The Mediterranean diet and osteoarthritis joint pain

Marion Hauser, MS, RD

Many people ask for nutritional guidance when it comes to helping their chronic knee pain. One constant in these people’s asking is “what works best?” It is not easy to convince people that what works best is compliance. You have to stick with an optimal diet plan and lifestyle changes if you want to impact knee, back, or any joint pain. You also must have a realistic expectation of what diet can do for your knee pain. If you are determined to avoid surgery and have a better quality of life, diet can help, but diet or the taking of any supplement may not offer the complete healing you are looking for. Regardless let’s look at the Mediterranean diet

Many researchers and doctors consider the Mediterranean diet a healthy eating lifestyle. The diet is modeled around the everyday eating habits of people who live in the dominance of the Mediterranean Sea. These are the people of Spain, Greece, and the southern portions of Italy, France, et al.

In many of my articles, I have discussed olives, red wine, spices, and other components of the Mediterranean diet as having a healthy impact on osteoarthritis and quality of life. In this article, we will look at the Mediterranean diet as a whole.

As we discussed, the key components of the Mediterranean diet are:

Olive oil. Olive oil is the source of almost all fat in the Mediterranean Diet. People in the Mediterranean region consume very little saturated fat (such as butter) and hardly use other vegetable oils. Coincidentally these other vegetable oils have been shown to promote heart disease and inflammation when used as cooking oils. This is a subject we will cover in another article.
- Bad oils when used as cooking oils: Canola Oil, Corn Oil, Soybean Oil, Corn oil, Peanut Oil, Sunflower Oil, Safflower Oil, Cottonseed Oil.
Drinking red wine in moderation is an important part of The Mediterranean diet
Proteins come from fish and poultry, red meat very rarely
Herbs and spices replace salt as a flavoring
Fruits, vegetables, whole grains, beans, nuts, lentils, and peas are important staples.

The Mediterranean Diet also requires a person have an active lifestyle.

The anti-inflammatory characteristics of the Mediterranean Diet

In the context of our work, we will focus on the aspects of the Mediterranean diet that have been shown to help people with arthritic joint pain.

For background please see my articles on foods that have a positive impact on joint pain and are recognized as key components of the Mediterranean diet

Broccoli and osteoarthritis In this article I look at the research surrounding broccoli’s beneficial effects on knee osteoarthritis by protecting the knee cartilage.
Resveratrol and osteoarthritis – Here I discuss foods that are rich in Resveratrol including Red Wine, peanuts, pistachios, cranberries, strawberries, almonds, and berries.
Olives and osteoarthritis – In this article, I look at the research surrounding the ability of olives and their components to alleviate and possibly reverse the symptoms and degenerative aspects of osteoarthritis.

An October 2020 study in the aptly named medical journal Nutrients (1) suggested that “food and nutritional interventions are considered beneficial in the treatment of pain and inflammatory conditions. For example, vegan and Mediterranean diets and the consumption of blueberry, strawberry, passion fruit peel extract, argan oil, fish oil (omega-3), olive oil, and undenatured type II collagen (a supplement from chicken sternum cartilage) and vitamin D gel capsules reduce musculoskeletal pain, specifically in adults with osteoarthritis. Besides pain improvement, nutritional interventions, including the consumption of strawberry and vitamin D gel capsules, decrease the levels of several inflammatory markers including IL-6, IL-1β, and TNF-α.”

In other words, these types of nutritional programs have an anti-inflammatory effect. The researchers also cited previous research that assessed and compared the effects of a Mediterranean diet and a normal diet and demonstrated significant reductions in musculoskeletal pain with specific diets.

Three more studies on the Mediterranean type diet

At the University of Kent in the United Kingdom, researchers published a paper entitled: “Effect of a Mediterranean type diet on inflammatory and cartilage degradation biomarkers in patients with osteoarthritis.”(2)

Here are the learning points:

A Mediterranean type diet (e.g. abundant in vegetables, fruits, beans, whole grains, olive oil and fish, and less red meat than typical Western diets) has been linked with reductions in joint inflammation in patients with rheumatoid arthritis. This study then examined the Mediterranean type diet in patients with osteoarthritis. This was done by measuring the effects of a short-term (16 week) dietary intervention (in accordance with a Mediterranean type diet) on perceptual, functional, and serum biomarkers in test subjects with osteoarthritis.
The main findings of the study were that:
- dietary intervention (advice and guidance from health professionals) was successful at changing eating behaviors in the Mediterranean type diet test group, and this was associated with weight loss.
- The inflammatory cytokine IL-1α (a small protein which initiates tissue breakdown,) which has been implicated in the development and progression of osteoarthritis was significantly reduced in the Mediterranean type diet test group.
- Significant improvements were seen in the Mediterranean type diet test group for a range of motion at the hip (rotation) and knee (flexion).
- Body mass reduction or weight loss is clearly important in helping patients with joint pain and osteoarthritis.

Please see our related articles on the impact of weight and joint pain.

Okay, it works great in Europe but how about in the US?

Researchers from England, the United Kingdom, and Italy measured the impact of the Mediterranean diet on over 4,000 North Americans. The results were published in the American Journal of Clinical Nutrition. (3)

The average age of the study participants was 61 years old and the majority were women.

Here are the learning points of their study:

The study demonstrated that North Americans who are more adherent to the Mediterranean diet reported a substantially better quality of life and decreased pain, disability, and depressive symptoms.
Of particular relevance is the finding that higher adherence to the Mediterranean diet reduced the prevalence of fractures. These findings seemingly support recent research that showed that the Mediterranean diet is associated with a reduced risk of hip fracture in postmenopausal women.
Higher adherence to the Mediterranean diet is associated with a decrease in inflammation, oxidative stress markers (please see our fascinating article Extracellular matrix in osteoarthritis | The soup of healing).
The Mediterranean diet seems to increase adiponectin, a hormone secreted by adipose tissue, with relevant insulin-sensitizing, antidiabetogenic (diabetic effect), and anti-inflammatory effects.
The study also suggests that higher adherence to the Mediterranean diet has anti-inflammatory and analgesic effects.
Because of unhealthy dietary habits in Westernized countries, including the United States, these findings emphasize that the Mediterranean diet may be one way to improve quality of life.

Nicola Veronese of the Italian national research council, the lead researcher on the above study, lead another research team in publishing the 2018 follow-up in the journal Clinical Rheumatology. In this study on the diet’s effect on knee osteoarthritis, the researchers noted that: “Higher adherence to a Mediterranean diet was found to be associated with a significant improvement in knee cartilage as assessed by MRI.”(4)

In December 2019 writing in the journal of Clinical Nutrition, Dr. Veronese as lead researcher followed up on his previous research by summarizing his findings this way in pati9ents examined in North America.

“(The) Mediterranean diet has several beneficial effects on health, but (research) regarding the association between the Mediterranean diet and knee osteoarthritis are limited. . . We investigated whether higher Mediterranean diet adherence is prospectively associated with lower risk of radiographic osteoarthritis, radiographic symptomatic knee osteoarthritis and pain worsening in North American people at high risk or having knee osteoarthritis.”

4330 subjects (average age: 61.1 years; 58.0% females) were included.
During an average follow-up period of 4 years, participants who were more highly adherent to a Mediterranean diet reported a lower risk of pain worsening
Conclusion: “Higher adherence to the Mediterranean diet is associated with a lower risk of pain worsening and symptomatic forms of knee osteoarthritis.”

If we put the Mediterranean Diet all together, we have the olive oil, vegetables, legumes, fish, chicken, fruits, and red wine. What you also have is FRESH food. Those in the Mediterranean parts of the world typically shop at fresh markets a couple of times per week. They are not consuming food out of boxes or cans. They are definitely not using microwaves to cook their food and are certainly not eating at fast-food restaurants. On top of these facts, the Mediterranean’s perception of life, food, and culture is very different from Americans. Italians in particular have a reverence for food and good conversation. Meals are pleasurable. People enjoy their food and fellowship, meals are a family and friends event. Certainly, this interaction with our friends and families can have a positive impact on our quality of life.

References:

1 Mendonça CR, Noll M, Castro MC, Silveira EA. Effects of Nutritional Interventions in the Control of Musculoskeletal Pain: An Integrative Review. Nutrients. 2020 Oct;12(10):3075. [Google Scholar]
2 Dyer J, Davison G, Marcora SM, Mauger AR. Effect of a Mediterranean type diet on inflammatory and cartilage degradation biomarkers in patients with osteoarthritis. The journal of nutrition, health & aging. 2017 May 1;21(5):562-6. [Google Scholar]
3 Veronese N, Stubbs B, Noale M, Solmi M, Luchini C, Maggi S. Adherence to the Mediterranean diet is associated with better quality of life: data from the Osteoarthritis Initiative. The American journal of clinical nutrition. 2016 Nov 1;104(5):1403-9. [Google Scholar]
4 Veronese N, La Tegola L, Crepaldi G, Maggi S, Rogoli D, Guglielmi G. The association between the Mediterranean diet and magnetic resonance parameters for knee osteoarthritis: data from the Osteoarthritis Initiative. Clinical rheumatology. 2018 Apr 3:1-7. [Google Scholar]
5 Veronese N, Koyanagi A, Stubbs B, Cooper C, Guglielmi G, Rizzoli R, Punzi L, Rogoli D, Caruso MG, Rotolo O, Notarnicola M. Mediterranean diet and knee osteoarthritis outcomes: A longitudinal cohort study. Clinical Nutrition. 2019 Dec 1;38(6):2735-9.

This article was updated June 21, 2021