Know about The Role of Antioxidant-Rich Foods in the Mediterranean Diet. Eating with all senses — Savoring Mediterranean flavors with a healthy mindset, with its rich reserve of antioxidants, as well as a holistic perspective, could indeed constitute a tasty and efficient means to a more vibrant, contented life.

Thus, explore the exciting world of Mediterranean cuisine; allow its antioxidants to do wonders to your body. We have a vision to end cancer as we know it, for everyone. Mediterranean Diet: Antioxidants for Health Home Blog Mediterranean Diet: Antioxidants for Health.

Know about The Role of Antioxidant-Rich Foods in the Mediterranean Diet Eating with all senses — Savoring Mediterranean flavors with a healthy mindset, with its rich reserve of antioxidants, as well as a holistic perspective, could indeed constitute a tasty and efficient means to a more vibrant, contented life.

Read More. Book Appointment. Evaluation of the antioxidant activity of Ruellia tuberosa. Uddin SN, Akond MA, Mubassara S, Yesmin MN. Antioxidants and antibacterial activities of Trema cannabina. Middle East Journal of antimicrobial Agents. Doughari JH. Chapter 1: Phytochemicals: Extraction Methods, Basic Structures and Mode of Action as Potential Chemotherapeutic Agents.

In: Venketeshwer R Edition, Phytochemicals - A Global Perspective of Their Role in Nutrition and Health. IntechOpen, ; Benlemlih M and Ghanem J. Polyphenol aux actions antioxydantes, anti-inflamatoires, anticancereuses, anti-veillissement et protectrices cardio-vasculaires. Deuxième editions, Medicatrix, Belgique, ; ISBN Sesso HD, Buring JE, Christen WG, et al.

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Determination of tocopherol contents of some olive varieties harvested at different ripening periods. Natural Product Research. Špika MJ, Kraljić K and Škevin D. Tocopherols: Chemical Structure, Bioactivity, and Variability in Croatian Virgin Olive Oils. In: Dimitrios Boskou and Maria Lisa Clodoveo editors, IntechOpen, DOI: Franco MN, Galeano-Díaz T, Sánchez J, De Miguel C and Martín-Vertedor D.

Total Phenolic Compounds and Tocopherols Profiles of Seven Olive Oil Varieties Grown in the South-West of Spain. Journal of Oleo Sciences. ess Ceci LN and Carelli AA. Characterization of Monovarietal Argentinian Olive Oils from New Productive Zones. Arslan D, Karabekir Y, Schreiner M.

Variations of phenolic compounds, fatty acids and some qualitative characteristics of Sarıulak olive oil as induced by growing area. Food Res Int. Baccouri O, Guerfel M, Baccouri B, Cerretani L, Bendini A, Lercker G, Zarrouk M, Daoud B, Miled D.

Chemical composition and oxidative stability of Tunisian Monovarietal virgin olive oils with regard to fruit ripening. Matos LC, Cunha SC, Amaral JS, Pereira JA, Andrade PB, Seabra RM, Oliveira BP. Chemometric characterization of three varietal olive oils Cvs.

Cobrançosa, Madural and Verdeal Transmontana extracted from olives with different maturation indices. Food Chem. Mikrou T, Pantelidou E, Parasyri N, Papaioannou A, Kapsokefalou M, Gardeli C and Mallouchos A.

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grown in three different locations. European Food Research and Technology. Olatunji TL and Afolayan AJ. The suitability of Chili pepper Capsicum annuum L.

for alleviating human micronutrient dietary deficiencies. Food Sci Nutr. Ben Mansour-Gueddes S, Tarchoun N, Teixeira Da Silva JA and Saguem S. Agronomic and Chemical Evaluation of Seven Hot Pepper Capsicum annuum L. Populations Grown in an Open Field. Fruit, Vegetable and Cereal Science and Biotechnology, Global Science Books.

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The social support and interactions, enjoying life events together with family and friends, preparing and cooking the food together, sharing the food, having lengthy meals with others and mealtime conversations are common practices in the traditional Mediterranean lifestyle.

In the past, the mealtimes have been even considered as opportunities for social interactions and have been used to keep families and communities together.

The pleasure associated with the conviviality of meals seems to positively affect the well-being and the health status of the people involved, who have been associated with lower risk of CVDs, lower cancer incidence, improved overall mortality and increased longevity [2,19,22,].

The oxidative stress is a result of the generation of oxidative species free radicals, reactive oxygen and reactive nitrogen species in the body, which is usually triggered by unhealthy diet and external factors, such as smoke, pollution, chemicals, drugs, UV rays, unhealthy lifestyle, etc.

The oxidative stress further causes structural and functional damages of the main biomolecules in the body, such as DNA, lipids, and proteins and has been implicated in the pathogenesis of many chronic degenerative diseases, inflammation, neuro-degenerative disorders and aging processes.

In particular, the imbalance between the production of oxidative species in the body and the antioxidant defense could lead to many pathological situations i. To counteract this oxidative stress caused by the reactive species, the body needs various types of antioxidants.

Therefore, the body needs a continuous supply of external antioxidants, which to ensure better health is preferred to come from the diet in form of dietary antioxidants [10,11,20,94,95].

In both cases, inflammatory processes have been implicated as undelaying cause of many serious diseases; actually many chronic metabolic diseases, viz. MD is considered as a highly antioxidant and anti-inflammatory diet due to the richness of phytochemicals originated from different MD ingredients, all acting in synergy and having antioxidant and anti-inflammatory effects.

The frequently-found nutrients in MD are given in Figure 2. Emphasis on polyphenolic compounds and their classification along with the chemical structures of some of the representatives of each class are also given in Figure 2 [,].

The phytochemicals, viz. polyphenols, carotenoids, tocopherols, vitamins and minerals are found in MD food ingredients, such as EVOO, vegetables, fruits, nuts, seeds, grains, spices, herbs, tea, wine and others.

The polyphenols as products of the secondary metabolism in the plants usually accumulate in the plant organs, like leaves, fruits, roots, and stems. They are essential for the plant life; they provide defense against harmful microorganisms and make the plants unpalatable to predators.

On the other hand, the wide spectrum of dietary phenolic compounds provides the health benefits and reduced risks for many Non-Communicable Diseases NCDs associated with this diet.

More specifically, the polyphenols coming from dietary sources in conjunction with the traditional Mediterranean cooking methods making them more bioavailable are characterized with high antioxidant, anti-cancer, anti-inflammatory, and anti-aging activities [18,96,,].

These phenolic compounds are also responsible for the organoleptic properties of the foods; the intensity of these properties mostly depends on the phenolic concentration and their structure. For instance, the phenolics are responsible for the bitterness, astringency, color, flavor, odor and oxidative stability of the food products where they are present [82,,].

The antioxidant properties of the phenolic compounds are expressed via different mechanisms, which can be summarized as follows: a ability to remove free radicals and inhibit the formation of reactive species, b ability to prevent the damage of lipids, proteins, nucleic acids, and c ability to prevent consequent cell damage and death as a result of the previous two mechanisms.

All of them are commonly associated with preventing the development of many human diseases, such as cardiovascular diseases, neurodegenerative diseases, autoimmune diseases, diabetes, cancer, but also very important is that they could modulate human gut microbiota [].

Polyphenols cover wide range of compounds and are classified in different ways; mainly they are divided into flavonoids and nonflavonoids phenolic acids, stilbenes, lignans, and other phenolics , but there are also other classifications in literature.

In general, polyphenols contain at least one aromatic ring with one or more hydroxyl groups Figure 2. Briefly, some of the polyphenolic compounds are described below along with their beneficial properties. Phenolic acids, such as gallic, vanillic, cinnamic, ascorbic caffeic, ferulic, and p-coumaric acids are non-flavonoids can be found in fruits, legumes, herbs and vegetables mainly as free phenolic acids, whereas grains contain bound phenolic acids.

They have high efficacy in food preservation, as well as antimicrobial, anticancer, antiinflammatory, anti-mutagenic protective effects []. Resveratrol is a stilbene non-flavonoid polyphenol , which is found in red grapes and its products red wine , and berries. The moderate wine consumption with meals in the Mediterranean dietary pattern has been linked to lower incidence of coronary heart diseases exactly due to the presence of resveratrol and other polyphenols found in the red wine.

Moreover, resveratrol has chemoprotective, anti-inflammatory and neuroprotective activities, because it can effectively scavenge free radicals and chelate metals []. Quercetin is a flavonol found in many vegetables onions, broccoli, peppers, cauliflower and cabbage and fruits berries, apples , nuts, seeds and grains.

It has been used for used for the treatment of allergic, metabolic, and inflammatory disorders, eye and cardiovascular diseases, and arthritis due to its pronounced antioxidant, antiviral, antibacterial, anti-cancer and anti-inflammatory properties [,].

Catechins are simple flavonols, such as Epicatechin EC , Epigallocatechin EGC , Epicatechin Gallate ECG , and Epigallocatechin Gallate EGCG.

They are usually present in apples, teas, grapes, berries, cacao, red wine, beer, etc. and have been found to reduce the incidence of CVDs, inhibit angiogenesis and, therefore, the cancer progression [].

Anthocyanins are flavonoids known for their effects as pigments, which determine the color of the fruits and vegetables blue, red, and purple. They are found naturally in a number of foods, such as berries, currants, grapes, leafy vegetables, roots, and grains and offer antioxidant, antiviral, anti-inflammatory, anti-obesity, antidiabetic and anti-cancer benefits.

The beneficial properties attributed to the consumption of anthocyanin-rich foods have been linked to improved eye health, reduced cardiovascular diseases, and beneficial neuroprotective effects [,]. Luteolin is a flavone that is found in broccoli, leaves, parsley, thyme, rosemary, green pepper, carrots, olive oil and chamomile tea and has anti-oxidant, anti-inflammatory, anti-bacterial, anti-diabetic and anti-proliferative activities [].

Lignans are present in a wide variety of plant foods, including seeds flax, pumpkin, sunflower, poppy and sesame , whole grains, beans, fruits and vegetables and they reduce the risk of certain cancers and cardiovascular diseases [].

The modifiable risk factors that contribute to this high percentage NDCs include unhealthy dietary and lifestyle habits, such as consumption of nutrient-poor food rich in refined sugars, ultra-processed fastfood choices, smoking, sleep deprivation, polluted environments, etc. Mediterranean diet, as a healthy dietary pattern and a lifestyle with a proven track that can be easily implemented outside the Mediterranean basin, could significantly reduce the incidence of NCDs worldwide [,].

MD is a plant-based dietary pattern, which emphasizes abundant consumption of fruits, vegetables, whole grains, nuts, legumes and seeds, herbs, spices and EVOO as a main source of healthy fats, followed by a moderate consumption of fish, poultry, low-fat dairy and fermented dairy products [2,].

The plant origin of the food choices in the MD, and especially the high polyphenolic content, variety of vitamins and minerals, heathy fats, probiotics and dietary fibers, have been linked to be responsible for the reduction of inflammatory and the oxidative processes in the body.

Beside the MD ingredients, the cooking methods characteristic for the Mediterranean cuisine are believed to help in preserving the phytochemicals and make them more bioavailable. Overall, all consumed phytochemicals in synergy contribute to the good health and the overall well-being of the people adhering to MD; in particular, reduced risks for many chronic diseases, CVDs and several types of cancers have been documented for those adhering to MD.

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In addition, in vitro-studies and animal studies have shown that antioxidants also possess anti-inflammatory properties [ 10 — 13 ]. This implies that antioxidative defence mechanisms are of particular importance for patients with RA and that the effects of antioxidative nutrients ought to be further investigated.

Most controlled studies investigating the therapeutic use of antioxidant supplementation have not shown any significant effects on RA symptoms reviewed in [ 14 ].

In contrast to these studies, in a placebo-controlled trial, vitamin E was reported to have a mild, but significant, analgesic effect [ 15 ].

Since many of the antioxidant compounds interact in the body, supplementation with individual antioxidants may not be the best way to strengthen the antioxidant defence. In a small study by Helmy et al [ 16 ] supplementation with a combination of antioxidants, in addition to standard treatment, gave better results regarding clinical indices of RA compared to standard treatment alone.

This indicates that supplementation with a combination of antioxidants, or a diet providing a cocktail of different antioxidants, may be more effective than supplementation with single nutrients.

Therefore, the beneficial effect of the Cretan Mediterranean diet, which we recently tested on patients with RA [ 1 ] could, at least in part, be attributable to the high content of antioxidants in this diet.

Since this needs to be investigated further, the aims of the present study were to examine our patients with respect to their antioxidant intake, their plasma level of antioxidants, and by means of a marker of oxidative stress malondialdehyde. The study has been approved by the local ethical committee and the ethical principles of the Helsinki Declaration were followed.

The patients were enrolled in groups of two to six persons, with new groups starting every third week from September to November After baseline measurements they were randomized to either a modified Cretan Mediterranean Diet MD group or a Control Diet CD group.

The randomization was done by means of block randomization, stratified for sex. Apart from this no differences were seen between the groups at the start of the study for details see reference 1. The pharmacological treatment had to have been kept stable prior to inclusion, i.

Furthermore, the daily dose of oral corticosteroids was not to exceed Patients who had other conditions that demanded active medical attention were not included in the trial. Vegetarians and patients already eating a Mediterranean-like diet were excluded.

Throughout the experimental period the doses of DMARD and corticosteroids were kept constant. The individual dose of NSAID could be adjusted, but the doses had to be documented in the study protocol. Four violations to the protocol in the form of intra-articular injections with triamcinolone hexacetonide were reported.

The injections were given to one MD patient and three CD patients for details see reference 1. None of these patients were excluded. If the subjects of the study used any dietary supplementation e. fish oils, vitamins, minerals, etc. prior to the study this was recorded.

All such supplementation had to be kept unchanged during the study. During the first three weeks both groups took part in an outpatient rehabilitation program at the Kalmar Hospital Rheumatology Unit. This program runs from 9 a. During these weeks Monday to Friday all the patients were served lunch and dinner Cretan diet or the ordinary hospital food, according to the randomization which were planned by the first author LH and managed by the hospital food service establishment.

For the following nine weeks the MD group continued to eat the Mediterranean diet, while the CD group ate their normal diet, now preparing all meals themselves. The Cretan Mediterranean diet has previously been tested by de Lorgeril et al , in a secondary prevention trial of coronary heart disease [ 18 ].

In the present study we based the experimental diet on the diet used in that study, but with some modifications in order to suit Swedish food habits. In brief, the instructions to our MD group were to eat a large amount of fruits, vegetables, pulses, cereals, fish particularly fish with a high content of ω-3 fatty acids and nuts and seeds with a high content of α-linolenic acid.

The intake of meat such as pork, beef, lamb or mutton , cured meat, sausage etc. were to be replaced by poultry, fish or vegetarian dishes.

Both olive oil and canola oil were used for food preparations, baking and in salad dressings. Furthermore, the MD group were advised to replace high fat dairy products with low fat products. The traditional Mediterranean diet is generally characterised by a moderate and regular alcohol consumption, especially in the form of red wine.

However, in the present study no recommendations were given regarding alcohol consumption. To compensate for the antioxidants in wine, we advised the MD group to drink green or black tea.

To promote good compliance to the Mediterranean diet some food items were supplied free to the MD group, namely: frozen vegetables, tea, olive oil, canola oil and the liquid and half-fat margarines based on canola oil.

During the three-week ORP, the MD group had six lessons from a dietician about Mediterranean food and cooking. They were also given written instructions and recipes to facilitate the preparation of meals at home. After the ORP the dietician was available weekly for telephone consultation, and every third week the MD group had the opportunity to meet the dietician and the other MD subjects.

At baseline and at week three and twelve, patients of both groups completed a self-administrated questionnaire. The questionnaire was specifically designed to investigate compliance with the Mediterranean diet and included 86 questions both open and closed questions mainly concerning food choices, food intolerance and dietary supplementation.

Some questions were about food frequencies, where the subjects should state their average intake of various food items by marking one of six alternatives ranging from "rarely or never" to "two or more times per day". To be able to compare the consumption between the two groups, as well as consumption at different points in time, the food frequencies were converted to average consumption per month.

For example, if a consumption of 3—5 times per week was marked this would be converted to 16 times per month. To obtain more detailed data on the energy and nutrient intake, diet history interviews were conducted with 34 patients from both the experimental group and the control group 15 women and 2 men from each group.

The only selection criterion for taking part in the diet history interviews was that the subjects were included in the study on February the 15 th , or later. One purpose of the diet history interviews was to study the compliance with the experimental and control diets when the patients were preparing their meals at home.

Therefore, all the interviews were performed between study weeks seven and twelve. It covered the intake during the past month but never included the ORP. The interview started with questions about the subject's meal patterns on weekdays and weekends.

Subsequently each meal and between-meal snack was discussed in detail, with questions about food choices, frequencies and portion sizes.

To estimate the average portion sizes, household measurements, validated food portion photographs [ 19 ], bags of rice of different sizes or standard weights of food items [ 20 ] were used. Most of the interviews were performed by the first author LH but two other specially trained dieticians interviewed five patients each.

The interviews were either conducted in the subject's home or at the rheumatology unit, Kalmar Hospital. For composite food items and supplements not listed in the database the nutrient content was entered manually.

When uncooked foods were used in cooked dishes the amount of ascorbic acid was adjusted by the program, i. To obtain a crude estimate of the validity of the diet history interviews, we compared the reported energy intake with the energy expenditure of the subjects.

The energy expenditure was estimated using a three-day activity registration method, previously used in the SOS Swedish Obese Subjects study [ 21 ]. If a person is in energy balance the habitual energy intake EI should equal the energy expenditure EE.

In the present study, subjects with a ratio EI:EE between 0. The diet history interviews were also validated by comparing the reported energy intake with the energy expenditure determined by the doubly labelled water method performed for 9 subjects , and the excretion of nitrogen, sodium and potassium in h urine samples, were used to validate the reported intake of protein, sodium and potassium.

The results of the validation with biological markers will be presented elsewhere. Blood samples were drawn into heparinazed vacutainer tubes between 8. When the blood had reached room temperature the samples were centrifuged at 2, rpm for 10 minutes and aliquots of plasma were transferred to 1.

After receiving instructions, each participant collected a morning urine sample 15 ml on the day of the visit to the hospital. On arrival the urine samples were frozen at °C. Louis IN, USA. The standard reference material b for carotenoids and tocopherols was obtained from the National Institute of Standards and Technology, Gaithersburg, MD, USA.

The urine was thawed, vortexed and centrifuged at 2, rpm for 5 minutes. After determining the specific density, aliquots of 50 μl urine were mixed with μl o-phosphorus acid 0. After this, the samples were incubated for 55 minutes at 95°C and then chilled on ice before they were centrifuged for 3 minutes at 14, g.

Malondialdehyde MDA was then determined using HPLC high performance liquid chromatography and 20 μl of each sample was injected and separated on a Chromolite Performance column × 4.

The malondialdehyde — thiobarbituric acid complex was detected with a fluorescence detector Merck-Hitatchi F Fluorescence Spectrophotometer with excitation and emission wavelengths of and nm, respectively.

Vitamin A, α- and γ-tocopherol and carotenoids, was determined using HPLC according to a method that has been described previously by Hess et al [ 23 ]. The quantification of the single compounds was performed by an external standard method based on peak area.

The concentrations of the different samples were also checked and compared with the standard reference materials b from the National Institute of Standards and Technology, USA carotenoids and vitamin E and INSTAND e. Düsseldorf, Germany vitamin A and E. Analyses of vitamin C and uric acid were also performed using HPLC.

Both vitamin C and uric acid were determined with a spectrophotometric detector at the wavelength nm. The HPLC pump was a PU and the detector a UV, both from Jasco Japan Spectroscopic Company Ltd. The analytical column was a Chromolite Performance column × 4.

Clinical and laboratory evaluations were performed at baseline and in week three, six and twelve, and comprised Disease Activity Score from 28 joints DAS28; a clinical assessment of disease activity , the Health Assessment Questionnaire HAQ; a self-administered questionnaire used to assess functional capacity for activities of daily living , the Westergren Erythrocyte Sedimentation Rate ESR , and the C-reactive protein CRP and thrombocyte count.

The Student's t-test for independent samples was used to test differences between groups regarding plasma levels of antioxidants, urine MDA and nutrient intake.

For these variables within-group differences from baseline to week 12 were evaluated using Student's t-test for paired samples. For variables with skewed distributions plasma β-carotene and intakes including supplements of retinol, β-carotene, α-tocopherol, total vitamin E and ascorbic acid, as well as retinol, β-carotene and vitamin C intake when supplements were excluded , and for reported consumption of food items, the Mann-Whitney U-test was performed to test differences between the groups.

For these variables the Wilcoxon signed ranks test was used to analyze differences within groups, from baseline to week To evaluate the association between dietary intake and the plasma levels of antioxidants, as well as between disease activity, MDA and plasma antioxidants, we used Pearson's product moment correlation.

However, Spearman's rank correlation was used for variables with skewed distributions plasma β-carotene, CRP and intakes of β-carotene, α-tocopherol, total vitamin E and ascorbic acid, when supplements were included.

When associations between plasma antioxidants and variables related to disease activity were evaluated, we used the baseline levels of all the study subjects. When relations between dietary intake of antioxidants and plasma levels of antioxidants were evaluated, we used the reported nutrient intake obtained from the diet history interviews and the mean plasma levels of antioxidants taken in the same time period, i.

between weeks 6 and The statistical analyses were performed using SPSS for Windows, version At baseline there were no significant differences between the groups regarding consumption frequencies of food items rich in antioxidants table 1.

The main increases in several antioxidant-rich food items were seen during the ORP week three , when lunch and dinner were served at the Rheumatology unit table 1.

At the end of the study, the intake frequencies of both raw and cooked vegetables, legumes, fish, shellfish and green tea, had increased in the MD group. In the control group there was a significant decrease in the reported intake frequency of fruit and berries.

When comparing the two groups the changes in food consumption frequencies of almost all the food items studied, were significantly greater in the MD group.

The nutrient intake during the second half of the study was estimated by means of the diet history interviews. When comparing the nutrient intakes excluding supplements , the MD group had a lower reported intake of retinol and a higher intakes of vitamin C, α-tocopherol, total vitamin E and selenium, compared to the CD group.

In comparison with the Average Requirement AR , according to the Nordic Nutrition Recommendations NNR [ 24 ], the intake excluding supplements of all the MD subjects exceeded the AR for vitamins A and C and selenium.

No AR for vitamin E has been stated in the NNR, but in the MD group the vitamin E intake of all the subjects exceeded the recommended intake NNR [ 24 , 25 ]. In the CD group, our data indicates that a number of patients did not reach the AR, namely one in the case of vitamin A, one regarding vitamin C and six regarding selenium.

Eight CD subjects did not reach the recommended intake of vitamin E. Of these eight subjects one had an intake of vitamin E that was below the lower limit of intake according to the NNR.

However, when under-reporters two CD subjects were excluded, all the CD subjects reached the AR for vitamins A and C. Only six control subjects had a vitamin E intake below the recommended intake and none under the lower limit of intake and four CD subjects still had a selenium intake below the AR.

The number of subjects that exceeded the AR and recommended intake did not change when we included the dietary supplements in the nutrient intake. No differences were seen between the groups regarding plasma levels of antioxidants or the marker of oxidative stress, MDA in urine, at the start of the study table 3.

At the end of the study α-tocopherol and γ-tocopherol were significantly below the baseline levels in the MD group. When the dietary intake including supplements of nutrients retinol, β-carotene, α-tocopherol and ascorbic acid was related to the plasma levels of the corresponding nutrients, no significant correlation was found.

However, the plasma levels of some nutrients were associated with variables related to disease activity. The concentration of MDA in urine did not change statistically in any of the groups during the study period.

No correlation was found between MDA and the indices of disease activity. In the present study we investigated the plasma levels and nutrient intake of antioxidants that are abundant in the traditional Mediterranean diet, i.

carotenoids, vitamin C, vitamin E and selenium [ 2 ]. After the intervention the consumption of several antioxidant-rich foods increased in the MD group, and as expected this group had a higher intake of most antioxidants compared to the CD group.

More surprising were the results for plasma antioxidants. Although the consumption of antioxidant-rich foods increased, the concentrations of plasma antioxidants were relatively constant throughout the study period.

From baseline to the end of the study the plasma levels of α-tocopherol and γ-tocopherol even decreased to significantly lower concentrations in the MD group. Since tocopherols circulate in the blood with the lipoproteins, the plasma levels are often influenced by the blood lipid concentration.

During the course of this study, the total cholesterol decreased significantly in the MD group results presented elsewhere [ 1 ] and it is possible that this change caused the decreased levels of plasma tocopherols as well.

When the concentration of cholesterol and triglycerides was adjusted for, the changes in plasma α-tocopherol did not reach statistical significance. When γ-tocopherol was presented in relation to triglycerides this concentration was also unchanged.

Nevertheless, although the reported intake of vitamin E was higher in the MD group, the lipid adjusted plasma levels did not increase. One reason for this could be a decreased intake of fat, since the bio-availability of vitamin E is affected by the presence of fat.

For the same reason the fat intake could also have affected the levels of β-carotene. However, the relation between the intake of fat and vitamin E in each meal must be investigated to clarify this. The intake of fat and biochemical markers of fat intake will be presented elsewhere. The levels of tocopherols in the MD group may also have been affected by the increased intake of fish or other foods rich in polyunsaturated fatty acids PUFA.

These fatty acids are easily oxidized and may therefore increase the expenditure of vitamin E. Tulleken et al [ 27 ], compared two groups of RA patients receiving either supplementation with fish oil rich in ω-3 PUFA plus Although the coconut oil-treated group received slightly less α-tocopherol, by the end of the study measures of vitamin E status were significantly higher in this group compared to the fish oil-treated group.

The influence of antioxidant-rich foods on the plasma concentration of antioxidants has been investigated in healthy subjects.

Zino et al [ 28 ], showed that an increased intake of fruit and vegetables resulted in a raised plasma concentration of vitamin C, α-carotene and β-carotene. Interestingly, these changes were seen within the first two weeks of intervention, indicating that the plasma antioxidants in question respond quite fast to changes in dietary intake of antioxidants.

In contrast, the levels of tocopherols may be more difficult to elevate by means of increasing the intake of vitamin E-rich foods [ 29 ]. In healthy individuals the plasma levels of antioxidants may be affected by many factors other than the nutrient intake, such as the degree of absorption, intake of other nutrients, homeostatic regulation etc.

How the plasma antioxidants of RA patients are influenced by intervention with an antioxidant-rich diet has, to our knowledge, not been studied before.

A possible explanation for the lack of correlation between dietary intake and plasma antioxidants, in the present investigation, is that the plasma levels of nutrients are mainly influenced by the inflammatory process, and to a lesser extent by the dietary intake.

Several authors have reported depressed antioxidant levels in the plasma or serum of RA patients [ 30 — 36 ]. They also reported that the low level of serum selenium found in RA patients was associated with joint score. We found that plasma retinol, ascorbic acid and uric acid were inversely related to indices of disease activity.

In contrast to our results, in one study the level of serum vitamin A was shown not to be associated with blood parameters of inflammation or the joint score [ 35 ]. Only disease activity assessed by the physician was related to the level of vitamin A.

However, in the NHANES III study, serum retinol was found to be lower in subjects with elevated CRP concentrations [ 38 ]. A number of authors have documented poor intakes of antioxidants among RA patients [ 34 , 39 — 41 ], but all studies are not in agreement [ 42 ].

Furthermore, in all of the studies where the nutrient intake was reported to be deficient, the energy intake was also rather low. Thus, it is not unlikely that the subjects have underreported their dietary intake.

In the present study we have primarily related the dietary intake to the AR according to the NNR. When under-reporters were excluded one MD and two CD subjects all the subjects reached the AR for vitamin A and C.

Hence, the result of this study does not point towards an inadequate nutrient intake, perhaps with the exception of selenium. However, our subjects had volunteered to participate in a dietary intervention study and may not have been representative for Swedish RA patients in general.

For instance, they might have had a greater interest in nutrition, and perhaps their dietary intake was, for this reason, better than the intake of other RA patients. Since antioxidant-rich foods, such as fruit and vegetables, are in general regarded as healthy, it is possible that the subjects have over-reported their intake of these food items and consequently the nutrient intake would be overestimated as well.

If this was the case it could explain the lack of correlation between nutrient intake and the plasma levels of the corresponding nutrient, at least if, for instance, subjects with a low nutrient intake over-report to a greater extent.

Even if the reported intake of food items and nutrients was correct, it may not have been sufficient to substantially raise the plasma levels. In the study on healthy subjects by Zino et al [ 28 ], an average extra intake of g of fruit and vegetables per day resulted in raised levels of plasma antioxidants vitamin C, α- and β-carotene.

For patients with RA the required amount could be even higher due to the impact of the disease. In the present study, we have mainly focused on well-known antioxidant nutrients. However, fruit, vegetables, olive oil and tea also contain phytochemicals, such as phenolic compounds, which in recent years have attracted increased interest [ 2 , 3 , 13 ].

Apart from functioning as antioxidants these compounds have been attributed anti-inflammatory, antibiotic, and anti-carcinogenic properties [ 43 ]. In a recent study by Halvorsen et al , the total antioxidant capacity of dietary plants was measured by the FRAP assay [ 44 ].

Their results suggest that other antioxidants may be of considerable importance for the total antioxidative capacity. However, at this point knowledge about the bio-availability and the in vivo activity of the different phenolic compounds is still insufficient.

Uric acid is an end product of purine metabolism, which also serves as a water soluble antioxidant and is present in high concentrations in plasma.

Situnayake et al [ 36 ] investigated the combined chain breaking antioxidant ability of human serum by means of the Total Peroxyl Radical-trapping Antioxidant Parameter TRAP assay.

They found that serum urate was the most important determinant of TRAP in RA patients. In contrast, in the healthy control group vitamin E explained most of the variance in TRAP [ 36 ]. It is not likely that a shift to a Mediterranean-type diet would lead to an increase in ingested nucleic acids, nor to increased hydrolysis of endogenous nucleic acids and thereby increase the plasma level of uric acid.

However, since uric acid contributes to the total antioxidant capacity we decided to investigate the uric acid level as well. There was a tendency to increased levels of uric acid in the MD group at the start of the study, however by week 12 there was no significant difference compared to baseline.

The inverse correlation between the thrombocyte count and uric acid indicates that the level of uric acid is associated with the degree of inflammation. In rheumatoid joints activated macrophages and neutrophils release several kinds of oxidants, which in high concentrations lead to oxidative stress causing damage to lipids, proteins, carbohydrates and DNA.

Important targets for oxidants are the unsaturated fatty acids in cell membranes. MDA is a product of lipid peroxidation and thereby functions as a marker of oxidative stress. The level of MDA in plasma or serum has been reported to be higher in RA patients than in control subjects [ 46 — 49 ].

Earlier studies have also shown that the level of MDA is related to RA disease activity. In one study Taysi et al [ 49 ], found that serum MDA correlated positively with disease activity score, and Deaney et al [ 50 ], have reported a correlation between ESR and MDA plus another lipid peroxidation product, 4-hydroxynonenal.

In the present study, where most patients had low to moderate disease activity, no correlation between urine MDA and disease activity variables were found. On the other hand, γ-tocopherol was inversely correlated to MDA at baseline. At a group level, no significant changes in MDA or adjusted MDA were seen from baseline to the end of the study, indicating that lipid peroxidation was not significantly affected by the intervention.

In conclusion, the intake frequencies of antioxidant rich food items were increased in the MD group, and this group also had a significantly higher intake of vitamin E and selenium compared to the CD group. Despite the reported increase in consumption frequency of antioxidant-rich foods, the plasma levels of carotenoids, vitamin C, lipid adjusted tocopherols, uric acid and MDA were unchanged by the end of the study.

The plasma levels of retinol, vitamin C and uric acid were, however, correlated to indices of disease activity. Sköldstam L, Hagfors L, Johansson G: An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Ann Rheum Dis.

Article PubMed PubMed Central Google Scholar. Visioli F: Antioxidants in Mediterranean diets. World Rev Nutr Diet. Article CAS PubMed Google Scholar. Trichopoulou A, Vasilopoulou E, Hollman P, Chamalides C, Foufa E, Kaloudis T, Kromhout D, Miskaki P, Petrochilou I, Poulima E, Stafilakis K, Theophilou D: Nutritional composition and flavonoid content of edible wild greens and green pies: A potential rich source of antioxidant nutrients in the Mediterranean diet.

Food Chem. Article CAS Google Scholar. Galli C, Visioli F: Antioxidant properties of Mediterranean diet. Int J Vitam Nutr Res. Trichopoulou A, Naska A, Vasilopoulou E: Guidelines for the intake of vegetables and fruit: the Mediterranean approach.

Heliövaara M, Knekt P, Aho R-K: Serum antioxidants and risk of rheumatoid arthritis. Comstock GW, Burke AE, Hoffman SC, Helzlsouer KJ, Bendich A, Masi AT, Norkus EP, Malamet RL, Gershwin ME: Serum concentrations of alpha tocopherol, beta carotene, and retinol preceding the diagnosis of rheumatoid arthritis and systemic lupus erythematosus.

Article CAS PubMed PubMed Central Google Scholar. Knekt P, Heliovaara M, Aho K, Alfthan G, Marniemi J, Aromaa A: Serum selenium, serum alpha-tocopherol, and the risk of rheumatoid arthritis.

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How It Works The Mediterranean diet is a primarily plant-based eating plan that includes daily intake of whole grains, olive oil, fruits, vegetables, beans and other legumes, nuts, herbs, and spices.

There are additional points that make this eating plan unique: An emphasis on healthy fats. Olive oil is recommended as the primary added fat, replacing other oils and fats butter, margarine.

Other foods naturally containing healthful fats are highlighted, such as avocados, nuts, and oily fish like salmon and sardines; among these, walnuts and fish are high in omega-3 fatty acids. Choosing fish as the preferred animal protein at least twice weekly and other animal proteins of poultry, eggs, and dairy cheese or yogurt in smaller portions either daily or a few times a week.

Red meat is limited to a few times per month. Choosing water as the main daily beverage, but allowing a moderate intake of wine with meals, about one to two glasses a day for men and one glass a day for women.

Stressing daily physical activity through enjoyable activities. Sample meal plan This sample meal plan is roughly calories, the recommended intake for an average person.

Breakfast: 1 cup cooked steel-cut oats mixed with 2 tablespoons chopped walnuts, ¾ cup fresh or frozen blueberries, sprinkle of cinnamon Snack: ¼ cup nuts, any type Lunch: Beans and rice — In medium pot, heat 1 tbsp olive oil. Add and sauté ½ chopped onion, 1 tsp cumin, and 1 tsp garlic powder until onion is softened.

Mix in 1 cup canned beans, drained and rinsed. Serve bean mixture over 1 cup cooked brown rice. References Willett WC, Sacks F, Trichopoulou A, Drescher G, Ferro-Luzzi A, Helsing E, Trichopoulos D.

Mediterranean diet pyramid: a cultural model for healthy eating. Gifford KD. Dietary fats, eating guides, and public policy: history, critique, and recommendations.

Am J Med. Fung TT, Rexrode KM, Mantzoros CS, Manson JE, Willett WC, Hu FB. Mediterranean diet and incidence of and mortality from coronary heart disease and stroke in women. Lopez-Garcia E, Rodriguez-Artalejo F, Li TY, Fung TT, Li S, Willett WC, Rimm EB, Hu FB.

The Mediterranean-style dietary pattern and mortality among men and women with cardiovascular disease. Ahmad S, Moorthy MV, Demler OV, Hu FB, Ridker PM, Chasman DI, Mora S.

Assessment of Risk Factors and Biomarkers Associated With Risk of Cardiovascular Disease Among Women Consuming a Mediterranean Diet. JAMA Network Open. Pant A, Gribbin S, McIntyre D, Trivedi R, Marschner S, Laranjo L, Mamas MA, Flood V, Chow CK, Zaman S.

Primary prevention of cardiovascular disease in women with a Mediterranean diet: systematic review and meta-analysis.

Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F, Gómez-Gracia E, Ruiz-Gutiérrez V, Fiol M, Lapetra J, Lamuela-Raventos RM.

Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts. New England Journal of Medicine.

Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. The National Academies Press , Salas-Salvadó J, Bulló M, Babio N, Martínez-González MÁ, Ibarrola-Jurado N, Basora J, Estruch R, Covas MI, Corella D, Arós F, Ruiz-Gutiérrez V.

Reduction in the incidence of type 2 diabetes with the Mediterranean diet. Diabetes care. Loughrey DG, Lavecchia S, Brennan S, Lawlor BA, Kelly ME.