Pain-Free Living

The Mediterranean Diet

by Linda Richards, RD, MS

After experiencing some foot problems, Minnesota resident Linda Appelgren was diagnosed with rheumatoid arthritis in the mid-1990s. As a registered dietitian, she had always been conscious of good nutrition. But now the focus of following a healthy diet that also helped reduce inflammation became top priority for her eating style. It also became the cornerstone of the nutrition education she provided the arthritis patients she counseled in her role as the nutrition department manager at Mercy Hospital in Moose Lake, Minnesota.

Appelgren says she recommends a diet with “tons of vegetables, the use of more beans and legumes, and cutting back on meats.” She also advises the use of oils and other foods that are high in monounsaturated fats, and she tells people to eat whole foods as opposed to highly processed foods.

An eating style that incorporates many of these principles is the Mediterranean diet, named for the traditional dietary patterns of residents of southern Italy, Spain, and Greece. People in that region tended to rely on local foods, which meant a lot of fruits and vegetables. Olive oil was their primary oil. Legumes such as the chickpea (garbanzo bean) provided a low-cost, protein-rich substitute for meat. Those who lived near the coast had access to fish.

The payoff for following this eating pattern appeared to be a longer life span, reduced rates of chronic diseases such as cardiovascular disease, and low rates of certain cancers. It is perhaps no surprise, then, that nutrition experts have devoted much time over the past few decades to studying what it is about the Mediterranean diet that yields these benefits.

What the science says

Scientific research backs up claims that diets rich in fruits, vegetables, fish, nuts, and beans have disease-fighting properties. One study involving people with rheumatoid arthritis showed that those who followed a Mediterranean-style diet had significantly lower disease activity and less joint swelling, tenderness, and pain. Physical functioning also improved, and participants reported a better sense of well-being compared with one year earlier.

Other studies show that the diet lowers blood pressure. And in a recent study involving thousands of Spanish participants over a five-year period, those who followed the Mediterranean diet showed a 30% reduction in the rate of heart disease, primarily strokes, compared with people who followed a low-fat diet. Harvard School of Public Health’s Walter Willett, MD, has commented that the Mediterranean diet is as good as statin drugs, which are the best available drugs for high cholesterol, but offers the additional benefit of reducing the risk of developing diabetes. In addition, consuming a higher proportion of lower-calorie foods—such as vegetables and legumes—can result in weight loss, which often lessens joint pain.

What exactly defines the Mediterranean diet is still being worked out, but it is generally understood to be largely plant-based, with high intakes of olive oil, vegetables, beans, fruits, nuts, and whole-grain cereals; moderate consumption of fish, poultry, dairy products, and eggs; low intakes of red meat and sweets; and often moderate consumption of alcohol, predominantly wine. This article takes a look at the major food groups in the Mediterranean diet and suggests simple ways to get more of the ones believed to be beneficial to your health.

More fish—or fish oil

The availability of fish varies widely across countries and regions of the world. Compared to other animal protein sources, fish contains more unsaturated fats, including the healthy omega-3 fatty acids that research shows exert a brake on the inflammation process.

Health experts recommend consuming 3–4 ounces of fish (a serving the size of a deck of cards) two times a week. Fish with higher fat contents, such as salmon, herring, and sardines, offer the highest amounts of omega-3 fatty acids. Tuna has slightly less. In general, freshwater fish have less omega-3 than saltwater fish.

Applegren has found that most of the people she counsels aren’t able to eat a lot of fatty fish due to either preference or availability. In these cases she encourages fish oil, which has been shown in studies to help with RA-associated joint pain. However, while fish oil is relatively safe, it does have blood-thinning properties, raising the risk of bleeding in people who take drugs or other dietary supplements that also thin the blood. It is therefore recommended that people check with their doctors before beginning fish oil supplements.

For those people who can safely take fish oil supplements, Appelgren recommends taking 1,000 milligrams per day of EPA and DHA, the omega-3s that form the active ingredients in fish oil. According to Applegren, “Personally I have found if I back off or skip the fish oil for more than a week at a time, I see an increase in the joint swelling in my hands.” She notes that caution is needed when reading supplement labels, because the bottles often list both the total weight of the gel tablets in milligrams, as well as the amount of omega-3s in milligrams. It’s the amount of omega-3s that’s important. “Some of my patients think they are getting all they need in one tablet, when in reality they should be taking three gel tablets per day. I also stress the need to check that the fish oil is coming from a reputable source and that it is mercury free.” To find such products, look for supplements labeled with a “USP Verified” seal, indicating that the product meets standards for purity and potency set by the US Pharmacopeial Convention, a federally recognized, nonprofit, standards-setting organization.

Suggestions for eating more fish include the following:

■ If you’re bored with your usual tuna fish sandwich, spice it up by adding cilantro, Dijon mustard, red onion, or other finely diced vegetables.

■ Splurge and try some smoked or cured fish from the deli section of the grocery store.

■ When planning your weekly menus, aim to have no more than one red meat meal per week, two poultry dishes, and two or more fish entrées. Have plant-based foods for your other meals.

Olive oil

It’s believed the first cultivation of olives took place on the Grecian island of Crete as long ago as 2500 BC, with archaeological findings dating the first amphorae, the ancient containers used to ship olive oil for trade, even earlier. Common in ancient Greece and Roman cuisine, olive oil is the primary oil in Mediterranean dishes.

Olive oil is considered a “healthy” oil because it is high in monounsaturated fat, which may help lower your risk of heart disease. Olives are also high in a compound that dampens the body’s inflammatory response and reduces pain sensitivity. Olive oil can be used in both cooking and cold dishes such as salads. In cases where olive oil doesn’t work as well, such as in high-heat cooking or some baked goods where the flavor might be too strong, canola oil, another rich source of unsaturated fats, can be used.

Suggestions for including more olive oil in your diet include the following:

■ Use a less-expensive olive oil for cooking and a premium, top-quality (extra-virgin) olive oil in salads and uncooked dishes.

■ For bread or toast, replace your usual spread with a seasoned olive oil.

Nuts and seeds

Ancient Greeks and Romans ate pine (also called pinyon or pignoli) nuts, and Mediterranean dwellers adopted almonds, walnuts, and pistachios from their neighbors in the Mideast. All nuts have high fat contents and therefore are high in calories, but much of the fat is unsaturated, and many nuts are high in omega-3 fatty acids. One study showed that consuming merely four walnuts was enough to increase blood levels of omega-3. Other research backs up their benefits. One study that followed people for over 15 years concluded that people who consumed the most nuts had a 51% lower risk of dying from an inflammatory disease than those who ate the fewest nuts.

Suggestions for adding nuts to meals and snacks include the following:

■ Add a couple tablespoons of nuts to a serving of cereal, stir-fry, salad, yogurt, or rice.

■ Have 1⁄4 cup of nuts as an afternoon snack.

■ Choose nuts that are especially high in nutrients, such as walnuts or Brazil nuts. Eating just one Brazil nut daily provides the daily recommendation for selenium, a trace mineral that is low in people with rheumatoid arthritis.

Legumes

While the chickpea is the most popular legume in Mediterranean cuisine, lentils, navy beans, fava beans, and red beans are also used in many dishes. Legumes have a number of antioxidant and anti-inflammatory compounds. For example, they are high in fiber, which helps to lower C-reactive protein, an indicator of inflammation, in the blood. Among plant foods, legumes are one of the best protein sources. They can be easily added to many types of dishes, including salads, stir-fries, casseroles, and soups. Chickpeas can be used to make hummus, which can be served as a dip or used as a nutrient-packed sandwich spread.

Suggestions for eating more legumes include the following:

■ If you don’t currently eat many legumes, look for simple recipes for lentil soup, chili, or other legume dishes you already know you like.

■ If you like chickpea hummus, look for recipes for hummus made with other types of beans, such as edamame (fresh soybeans) or white beans.

Fruits and vegetables

The Mediterranean’s climate supports the growing of many fruits and vegetables, with figs and dates the most ancient fruits in cultivation. Artichokes, celery, asparagus, and parsnips originated in the area and were popular Roman foods. Today, residents of Greece, Spain, and Italy typically eat six to seven servings of fruits and vegetables a day. Fresh fruit is a popular dessert.

“Many of my patients come to me consuming only one to two servings a day of fruits and vegetables, not counting French fries,” says Appelgren, so the goal of seven to eight daily servings set out by the latest Dietary Guidelines for Americans can be a challenge. Because people struggle most with getting enough vegetables, she suggests adding diced vegetables to omelets or scrambled eggs, or serving salsa on eggs. For lunch, Appelgren recommends adding vegetable soup to one’s midday sandwich, and she advises eating raw vegetables for snacks. For dinner, she suggests striving for one cooked and one raw vegetable serving at the meal.

Some researchers have speculated that vegetables in the nightshade family—potatoes, tomatoes, sweet and hot peppers, eggplant, tomatillos, pimentos, paprika, and cayenne peppers—have compounds (alkaloids) that might worsen inflammation in sensitive people.

Applegren does not recommend eliminating any nightshade foods. “I think they are incredibly nutritious foods and would not make a blanket statement for [my patients] to be eliminating red bell peppers, tomatoes, baked potatoes, etc. If I have a patient who has tried everything else and is still suffering, I will occasionally suggest that they do a several-week elimination trial of the nightshades to see if it helps. So far I haven’t had any positive outcomes reported to me as a result of eliminating the nightshades.” Although Applegren hasn’t found a sensitive person, experts agree that if you suspect you’re sensitive to nightshades, gradually remove any suspect foods to see if that helps you identify problematic foods.

Appelgren emphasizes the seasonal approach. “Buying seasonal is more economical, plus the taste and quality is so much better,” she says.

Suggestions for eating more fruits and vegetables include the following:

■ Add berries (fresh, frozen, or dried), which are particularly high in disease-fighting phytochemicals, to dishes such as homemade pancakes, salads, and yogurt.

■ Start a garden, and check whether your community has a garden-sharing program, which introduces people to new foods they haven’t considered.

Whole grains

Bread is a common food in the Mediterranean diet, with whole-grain breads being a healthier choice than those made from refined flours. Whole grains provide fiber, antioxidants, vitamins, and minerals that confer many health benefits.

Here are some suggestions for making more of your grain choices whole grains:

■ Choose rolled or steel-cut oats or a multigrain cereal for breakfast.

■ Try barley, buckwheat (kasha), bulgur, or quinoa in place of rice or pasta.

■ Replace refined or white flour products with unrefined, whole-grain products.

Wine

Some versions of the Mediterranean diet emphasize moderate wine consumption, although most experts don’t recommend starting to drink alcohol if you don’t currently consume it. In a large study published in February 2013, participants who followed a Mediterranean-style diet that included at least seven glasses of wine per week, with meals, had a significantly lower chance of having heart attacks, strokes, and/or deaths from heart disease.

Making the transition

Even adopting some of these suggestions can have health benefits, while adding some new and exciting foods to your regular routine. For more tips on making your meals Mediterranean, visit the Oldways Web site, http://oldwayspt.org.

Last Reviewed May 28, 2014

Linda Richards has been a medical writer since 1995 and lives in Redlands, California.

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