Dietetics and Nutrition in the Mediterranean

By Dr. ssa Fabiana Avallone

Mediterranean diet rulesThe Mediterranean diet is principally a plant based diet. Everyday the “mediterranean way” consists of: • vegetables (at least 300-400 g a day) • fruit (at least 4 pieces or 400 g a day)• legumes and pulses• grains, pasta and/or bread (mostly wholemeal and

unrefined) • olive oil and nuts• an abundant use of herbs and spices• water (more than 2 liters per day)• wine during meals ( maximum 2 glasses per day )

Mediterranean diet rules

In the Mediterranean diet the most important source of animal food is fish. The Mediterranean is a sea which is rich in fish, and to do things the “mediterranean way” we need to eat seafood frequently:

• seafood (fish, shellfish, mollusc), recommended 4-6 times a week, at least twice weekly

Mediterranean diet rulesThe intake of dairy produce is low to moderate and usually in the form of goat’s and sheep’s cheese or yoghurt.

• yoghurt, recommended 2 - 4 times per week• cheese, recommended 1 - 4 times per week• milk, recommended 1 - 2 times per week• eggs, recommended 1 - 4 eggs per week

(maximum 1 a day)

Mediterranean diet rulesThe Mediterranean diet consists in a low intake of sweets, poultry and red meat, these types of foods are a sort of “special occasion food”. Processed food and junk food are forbidden.

• poultry, recommended 1 - 2 times per week• red meat, recommended 0 - 1 time a week • sweets, recommended 0 - 1 time per week • no junk food

Mediterranean VegetablesVegetables are the most complex food we eat. 1. Roots and tubers (potatoes, carrots and

parsnip)2. Lower stems and bulbs (beets, celery root,

turnip, radish, onion, garlic, leeks) 3. Stems and stalks (asparagus, celery, fennel,

kohlrabi, cardoons)4. Leaves (lettuces, chicories, dandelion greens,

cabbage, kale, brussels sprouts, rocket, spinach)5. Flowers (artichokes, broccoli, cauliflowers) 6. Fruits used as vegetables (tomatoes, eggplant,

sweet peppers, cucumber, zucchini, pumpkin)

Mediterranean FruitsCherriesWatermelonFig, fresh and driedKakiMelonPomegranateMedlarKiwiClementinePeachesGrapefruitBlackberry

RaspberryBlueberryRedcurrantLemonPersimmonPlum, fresh and driedGrapeAppleApricotOrangeStrawberryPear

Mediterranean legumes

• Chickpeas (dried and flour)• Lentils• Fava beans (fresh and dried)• Borlotti beans (fresh and dried)• Cannellini beans (fresh and dried)• Peas• Black Eyed Beans• Grass Pea

Mediterranean Grains

• Durum wheat (whole pasta or refined, couscous)• Soft wheat (whole bread or refined)• Farro • Rice (whole or refined)• Maize (cornmeal)

Mediterranean Fats

• Extravirgn olive-oil• Olive• Almond• Hazelnut• Walnut• Pine nuts• Pistachios • Flaxseeds

Mediterranean Seafood• Anchovies• Sardines• Tuna• Swordfish• Mackerel• Eel • Trout• Oyster• Mussels• Clam• Octopus• Squid

• Ray• Shrimp• Cod• Cuttlefish• John Dory• Ombrine• Dogfish• Pike • Lobster• Sole• Salmon

Mediterranean Diet Rules• vegetables (at least 300-400 g a day) • fruit (at least 4 pieces or 400 g a day)• legumes and pulses• grains, pasta and/or bread (mostly whole) • olive oil and nuts• water (more than 2 liters per day)• wine during meals ( maximum 2 glasses per day )• seafood (fish, shellfish, mollusc), 4-6 times a week• yoghurt, 2 - 4 times per week• cheese, 1 - 4 times per week• milk, 1 - 2 times per week• eggs, 1 - 4 eggs per week (maximun 1 per day)• poultry, 1 - 2 times per week• red meat, 0 - 1 time a week • sweets, 0 - 1 time per week

Vegetarian diets: historical contextFor centuries vegetarian diets have been used in different parts of the world for various reasons. Phythagoras is considered the founder of the vegetarian movement and advocates included other ancient Greeks, Hebrew writings documented the practice of vegetarian diets even from Old Testament Bible times. Eastern religions, including Buddhism, Zainism, and Hinduism, also promote vegetarian diets and continue to urge preservation of animal life.

Vegetarian diets: historical contextIn the 18 th century, Benjamin Franklin was perhaps the most famous of the scientists, physicians, and philosophers who supported vegetarian diets. The vegetarian movement expanded considerably in the 19 th and 20 th century. A 1994 survey reported that some 12.4 million people in the United States call themselves vegetarians. The same poll administered in the year 2000 concluded that 2.5% of the USA population can be considered vegetarian.

Vegetarian diets: historical contextThe reasons for adopting a vegetarian lifestyle are varied. Historically, vegetarian diets were associated with certain religious practices. Currently, health appears to be the primary reason for adopting a vegetarian diet. Other reasons encompass ecologic and environmental issues relating to the large differences in resources necessary to support animal and plant based diets. Another common reason relates to ethical concerns about the treatment of animals for clothing or research. In many cases, however, multiple reasons underlie vegetarian dietary practices.

Vegetarian diets: definitionsThe term vegetarian encompasses a wide range of dietary practices; cereal grains, fruits, vegetables, legumes, nuts and seeds form the basis of vegetarian diets, with varying amounts of dairy products and eggs. Vegetarians exclude meat; the type of animal products included frequently are used to identify the kind of vegetarian diet: • Lactoovovegetarians (LOVs)• Lactovegetarians • Ovovegetarians • Vegans (exclude all animal products)• Fruitarians (fruits, vegetables fruits, nuts, seeds)

Vegetarian diets: dietary intakeDiets of vegetarians tend to be lower in total fat, saturated fat and cholesterol, and higher in fiber, than the diets of non-vegetarians. Vegetarians tend to consume more grains, legumes, vegetables, fruit and wine than non-vegetarians. Other studies also reported that, among vegetarians, intakes of soy and nutrients such as folate, vitamin C, beta-carotene, vitamin E, copper, and magnesium are higher than among non-vegetarians, but intakes of vitamin A, vitamin B12, vitamin D, omega-3, calcium, selenium and zinc are lower.

Vegetarian diets and proteinOne of the most frequent questions regarding the nutritional adequacy of vegetarian diets relates to protein requirements. However, the inadequate energy intake in some vegetarians may compromise protein status as well. Moreover, because of the lower digestibility of plant proteins, the protein requirement of vegans may be higher than those of non-vegetarians. Foods of plant origin are often said to lack certain indispensable amino acids and thus to provide protein of lesser quality than in foods of animal origin.

Recommended Protein Intake

• Infants: 2.2 grams per kg of body weight.

• Children: 1.0-1.6 grams per kg of body weight.

• Adults: 0.8 grams per kg of body weight.

• Adult athletes: 1.5-2.0 grams per kg of body weight.

Current evidence suggests that a lower intake of animal protein may be beneficial and may lower urinary calcium excretion and slow the progression of renal disease and osteoporosis; this relathionship is not seen when plant protein is consumed.

Vegetarian diets and proteinTwo amino acids are of particular interest in vegetarian diets; lysine, the limiting amino acid in cereal grains, and methionine, the limiting amino acid in legumes.

Protein sourceLimiting amino

acid

Wheat Lysine

Rice Lysine

LegumesTryptophan or methionine (or

cysteine)

MaizeLysine and tryptophan

Legume Seed

Water Protein Fats Carbohydrates

Common bean

14 22 2 61

Fava bean 14 25 1 58

Black-eyed Pea

14 24 1 60

Soybean 10 37 18 34

Lentil 14 25 1 60

Chickpea 14 21 5 61

Pea 14 24 1 60

Lupins 10 30 10 50

Composition of Dry Legumes

Vegetarians, Legumes and Protein

Legumes are 20 to 25% protein by weight, which is double the protein content of wheat and three times that of rice. For this reason, legumes are called "vegetarian's meat". While legumes are generally high in protein, and the digestibility of that protein is also high, they are often relatively poor in the essential amino acid methionine. Grains (which are themselves deficient in lysine) are commonly consumed along with legumes to form a complete protein diet for vegetarians.

Legumes and Aminoacids

Legumes contain relatively low quantities of the essential amino acid methionine. To compensate, the Mediterranean Diet serves legumes along with grains, which are low in the essential amino acid lysine, which legumes contain. Thus a combination of legumes with grains forms a well-balanced diet for vegetarians. Common examples of such combinations are pasta and beans “pasta e fagioli” and emmer wheat and legume soup “zuppa di legumi e farro”.

Complete protein food for vegetarians Complete proteins contain a balanced set of essential amino acids for humans. Animal sources such as meat, poultry, eggs, fish, milk, and cheese provide all of the essential amino acids. Near-complete proteins are also found in some plant sources such as quinoa, buckwheat, and amaranth. Soya appears as lower in methionine and cysteine. It is not necessary to consume plant foods containing complete proteins as long as a reasonably varied diet is maintained. By consuming a wide variety of plant foods, a full set of essential amino acids will be supplied and the human body can convert the amino acids into proteins.

Vegetarians and Iron Non-heme iron from plant foods is less available than heme iron, and plant foods contain a variety of substances known to reduce iron availability. However, plant foods also contain other substances that enhance iron uptake, and well-planned vegetarian diets often contain more iron than omnivorous diets. Some studies suggest that long-term LOVs, even with a higher fiber intake, maintain iron status no different from that of omnivores. The high levels of iron in well planned vegetarian diets (15-20mg per day) combined with the frequent intake of fruits and vegetables rich in vitamin C appear to protect against iron deficiency.

Top 10 plant foods richest in iron/100 g

1. 14,30 mg pure cocoa2. 10,00 mg germ of wheat3. 9,00 mg dried beans4. 8,00 mg lentils5. 7,80 mg green radicchio6. 7,30 mg pistachios7. 6,40 mg chickpeas8. 5,30 mg dried apricots9. 5,20 mg arugula, oats10.5,00 mg dark chocolate, fava beans11.4,50 mg peas

Top 10 plant foods richest in iron/100 g 12.4,00 mg buckwheat13.3,90 mg dried plums14.3,50 mg peanuts, olives15.3,30 mg hazelnuts, raisins16.3,00 mg dried figs, almonds, whole flour, dried

dates17.2,90 mg spinach 18.2,70 mg green beetroots19. 2,60 mg walnuts20. 2,00 mg chard21. 2,00 mg zucchini flowers22. 1,70 mg endives

Top 10 foods for Vitamin C content /100g

1. Redcurrants 200 mg 2. Red peppers 151 mg 3. Broccoli and arugula 110 mg 4. Kiwis 85 mg5. Brussel sprouts and turnip 81 mg 6. Cauliflower 59 mg 7. Strawberries, clementines, spinach 54 mg 8. Oranges and lemons 50 mg 9. Kale 47 mg 10. Tangerines 42 mg

Top 10 fruits for Vitamin C content /100g

1. Redcurrants 200 mg 2. Kiwis 85 mg 3. Strawberries and clementines 54 mg4. Oranges and lemons 50 mg 5. Tangerines 42 mg 6. Grapefruit 40 mg 7. Melons 32 mg 8. Raspberries 25 mg 9. Persimmons 23 mg 10. Blackberries 19 mg

Vegetarians and Vitamin B12The usual dietary sources of this vitamin are animal products, plants do not synthesize or store vitamin B12; persons who include only plant foods in their diet, such as vegans and others who consume only raw foods, are at increased risk of deficiency. Vitamin B12 deficiency can result in serious and irreversible neurologic and neuropsychiatric abnormalities. Serum vitamin B12 levels in vegans are generally lower than those in omnivores, with intermediate levels found in LOVs. The requirement of vitamin B12 is very low and cases of B12 deficiency are rare.

Foods rich in Vitamin A mcg/100g

1. Carrots 11492. Pumpkin 5993. Spinach 4854. Pecorino 3805. Parmigiano 3736. Apricots 3607. Cicory 2678. Chard 2639. Kaki 23710. Lettuce 229

11.Broccoli and eggs 22512. Brussel sprouts 22013. Mozzarella 21914. Endives 21315. Celery 20716. Melon 18917. Medlar 17018. Escarole 16719. Sweet peppers 13920. Ricotta 128

Vegetarians: Calcium and Vitamin DAdequate calcium and vitamin D intakes are important to ensure optimal bone status over lifetime. Evidence suggests that calcium may also be important in regulating blood pressure and preventing colon cancer (milk and dairy products supply 70% of calcium in US diets). Calcium intake among LOVs appears to be similar to that of omnivores, whereas intake in vegans is less; in addition, vegans, consume less vitamin D. The low consumption of vitamin D may be further exacerbated in some cases by limited exposure to light.

Vegetarians: Calcium and Vitamin DLow vitamin D concentrations and secondary hyperparathyroidism were documented during the winter in vegans living at northern latitudes. In some cases bone mineral density tended to be lower in the vegan group compared with lactovegetarians and omnivores. A high intake of sodium increases calcium excretion (the same for animal protein).Vegans may need to give attention to obtaining an appropriate calcium intake especially during periods of growth.

Foods richest in Calcium content mg/100g 1. Pecorino 11602. Parmigiano 11593. Arugula 3094. Ricotta 2955. Almonds 2406. Dried figs 1867. Oysters 1868. Green beet 1609. Mozzarella 16010. Hazelnuts 15211. Cicory 15012. Anchovies 14813. Octopus 14414. Squid 14315. Chickpeas 14216. Cannellini 13217. Walnuts 131

18. Agretti 131 19. Pistachios 130 20. Yogurt 12521. Milk 11922. Radicchio 11523. Shrimps 11024. Buckwheat 11025. Borlotti 10226. Broccoli 9727. Cardoons 9628. Endives 9329. Fava beans 9030. Mussels 8831. Artichokes 8632. Dried apricots 8533. Spinach 7834. Raisins 78

35. Dates 6936. Chard 6737. Jhon Dory 6538. Hare 6439. Olives 6340. Kale 6241. Cauliflower 60

Foods richest in Vitamin D content mcg/100g1. Tuna 16.30

2. Anchovies 113. Swordfish 114. Trout 10.605. Pike 10.606. Carp 10.607. Shark 9.108. Salmon 89. Eel 4.9010. Sardines 4.5011. Butter 4.3512. Eggs 1.75

Vegetarians and ZincMeat, fish, and poultry provide 40 to 45% of the zinc in the US diet; the absorption for zinc is reduced with vegetarian diets.

An Australian study found that vegetarian women had significantly lower zinc intake than omnivores, but their zinc concentration was not different.

A lower zinc intake was found among vegetarian children and adolescents, but growth was not affected; the vegetarians in the study were slightly taller than the non-vegetarians.

Foods with richest zinc content mg/100g 1. Beef liver 62. Beef 5,703. Ham 5,204. Octopus 5,105. Anchovies 4,206. Cuttlefish 4,207. Parmigiano 48. Rabbit 3,909. Bresaola 3,8710.Horse meat 3,7211.Hare 3,6512.Cannellini 3,6

13. Pecorino 3,5014. Chickpeas 3,2015.Squid 3,1016. Oats 3,1017. Walnuts 318. Whole pasta 319.Artichoke 2,9020. Borlotti 2,9021. Lentils 2,9022. Mozzarella 2,6023. Mushrooms 1,5024. Spinach 1,43

Vegetarians and omega-3

Vegetarian diets are typically low in omega-3 polyunsaturated fatty acids.

Sources rich in omega-3 such as flaxseed, walnuts, canola oils and soy oils should be included in the vegetarian diet, and the intake of rich omega-6 fatty acids should be decreased to optimize conversion to eicosapentanoic acid and DHA.

Oil Omega-3 Alpha-

Linolinic Acid

Omega-6 Linolenic

Acid

Proportion of Omega-

6 to Omega-3

Omega-9 Oleic Acid

Flaxseed 53% 13% 1 to 4 20%

Canola 9% 20% 2 to 1 56%

Soy 7% 51% 7 to 1 23%

Olive 1% 9% 9 to 1 72%

Corn 1% 54% 54 to 1 27%

Peanut ≤ 1% 32% 32 to 1 45%

Safflower ≤ 1% 75% 75 to 1 14%

Percentage of Omega-3, Omega 6, and Omega-9 Fatty Acids In Some Salad Cooking Oils

OSTEOPOROSIS

Osteoporosis

One and half million osteoporotic fractures of the spine, wrist, hip and other sites occur each year, primarily in postmenopausal white women. In the United States, direct medical costs of fractures among the population age 45 an older totaled nearly $14 billion in 1995. Treatment of men accounted for approximately $3 billion, or 20% of the total amount. Physical inactivity and diet are the most important risk factors of this pathology.

Osteoporosis

The term osteoporosis refers to a condition in which the skeleton is subject to an increased risk of fractures due to the decreased mass and alteration of bone microarchitecture.Osteoporosis, although generally considered as a disease of the bones, for some is a paraphysiological process; the presence of which predisposes to a greater development of diseases and a consequent reduction in life expectancy, if not properly treated.

Types Osteoporosis is divided into primary (original) or a secondary event related to or

achieved (hyperparathyroidism, osteotoxic drugs, etc.). The primary form is the most exclusive form (95% of cases).

Primary osteoporosis

* Idiopathic osteoporosis (the rarest form of all, the cause is unclear * Type I osteoporosis or postmenopausal (due to a fall in hormone production)

* Type II or senile osteoporosis (due to various causes, including immobilization, reduced production of somatotropin, testosterone, calcium, magnesium, vitamin D and other important micronutrients, reduced function of the enzyme 1a-hydroxylase which produces the active hormone vitamin D, ie, calcitriol).

Occurs mainly in trabecular bone, this is the shape with a greater number of fractures.

Secondary osteoporosis The secondary osteoporosis is a group full of

variations, but they represent only 5% of osteoporosis. The main ones are classified as caused by:

* Hyperparathyroidism * Osteopenizzanti drug use (steroids, antiepileptic drugs, heparin, oral anticoagulants, loop diuretics) * Low body weight * Prolonged immobilization * Hypersurrenalism * Hypercalciuria * COPD (chronic obstructive pulmonary disease) * Rheumatoid arthritis Sarcoidosis * * Celiac disease * Malignancy * Reduced intestinal absorption of nutrients

Etiology The cause is the loss of the balance between

osteoblasts and osteoclasts. The first category of cells contributes to bone formation, the latter contributes to bone reabsorption, where osteoclasts working faster than osteoblasts, the bone deteriorates. Menopause (form I) there is an increased production of osteoclasts, due to loss of estrogen that leads to a possible elevation of cytokines, related to the production of osteoclasts. In the second form, with advancing age the activity of osteoblasts decreases.

Symptomatology

Osteoporosis is manifested initially by a decrease in tone calcium in bone mass (osteopenia). The bones more easily affected by the decrease in tone lime are the vertebrae back injury, the femur and the wrist.

Initially asymptomatic, that is for 2 / 3 of people. The first signs appear with fractures, bone pain and muscle such as is typical of the presence of fractures, but they may also go unnoticed by the individual and can show even the least traumatic. Usually the pain is back, is acute and growing in the presence of load. With the further development of osteopenia vertebral collapse or fracture of femoral neck may occur.

The fractures can lead to cervical cyphosis and lordosis.

Risk factors

Uneditable * Age - is the highest risk factor, as usually happens

in old age deterioration of bone mass, very important for women is also the age at which you reach the menopause

* Genetic factors, including whether or not you are completely * Lack of hormones such as estrogen (for females), somatotropin, testosterone (for both males and females, the only form II);

* Presence of diseases like cirrhosis, rheumatoid arthritis * Hereditary diseases: osteogenesis imperfecta, homocystinuria, renal tubular acidosis

* Endocrine abnormalities, Cushing's syndrome (excess cortisol)

Invariant * Diet, lack of calcium, protein, vitamin C. and

vitamin D * Low body weight must be less than 85% of that

considered ideal, or otherwise generally around 55 kg;

* Abuse of alcohol * Cigarette smoking * Algodystrophy * Anorexia nervosa * Physical inactivity, which ranges from a sedentary

lifestyle until the paralysis; * Hypercalciuria (urine pH low acid)

Hypogonadism * Use of drugs such as heparin, methotrexate,

ethanol and glucocorticoids, which alter the metabolism and produce damage to bones

* Neoplasms bone marrow

Nutritional determinants of bone densityMany nutritional factors have been examined for associations with osteoporosis and bone mass. Calcium, phosphorus, trace minerals, and protein are components of bone tissue. The most important nutritional determinants are: • calcium intake• vitamin D, A, K • potassium• protein• Sodium• caffeine• alcohol

Bone density and calciumBone mass during childhood and adolescence can be increased by increasing calcium intake; adequate intake values of 1300 mg/day for age 9 through 18 years and 1000 mg for ages 19 through 50 years, for both men and women.Increased calcium intake causes about a 10 to 15% reduction in the bone remodeling rate in adult women; 1000-1500 mg/day is correct calcium intake for premenopausal and postmenopausal women. With foods rich in vitamin C it is possible to absorb more calcium.

Foods richest in Calcium content mg/100g 1. Pecorino 11602. Parmigiano 11593. Arugula 3094. Ricotta 2955. Almonds 2406. Dried figs 1867. Oyster 1868. Green beet 1609. Mozzarella 16010. Hazelnuts 15211. Cicory 15012. Anchovies 14813. Octopus 14414. Squid 14315. Chickpeas 14216. Cannellini 13217. Walnuts 131

18. Agretti 131 19. Pistachios 130 20. Yogurt 12521. Milk 11922. Radicchio 11523. Shrimp 11024. Buckwheat 11025. Borlotti 10226. Broccoli 9727. Cardoons 9628. Endive 9329. Fava beans 9030. Mussels 8831. Artichoke 8632. Dried apricot 8533. Spinach 7834. Raisin 78

35. Dates 6936. Chard 6737. Jhon Dory 6538. Hare 6439. Olive 6340. Kale 6241. Cauliflower 60

Top 10 foods for Vitamin C content/100g

1. Redcurrant 200 mg 2. Red pepper 151 mg 3. Broccoli and arugula 110 mg 4. Kiwi 85 mg5. Brussels sprouts and turnip 81 mg 6. Cauliflower 59 mg 7. Strawberry, clementines, spinach 54 mg 8. Orange and lemon 50 mg 9. Kale 47 mg 10. Tangerines 42 mg

Top 10 fruits for Vitamin C content /100g

1. Redcurrant 200 mg 2. Kiwi 85 mg 3. Strawberry and clementines 54 mg4. Orange and lemon 50 mg 5. Tangerines 42 mg 6. Grapefruit 40 mg 7. Melon 32 mg 8. Raspberries 25 mg 9. Persimmon 23 mg 10. Blackberries 19 mg

Bone density and Vitamin D

The role of vitamin D insufficiency in osteoporosis is recognized. Increasing intake of vitamin D can increase intestinal calcium absorption, lower the circulating levels of PTH (parathyroid hormone) and reduce rate of bone loss.

There is also evidence that supplementation with vitamin D can lower fractures.

Vitamin D richest food mcg/100g1. Tuna 16,302. Anchovies 113. Swordfish 114. Trout 10,605. Pike 10,606. Carp 10.607. Shark 9,108. Salmon 89. Eel 4,9010. Sardines 4,5011. Butter 4,3512. Eggs 1,75

40 to 80 mcg of vitamin D are recommended in osteoporosis

Bone density and potassiumAn increase in serum potassium concentration arising from high dietary potassium intake, stimulates intestinal calcium absorption; increasing potassium has an opposing effect on calcium lost through the urine.

Prolonged dietary potassium deficiency can deplete the serum level and result in enhanced resorption of this mineral from bone. For a portion of the elderly population, potassium deficiency is a concern.

Top 10 fruits for potassium content/100g1. kiwi 4002. bananas 3503. melon 3334. apricots 3205. pomegranate 2906. watermelon 2807. figs 2708. peches, blackberries 2609. ananas, medlar, 25010. grapefruit 23011. cherries 229

12. raspberries 22013. clementines21014. oranges 20015. grape 19216. plums, susine 19017. kaki 17018. strawberries, blueberries

16019. pear 12720. apple 125

Bone density and sodiumSodium causes an increase in renal calcium excretion. At the high levels of sodium intake typical in US, more than 90% of ingested sodium is excreted.

Optimal intake to minimize bone loss were estimated at approximately 1000 mg/day of calcium, 4000 mg/day of potassium and no more than 2000 mg of sodium