasting
followed by a MFP [60]. In this work the authors assessed
whether it was possible to modify dietary lifestyle, disease
activity and cardiovascular risk in female patients with RA
living in areas of social deprivation by introducing them to a
Mediterranean-type d iet. They demonstrated that this inter-
vention was achievable and well received by patients who
showed a modest improvement in a number of measures of
disease activity such as pain score, patient global assessment
and patient function. This study has shown that Medite-
rranean-type diet may be a useful therapeutic adjunct to
conventional DMARDs, feasible in routine clinical practice
and popular with patients.
Finally, the original description of the MD involved the
idea of extensive physical activity (mainly related to work
and outdoor leisure activities) something quite common
among Mediterranean populations until the 1960s. Recove-
ring a higher level of physical activity may provide benefits
in addition to those associated with the regular consumption
of functional ingredients, even if we have not to forget that
patients with RA are sometime limited by their condition and
therefore need to participate in adequate exercise progra-
mmes [61,62].
CONCLUSION
Over the last 50 years much attention has been focused to
the role of certain food on the development and progression
of chronic diseases. In this context the Mediterranean dietary
model has showed a number of beneficial and healthy effects
not only in preventing cardiovascular diseases and cancer,
but also diabetes, metabolic syndrome, visceral obesity and
arthritis.
Most of these effects are related to the consumption of
extravirgin olive oil which, with its high content of MUFA
and non-fat microcomponents such as phenolic compounds,
squalene and oleocanthal, has demonstrated important
antinflammatory effects both in vitro and in vivo.
A number of aspects remain to be elucidated with regard
to the mechanisms of action by which the MFP exerts its
beneficial effects, and whether the Mediterranean diet is able
to modify objectively the disease. The level of evidence
favouring Mediterranean diet in RA is limited because it is
based on relatively small and most often single trial. This
Mediterrane an Food Pa ttern in Rheumatoid Arthritis Current Rhe umatolog y Reviews , 2009, Vol. 5, No. 4 239
important limitation preclude any firm conclusion on the
magnitude of the benefit of the diet and the level of benefit
for the patients. On the other hand the Mediterranean diet is
generally considered nutritionally adequate, covering all the
food groups, and it is recommended for people with heart
disease and osteoporosis. Therefore, this antioxidant and
antinflammatory diet pattern may represent a valuable
support to the pharmacological treatment in RA that in no
case should be substitute. New trials sufficiently powered are
necessary to enhance our knowledge on the possible benefits
of dietary interventions in RA.
Further prospective, population-based studies using
robust dietary assessment methods are required to determine
whether diet plays a role in susceptibility to RA.
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Received: August 29, 2009 Revised: November 11, 2009 Accepted: November 12, 2009
... It is hypothesised that changes in environmental and lifestyle factors [4], one of which is diet, may contribute to the expression and severity of RA [5]. As such, dietary manipulation is commonly used to manage and minimise the symptoms of RA [6] through several mechanisms, such as lowering inflammation, increasing antioxidant levels, altering lipid profiles in favour of lipids 1 3 that provide anti-inflammatory benefits, as well as potentially modifying the intestinal flora [5][6][7]. ...
... The scientific and general interest in MD has grown dramatically in recent years as a healthy and recommended dietary pattern for the prevention and treatment of a range of health conditions including primary and secondary prevention of cardiovascular disease (CVD) [11,12], type 2 diabetes mellitus [13,14], dementia [15] and various types of cancer [16][17][18]. While there is evidence to recommend MD as a beneficial dietary regime for conditions associated with inflammation, e.g., the prevention of CVD [19], to date, there is limited evidence to suggest that the MD is beneficial in the prevention and treatment of other conditions, including RA [5,7]. Several reviews have aimed to evaluate the effectiveness of a range of different dietary interventions, including vegetarian or vegan, MD, elimination, fasting and elemental diets, for the treatment of RA, and management of its side effects, including fatigue [6,[20][21][22][23], however, the results remain largely inconclusive and there is lack of systematic reviews analysing the role of the MD in both the aetiology and the management of pain and stiffness in RA. ...
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Rheumatoid arthritis is a progressive autoimmune disease characterised by severely swollen and painful joints. To compliment pharmacotherapy, people living with rheumatoid arthritis often turn to dietary interventions such as the Mediterranean diet. The aim of the present systematic review is to discuss the effects of the Mediterranean diet on the management and prevention of rheumatoid arthritis in human prospective studies. Four studies met the inclusion criteria, including two intervention studies reporting improvement in the pain visual analogue scale (p < 0.05) and a decrease in the health assessment questionnaire for rheumatoid arthritis score (p < 0.05) in the Mediterranean diet groups. Only one study reported a reduction in the 28 joint count disease activity score for rheumatoid arthritis for the Mediterranean diet group (p < 0.05). This review has identified beneficial effects of the Mediterranean diet in reducing pain and increasing physical function in people living with rheumatoid arthritis. However, there is currently insufficient evidence to support widespread recommendation of the Mediterranean diet for prevention of rheumatoid arthritis.
... Olive oil's beneficial effects has been attributed to its highly present antioxidant phenolic compounds, vitamin E and high concentration in monounsaturated fatty acids (Musumeci et al., 2013b). Recently, various phenolic compounds extracted from EVOO and olive leaves have attracted much attention due to their antioxidant and antiinflammatory properties (Oliviero et al., 2009). Moreover, in our previous study, we investigated a possible preventive treatment for OA, given by the combination of Mediterranean diet, based on consumption of EVOO, and mild physical activity. ...
... Phenolic compounds in EVOO have been shown to exert beneficial impact, as they may interact with the inflammatory cascade (Rosillo et al., 2014) and have an anti-inflammatory effect with reductions in joint edema and migration of inflammatory cells. This interaction is primarily related to their ability to scavenge free radicals (Oliviero et al., 2009;Rosignoli et al., 2013). On the other hand, other reports on the biological properties of olive oil constituents (Visioli and Bernardini, 2011;Rosignoli et al., 2013) suggest that the anti-inflammatory effects of phenolic olive oil extracts are likely dependent on the mixture of the different phenolic compounds considering the different synergic links that could exist between these compounds. ...
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Osteoarthritis (OA) is a common joint disease with important socio-economic impact. Looking for a novel natural treatment represents an important challenge and a public health objective. A wide range of previous studies highlighted the antioxidant and anti-inflammatory properties especially of phenolic compounds present in olive oil. Therefore, the aim of this study was to investigate the anti-inflammatory activity of Tunisian Extra Virgin Olive Oil (EVOO) extracts in an in vitro OA model. To this aim we evaluated the polar and apolar olive oil fractions and olive leaf extract. The antioxidant capacity of these extracts was determined by using DPPH and FRAP assays. For the in vitro study, the human OA chondrocytes were exposed to lipopolysaccharide (LPS) to induce inflammatory response. The inducible isoform of nitric oxide syntheses (iNOS) and collagen type II expressions were evaluated by immunocytochemistry and western blot analysis. Principal outcome showed that the extracts had important anti-inflammatory potential by decreasing iNOS synthesis in OA chondrocytes. The anti-inflammatory effect was dependent on the extract composition and the used dose. An insignificant effect was seen on collagen type II expression. These results show that nutritional components contained in Tunisian EVOO influence the cellular metabolism, suggesting their potential therapeutic use in patients with inflammatory joint diseases.
... In that study, only recommendations were given, and the diets differed under all aspects. However, there is limited but univocal evidence to suggest that the Mediterranean diet is beneficial in the prevention and treatment of pathological conditions, including RA [5,18,50]. The protective effect of the Mediterranean diet on RA disease activity may be due to changes in the gut microbiota of the patients as shown in the study Prevention with Mediterranean Diet-(PREDIMED): [51]. ...
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Introduction: Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease affecting the synovial joints and causing severe disability. Environmental and lifestyle factors, including diet, have been proposed to play a role in the onset and severity of RA. Dietary manipulation may help to manage the symptoms of RA by lowering inflammation and potentially decreasing pain. Methods: In 40 patients with long-standing RA with stable symptoms and treated with conventional (c-) and biological (b-) disease modifying anti-rheumatic drugs (DMARDs), the effect of a 3-month diet avoiding meat, gluten, and lactose (and all dairy products; privative diet) was evaluated in comparison with a control balanced diet including those foods. Both diets were designed to reduce weight since all patients were overweight or obese. Patients were randomly assigned to one of the diets, and RA was clinically assessed at Time 0 (T0), through the Visual Analogue Scale (VAS), for pain, and the Disease Activity Score of 28 joints (DAS 28) for RA activity. Patients were also administered the Short Form Health survey (SF-36) and the Health Assessment Questionnaire (HAQ). At T0, a blood sample was collected for laboratory tests and adipokines measurements, and anthropometric measurements were compared. These evaluations were repeated at the end of the 3 months' dietary regimens. Results: A significant decrease in VAS and the improvement of the overall state of physical and mental health, assessed through SF-36, was observed in patients assigned to the privative diet. Both dietary regimens resulted in the improvement of quality of life compared to baseline values; however, the change was significant only for the privative diet. With either diet, patients showed significant decreases in body weight and body mass index, with a reduction in waist and hips circumference and lower basal glucose and circulating leptin levels. A privative diet was also able to significantly reduce systolic (p = 0.003) and diastolic (p = 0.025) arterial pressure. The number of circulating leukocytes and neutrophils, and the level of hs-C-Reactive Protein also decreased after 3 months of the meat-, lactose-, and gluten-free diet. Conclusions: Our results suggest that a privative diet can result in a better control of inflammation in RA patients under stable optimized drug treatment.
... In particular, an interesting discussion has arisen among the scientific community about the origin of the positive effects of the so-called Mediterranean diet on the individual well-being, since its first announcement in the Seven Country Study in 1970 [1]. During this period, a number of papers has been published attempting to establish a rational link between the habit of a Mediterranean diet and the reduction of some degenerative diseases, such as cardiovascular and metabolic diseases, Alzheimer's, cancer and inflammatory disorders, as well as a life span expectation [2][3][4][5][6][7][8][9][10][11][12]. The traditional Mediterranean diet is based on the intake of vegetables, fish, fruits, grains and extra-virgin olive oil (EVOO) as main lipid supplies. ...
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This review is a brief but comprehensive overview on the multi-target profile of oleocanthal, an extra-virgin olive oil (EVOO) phenol corresponding to the (-)-decarboxymethylligstroside aglycone, speculating about its potential in the prevention and/or treatment of various diseases, such as neurodegeneration, inflammation and cancer.
... Specific components of the MDP have received increasing attention because of a variety of health-promoting properties in chronic inflammatory and degenerative diseases [41]. Both nutritive (fat) and non-nutritive (nonfat) components of the MDP have been shown to exert important anti-inflammatory activities both in vitro and in vivo by modulating the arachidonic acid cascade, the expression of some proinflammatory genes, and the activity of immune cells [1]. ...
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Arthritis encompasses a heterogeneous group of diseases characterised by inflammation that leads not only to joint damage, bone erosion, severe pain and disability, but also affects other organs of the body, resulting in increased morbidity and mortality. Although the mechanisms underlying the pathogenesis of joint diseases are for the most part unknown, a number of nutrient and non-nutrient components of food have been shown to affect the inflammatory process and, in particular, to influence clinical disease progression. The Mediterranean diet model has already been linked to a number of beneficial health effects: both fat and non-fat components of the Mediterranean dietary pattern have been shown to exert important anti-inflammatory activities by affecting the arachidonic acid cascade, the expression of some proinflammatory genes, and the activity of immune cells. N-3 polyunsaturated fatty acids, in particular, have been shown to affect lymphocyte and monocyte functions, crucially involved in adaptive and innate immunity. Although some aspects concerning the mechanisms of action through which the Mediterranean diet pattern exerts its beneficial effects remain to be elucidated, arthritis patients may potentially benefit from it in view of their increased cardiovascular risk and the treatment they require which may have side effects.
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Ten years ago the Mediterranean diet was inscribed into the United Nations Educational, Scientific and Cultural Organization (UNESCO) Representative List of Intangible Cultural Heritage of Humanity. This official recognition of the Mediterranean diet as intangible cultural heritage, and awareness of its significance, has provided us with a measure with which to monitor our path in the field. Indeed, the last ten years has seen several undertakings with varying implications in the years to come. Emphasis on safeguarding the intangible heritage of the Mediterranean diet and activities to avoid possible erosions which may affect it at a national, regional and local level have taken centre stage. Preserving our heritage also recognized the importance of further research and we ask what needs to be focused on over the next ten years. Gradually, several myths and misconceptions associated with the traditional Mediterranean diet have emerged and should be clearly addressed and dispelled, particularly those that label as "Mediterranean" an eating pattern that is not in line with the traditional diet. Going beyond physical health benefits, the Mediterranean diet naturally infuses any reference to 'Sustainability' by pure definition as ideally, sustainable diets are protective and respectful of biodiversity, culturally acceptable, accessible, economically affordable, nutritionally adequate, and safe and healthy. As our ‘Regional’ Mediterranean diet becomes the base for a global reference diet with all the acknowledged benefits, we agree that ‘humanity as a whole’ will benefit from its preservation and scientific-based evidence. A true ‘intangible cultural heritage of humanity’.
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Chapter
This chapter reviews the main aspects of the health properties of the Mediterranean diet in arthritis. Arthritis encompasses a wide spectrum of conditions affecting the bones, muscles, and joints. Although with different expressions, they share common inflammatory pathways, severe pain, and disability. An increased mortality is associated with arthritis when damage to extra-articular organs of the body is involved. The Mediterranean food pattern has shown a number of beneficial and healthy effects in arthritis, in particular, with regard to inflammation and clinical disease progression. Most of these effects are related to the consumption of extra-virgin olive oil that, with its high content of monounsaturated fatty acids and nonfat bioactive components such as phenolic compounds, has demonstrated important antiinflammatory effects both in vitro and in vivo. Furthermore, growing evidences indicate an important role for Mediterranean diet components in affecting gut microbiota composition and its relation to chronic inflammatory and autoimmune processes. Although large-scale trials are warranted to enhance our knowledge on the possible benefits of dietary interventions in arthritis, the antiinflammatory Mediterranean diet pattern should be considered a valuable support to pharmacological treatment in arthritis.
Chapter
Arthritis is an umbrella term for about a hundred rheumatic diseases and conditions affecting the musculoskeletal system. Arthritis causes not only inflammation and damage to joints, with subsequent bone erosion, severe pain, and disability, but can also cause damage to other organs of the body, leading to increased mortality.Although the mechanisms underlying the pathogenesis of joint diseases are for the most part unknown, a number of nutrient and non-nutrient dietary components have been shown to affect the inflammatory process and, in particular, to influence clinical disease progression. This chapter will focus on the benefit of the Mediterranean diet (MD) on arthritis patients. The antinflammatory MD pattern should be considered a valuable support to pharmacological treatment in arthritis. New, large-scale trials are warranted to confirm precedent findings and to enhance our knowledge of the possible benefits of dietary interventions in arthritis.
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Diet-derived natural ligands of the peroxisome proliferator-activated receptor (PPAR) family of nuclear receptors have been widely reported to activate PPAR signaling, modifying gene and protein expressions in a variety of cells and tissues. Examples of such dietary factors include unsaturated fatty acids, spices, soy protein, and polyphenols. Recent data suggest that these nutrients may affect inflammation and immunity in arthritic diseases. This review describes these nutrients and their potential modulating effects on the pathophysiology of inflammatory and degenerative arthritis through PPAR signaling.
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Objective: Resveratrol is a naturally occurring polyphenol, which possesses chemotherapeutic potential through its ability to trigger apoptosis. The objective of this study was to investigate the major determinant for the apoptotic cell death induction by resveratrol in fibroblast-like synoviocytes (FLS) derived from patients with RA. Methods: The effect of resveratrol on apoptotic cell death was quantified in a population of subG1 in RA FLS by flow cytometry. The underlying signalling mechanism for apoptotic death was examined by analysing mitochondrial membrane potential, activation of the caspase cascade and translocation of Bid. Results: We show that activation of caspase-8 is essential for triggering resveratrol-induced apoptotic signalling via the involvement of the mitochondrial pathway in RA FLS. Our findings also suggest that this enhanced apoptosis caused by resveratrol occurred in RA FLS irrespective of p53 status. Exposure to resveratrol caused extensive apoptotic cell death, along with a caspase-dependent (activation of caspase-9 and -3, poly ADPribose polymerase (PARP) cleavage and mitochondrial cytochrome c release) or caspase-independent [translocation of apoptosis-inducing factor (AIF) to the nucleus] signalling pathway. Analysis of upstream signalling events affected by resveratrol revealed that the activated caspase-8 triggered mitochondrial apoptotic events by inducing Bid cleavage without any alteration in the levels of Bax, Bcl-xL or Bcl2. The caspase-8 inhibitor or over-expression of crmA abrogated cell death induced by resveratrol and prevented processing of the downstream cascade. Conclusion: The results suggest that resveratrol causes activation of caspase-8, which in turn results in modulation of mitochondrial apoptotic machinery to promote apoptosis of RA FLS.
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The effect of each of twelve mammalian lignun derivatives on the growth of human mammary tumor ZR-75-1 cells was examined. At a concentration less than 10 μ g/ml, tumor cell growth was inhibited from 18-68%. The effect of 2,3-dibenzylbutane-1,4-diol (hattalin) was found to be strongest, inhibiting growth by 50% at a concentration (EC50 of 2.1 μ g/ml. Hattalin inhibited membrane Na%, K%-ATPase of canine kidney cortex. It also inhibited the ATPase of the plasma membrane fraction from both cultured cells and a section of human breast cancer tissue at a concentration ranging from 0.5 to 2.0 mM. However, only a few percent of membrane ATPase from either ZR-75-1 cells or breast carcinoma tissue was inhibited by 2.0 mM of ouabain, suggesting that the target ATPase of hattalin was other than ouabainsensitive ATPase. The relative incorporation of [3H]thymidine per 1 105 cells into the acid-precipitable fraction of ZR-75-1 cells was not affected by 1-50 μg/ml of hattalin, while a marked decrease resulted from 1-10 μg/ml of 5-fluorouracil (5-FU). These results suggest that the suppressive effect of hattalin on tumor cell growth my not occur through inhibition of DNA synthesis but rather partly by inhibition of the plasma membrane ATPase other than Na% and K% -dependent ones.
Article
T HE METABOLIC SYNDROME CON-sists of a constellation of fac-tors that increase the risk of cardiovascular disease and type 2 diabetes. Recent estimates indicate that the metabolic syndrome is highly prevalent in the United States, with an estimated 24% of the adult population affected. 1 Its clinical identification is based on measures of abdominal obe-sity, atherogenic dyslipidemia, el-evated blood pressure, and glucose intolerance. 2 The etiology of this syn-drome is largely unknown but presum-ably represents a complex interaction between genetic, metabolic, and envi-ronmental factors including diet. 3,4 Sev-eral recent studies also suggest that a proinflammatory state is one compo-nent of the metabolic syndrome. 5-8 Moreover, evidence has accumulated indicating that low-grade inflamma-tion is associated with endothelial dys-function. 9,10 Context The metabolic syndrome has been identified as a target for dietary thera-pies to reduce risk of cardiovascular disease; however, the role of diet in the etiology of the metabolic syndrome is poorly understood. Objective To assess the effect of a Mediterranean-style diet on endothelial func-tion and vascular inflammatory markers in patients with the metabolic syndrome. Design, Setting, and Patients Randomized, single-blind trial conducted from June 2001 to January 2004 at a university hospital in Italy among 180 patients (99 men and 81 women) with the metabolic syndrome, as defined by the Adult Treat-ment Panel III. Interventions Patients in the intervention group (n=90) were instructed to follow a Mediterranean-style diet and received detailed advice about how to increase daily consumption of whole grains, fruits, vegetables, nuts, and olive oil; patients in the con-trol group (n=90) followed a prudent diet (carbohydrates, 50%-60%; proteins, 15%-20%; total fat, 30%). Main Outcome Measures Nutrient intake; endothelial function score as a mea-sure of blood pressure and platelet aggregation response to L-arginine; lipid and glu-cose parameters; insulin sensitivity; and circulating levels of high-sensitivity C-reactive protein (hs-CRP) and interleukins 6 (IL-6), 7 (IL-7), and 18 (IL-18).
Article
Objective To evaluate the impact of a 2-year program of strength training on muscle strength, bone mineral density (BMD), physical function, joint damage, and disease activity in patients with recent-onset (<2 years) rheumatoid arthritis (RA).Methods In this prospective trial, 70 RA patients were randomly assigned to perform either strength training (all major muscle groups of the lower and upper extremities and trunk, with loads of 50–70% of repetition maximum) or range of motion exercises (without resistance) twice a week; all were encouraged to engage in recreational activities 2–3 times a week. All patients completed training diaries (evaluated bimonthly) and were examined at 6-month intervals. All were treated with medications to achieve disease remission. Maximum strength of the knee extensors, trunk flexors and extensors, and grip strength was measured with dynamometers. BMD was measured at the femoral neck and lumbar spine by dual x-ray densitometry. Disease activity was determined by the Disease Activity Score, the extent of joint damage by the Larsen score, and functional capacity by the Health Assessment Questionnaire (HAQ); walking speed was also measured.ResultsSixty-two patients (31 per group) completed the study. Strength training compliance averaged 1.4–1.5 times/week. The maximum strength of all muscle groups examined increased significantly (19–59%) in the strength-training group, with statistically significant improvements in clinical disease activity parameters, HAQ scores, and walking speed. While muscle strength, disease activity parameters, and physical function also improved significantly in the control group, the changes were not as great as those in the strength-training group. BMD in the femoral neck and spine increased by a mean ± SD of 0.51 ± 1.64% and by 1.17 ± 5.34%, respectively, in the strength-training group, but decreased by 0.70 ± 2.25% and 0.91 ± 4.07% in the controls. Femoral neck BMD in the 17 patients with high initial disease activity (and subsequent use of oral glucocorticoids) remained constantly at a statistically significantly lower level than that in the other 45 patients.Conclusion Regular dynamic strength training combined with endurance-type physical activities improves muscle strength and physical function, but not BMD, in patients with early RA, without detrimental effects on disease activity.
Article
To evaluate the association between diet and cancer risk in Mediterranean countries, data presented from a series of case-control studies conducted in Italy were reviewed. The series comprised over 20,000 cases affecting 20 cancer sites and included 18,000 controls. For most epithelial cancers, risk decreased with increasing vegetable and fruit consumption. Fish and whole grains (but not refined grains) were also favorable diet indicators. Olive oil and other monounsaturated and unsaturated fats were inversely related to cancer risk at several sites. A Mediterranean diet pattern appears to be favorable for a reduced cancer risk, indicating the importance of dietary patterns.
Article
The PREDIMED (Prevencion con Dieta Mediterránea, meaning Prevention with Mediterranean Diet) study is a large-scale, ongoing, multicenter, randomized, primary prevention trial in a high-risk population to assess the effects of three healthy diets (low-fat diet, Mediterranean diet rich in olive oil, and Mediterranean diet rich in tree nuts) on cardiovascular outcomes (http://www.unav.es/preventiva/predimed).17 In the pilot study, 772 asymptomatic persons aged 55 to 80 years with at least one of the two following eligibility criteria were included: 1) type 2 diabetes and 2) ≥3 major cardiovascular risk factors (current smoker, hypertension, LDL cholesterol ≥160 mg/dL, HDL cholesterol ≤40 mg/dL, BMI ≥ 25 kg/m2, or a family history of premature cardiovascular disease). Personalized dietary advice, which included recommendations on the desired frequency of intake of specific foods as well as advice to reduce the intake of all types of fat, was given to each participant during a 30-minute session, along with a leaflet that included American Heart Association recommendations. Those assigned to the two Mediterranean diet groups had a more intense behavioral and educational intervention. Depending on the group, participants allocated to the two Mediterranean-type diets were given either complimentary virgin olive oil or walnuts (15 g/day), hazelnuts (7.5 g/day), and almonds (7.5 g/day). A 1-hour group session at baseline was conducted specifically for each Mediterranean group, during which participants were provided with written materials. Body weight, blood pressure, lipid profile, glucose levels, and inflammatory molecules were evaluated at 3 months of follow-up.
Article
To the Editor: Dr Féart and colleagues1 performed a prospective cohort study and concluded that adherence to a Mediterranean diet was associated with slower cognitive decline as assessed by the Mini-Mental State Examination (MMSE). We have a number of concerns about the study.First, the study participants were not blinded, and using the 24-hour dietary recall introduced potential recall bias because participants might recall differently depending on their disease status.2 Second, using MMSE as a scale for assessing cognitive function may not have been an optimal choice. A study using the French versions of the Severe Impairment Battery and MMSE in 69 patients with probable Alzheimer disease concluded that the Severe Impairment Battery was better able to discriminate among patients who had scores lower than 11 points on the MMSE.3 Third, accuracy of the MMSE depends on the educational status of the individual.4 Fourth, accuracy of the MMSE has also been shown to vary based on age.5
Article
Background: The aim of the present work was to evaluate the relationships between socio-demographic, clinical, lifestyle and psychological characteristics and the presence of obesity, among elderly individuals without known cardiovascular disease. Methods: During 2005-2007, 553 elderly men and 637 elderly women (mean age 74 ± 7 years) from eight Mediterranean Islands in Greece and Cyprus were enrolled. The retrieved information included demographic, bio-clinical and dietary characteristics. The MedDietScore assessed adherence to the Mediterranean dietary pattern. Results: The prevalence of obesity was 27% in males and 41% in females (P <0.001), while 48% of males and 39% of females were overweight. The prevalence of diabetes, hypercholesterolemia and hypertension was higher in the obese elderly than in the overweight or normal (P <0.001). After adjusting for various confounders, one unit increase in the MedDietScore was associated with 88% (P =0.07) lower likelihood of being obese; similarly, physical activity was associated with 81% lower likelihood of obesity (P <0.001). Conclusions: Roughly seven out of 10 of our elderly were overweight or obese, while the majority of them presented other co-morbidities, too. Greater adherence to the Mediterranean diet may reduce the burden of obesity among elderly individuals.