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.

In November 2023 researchers presented the most current literature on the effect of common diet regimes, additions, and eliminations on chronic musculoskeletal pain in the journal Pain Physician (2) . They looked at:

  • The Mediterranean diets
  • vegetarian and vegan diets
  • oils, seafood, and omega-3 fatty acids
  • fruits
  • spices and herbal teas; and
  • elimination diets on patient-reported musculoskeletal pain scores.

In total they examined 32 papers to develop grades of dietary recommendations. These are those findings and recommendations:

  • There is fair evidence that diverse, plant-based Mediterranean, vegetarian, and vegan diets may reduce musculoskeletal pain.
  • Other dietary considerations, including adding marine oils, seafood, omega-3 fatty acids, antioxidant-rich fruits, and turmeric may also benefit patients with chronic musculoskeletal pain.
  • There is poor-quality or insufficient evidence (does not mean they do not work, there is not enough research) to support adding olive oil, ginger, or herbal teas to reduce pain.
  • While eliminating aspartame and monosodium glutamate may reduce inflammation, there is poor-quality evidence that it reduces musculoskeletal pain.

Mediterranean type diet impact on inflammatory and cartilage degradation

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.”(3)

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.

Knee pain patients helped

A January 2022 paper in the International journal of clinical practice (4) compared the effects of Mediterranean and low-fat diet on pain, stiffness, and physical function in patients with knee osteoarthritis.

  • 129 patients with knee osteoarthritis were enrolled.
  • Participants were randomly allocated to the Mediterranean diet, low-fat diet, and control group for 12 weeks.

Results:

  • Pain was significantly decreased in the Mediterranean-style compared with the low-fat and regular diet groups.
  • Physical function was significantly improved in the Mediterranean diet compared with the regular diet group, but had no significant difference with the low-fat one.
  • Stiffness had no significant difference among the dietary groups.

Conclusion: “It seems that dietary components in the Mediterranean diet, regardless of weight loss effect, are effective on pain reduction in patients with knee osteoarthritis.

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. (5)

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.”(6)

In December 2019 writing in the journal of Clinical Nutrition, (7) Dr. Veronese as lead researcher followed up on his previous research by summarizing his findings this way in patients 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.”

Reducing Bone Loss with the Mediterranean Diet

A July 2023 study in the journal Nutrients (8) suggested that Mediterranean diet adherence plays a positive role in terms of promoting bone mineral density, muscle mass and physical function, and preventing osteoporosis and sarcopenia. The researchers recommended that the Mediterranean diet as “a therapeutic tool” that could slow down the onset of osteoporosis and sarcopenia. However, data could not confirm reduction of fracture risk. The effect of the Mediterranean diet on muscle and bone may possibly be influenced by the quantity and quality of some constituent foods such as extras virgin olive oil, fruit, vegetables and fish due to their anti-inflammatory and antioxidant properties.

A September 2018 study in The American journal of clinical nutrition (9) showed that consuming a Mediterranean diet may reduce bone loss in people with osteoporosis. In the study, 1,142 people between the ages of 65 to 79 were followed for 12 months. Bone density was checked at the beginning and the end of the study. Although there was no discernable difference in the study participants with normal bone density, those who had osteoporosis showed an increase in bone density at the femoral neck, or shaft of the thigh bone. That is a particularly neat result since it is the area of the hip joint commonly involved in hip fractures in elderly people with osteoporosis.

People with osteoporosis lose bone at a much faster rate than those who do not. Therefore, if osteoporosis can be slowed down by following this diet, people at higher risk have an excellent reason to improve their eating habits. We’re not surprised that following a healthy, fresh food diet and eliminating processed foods brings about great results.


Hip replacement patients seem to eat poorly.

A November 2023 study in the journal Nutrients (8) examined dietary habits and adherence to the Mediterranean diet in 57 older patients about to undergo hip replacement. What they found was only one in ten patients exhibited high adherence to the Mediterranean diet. They found patients regularly consuming olive oil reported minor hip disability compared to those using it less frequently. Patients who reported daily ingestion of less than one serving of meat versus those consuming more than 1.5 servings had greater cumulative comorbidity (diseases), with meat consumption independently predicting walking ability, mobility, and balance. The researchers concluded: “our patients seem to eat poorly.”

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 Kurapatti M, Carreira D. Diet Composition’s Effect on Chronic Musculoskeletal Pain: A Narrative Review. Pain physician. 2023 Nov;26(7):527-34. [Google Scholar]
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]
4 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. International Journal of Clinical Practice. 2022 Jan 31;2022. [Google Scholar]
5 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]
6 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]
7 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. [Google Scholar]
8 Andreo-López MC, Contreras-Bolívar V, García-Fontana B, García-Fontana C, Muñoz-Torres M. The influence of the Mediterranean dietary pattern on osteoporosis and sarcopenia. Nutrients. 2023 Jul 20;15(14):3224. [Google Scholar]
9 Jennings A, Cashman KD, Gillings R, Cassidy A, Tang J, Fraser W, Dowling KG, Hull GL, Berendsen AA, de Groot LC, Pietruszka B. A Mediterranean-like dietary pattern with vitamin D3 (10 µg/d) supplements reduced the rate of bone loss in older Europeans with osteoporosis at baseline: results of a 1-y randomized controlled trial. The American journal of clinical nutrition. 2018 Sep 1;108(3):633-40. [Google Scholar]
10 Briguglio M, Sirtori P, Mangiavini L, Buzzi S, Cordani C, Zerni MF, Wainwright TW, Ursino N, Peretti GM, Banfi G. How Do Older Patients with End-Stage Osteoarthritis of the Hip Eat Prior to Hip Replacement? A Preliminary Snapshot That Highlights a Poor Diet. Nutrients. 2023 Nov 22;15(23):4868. [Google Scholar]

This article was updated April 17, 2024

 

Get Help Now!

You deserve the best possible results from your treatment. Let’s make this happen! Talk to our team about your case to find out if you are a good candidate.